Got wrong

The nurse teaches a client who had a radical retropubic prostatectomy about potential complications of the surgery. Which client statement indicates the teaching was successful?

"I will perform Kegel exercises. Not: I need to self-catheterize."-is not indicated Rationale: Pelvic floor exercises (Kegel) prevent or reduce the severity of urinary incontinence after a radical retropubic prostatectomy.

a client with head injury can confirm they are developing Cushing triad with which signs

-Bradcardia (pulse of 52/beats per minute and irregular) -high blood pressure with widening pulse (180/58) Not: respiratory, O2, temp

Danger signs of pregnancy

-Continuous headaches during the last 3 months -sudden swelling of extremities during the last 3 months -blurring of vision during the last 3 months -decreased fetal movement after 24 hrs

Diabetic Client on high dose corticosteroids at risk for which complication

-Delayed wound healing, (due to med) -erythematous plaques on legs (due to diabetes's) -, descrease subq fat over extremities ( due to diabetes and meds)

whic clients does the nurse port to the health care provider

-positive nitrates in the urinalysis of a client receivign chemotherapy* nitrates mean they have an infection cause by e. coli -a blood glucose level of 140 in a client diagnose with diabetes mellitus* -a potassium level of 3.3 in a client receiving IV antibiotics not: aptt level of 78 second in a client receiving an IV heparin infusion it is in a therapeutic range

Pt in hospice died how does nurse tell family -provide condolences and offer them viewing time Or Tell them I will give you some time to spend with you love them let me know if you need anything

-provide condolences and offer them viewing time

correct teaching of migraine headaches

-should track the number of hours i sleep each day -avoid red wine, even at parties -i need a new favorite snack since i cant have cheddar cheese*(contains tyramine a migraine trigger) not: zolmitriptan will prevent migraines if i take a doese weekely: it is not take as needed,

Bucks traction interventions

-the nurse removes the foam boot 3 times per day to inspect the skin -the staff turns the client to the unaffected side -the nurse asks the client to dorsiflex the foot on the affected leg (assess peroneal nerve, weakness meand correction required to prevent permanent damage) -the staff elevates the foot of the clients bed. -the staff provides back care for the client every 2 hours (not once per shift)* not: to prevent pressure sores and discomf

a young adult female is prescribed atorvastatin to treat familial hypercholesterolemia. what teaching does she require

-use contraception while taking statin medications (they should not be taken during pregnancy) -most people taking statin medication experience few adverse effects -*plan to have work done at least yearly if you take atorvastatin (will need liver function tests monitored to make sure no adverse effects occur)

Hypothermic pt in near drowning experience needs which intervention

-warmed iv fluids -mechanical vent -covering the client with warm blankets -cardiac monitor (prone to have v-fib at temps under 95 NOT: log rolling( contraindicated can cause v-fib)

to recommendation for cancer screening

-women should have a papanicolau test every 3 year between 21 and 29 years -colonoscopy every 10 years starting at 50 -fecal occult blood test every year starting at age 50

The nurse assess a client who is in the 24th week of gestation. Which finding is a priority for the nurse to follow-up?

. Fundal level at 3 fingers below the umbilicus. not:Fetal heart rate of 130 to 140 beats/min (normal:110-160) raionale: Fundal height should be at the level of the umbilicus at 20 weeks. Three fingers below this height indicates a fetal problem.

which would cause the nurse to intervene if an LPN administers

1) cardevilol to a pt with a documented allergy to nadolol 2) thiorizadine to a pt with a documented allergy to promethazine 3) ceftriaxone to a pt with a documented allergy to cefazolin not: hydralazine to a pt with a documented allergy to hydroxyzine rationale: hydralazine: is a vasodilator hydroxyzine is an antihistamine: no interaction

Before starting a urinary cath what should the nurse do

1) confirm the clients identity 2) confirm the medical record with wristband and prescription 3) confirm name via wristband and prescription

A patient with cirrhosis would have which signs and symptoms

1) cyanosis 2)poor tissue turgor 3) bruises

blind client with bilateral eye patches, nurse should take which actions 1) frequently touch the client 2) maintain a calm, dark environment

1) frequently touch the client this provides reassurance, when entering the room staff should speak to client to not startle not: 2) maintain a calm, dark environment this is only appropirate for sleeping at night, during the day a client needs stimulation, and interaction.

which is an example of primary health prevention 1) teaching a class on danger or smoking 2) encouraging clients to perform breast self-exam

1) teaching a class on danger or smoking not: 2) encouraging clients to perform breast self-exam this is screening

A nurse from the emergency department (ED) is floated to the surgical unit. Which clients will the charge nurse appropriately assign to the ED nurse? 1. A client who had a stroke 3 days ago and requires total care and enteral feedings. 2. A client admitted with pneumonia requiring IV antibiotics 3. A client admitted with anemia requiring a blood transfusion. 4. A client with a new diagnosis of heart failure to be discharged in 24 hours.

1. A client who had a stroke 3 days ago and requires total care and enteral feedings. * (delegate stable clients with expected outcomes and routine tasks. The client with a stroke 3 days ago requiring enteral feedings is a stable client. 2. A client admitted with pneumonia requiring IV antibiotics 3. A client admitted with anemia requiring a blood transfusion. not: 4. A client with a new diagnosis of heart failure to be discharged in 24 hours. (the client with heart failure will require speciallized teaching and management of care due to the complex new diagnosis. Assign this client to regular staff.

The nurse provides care for a postoperative client. The nurse notes the client is restless. The client grabs at the incisional area. The nurse notes the client's blood pressure to be 146/96 mm Hg. Which action should the nurse take next? 1. Ask the client to rate the pain level. 2. Assess the incisional site.

1. Ask the client to rate the pain level. rationale: These signs and symptoms indicate the client is having pain. Assess the client for pain characteristics and to determine the level of pain.

A client is concerned over symptoms that the health care provider thinks indicate a new diagnosis of multiple sclerosis (MS). Which clinical manifestation found during the assessment supports the nursing diagnosis of impaired mobility? 1. Bilateral weak extremities. 2. Muscle rigidity.

1. Bilateral weak extremities. rationale: MS is a progressive demyelinating disease that has a variety of manifestations. The most common manifestations include diplopia (double vision), tinnitus (ringing in the ears), vertigo (dizziness), and muscle weakness.

The nurse educator plans an educational program to review transmission-based precautions with unit staff. Which substance is included on the list of potential sources of infection as outlined by the Centers for Disease Control and Prevention (CDCP)? (Select all that apply.) 1. Blood. 2. Vaginal secretions. 3. Sputum. 4. Non-intact skin. 5. Sweat.

1. Blood. 2. Vaginal secretions. 3. Sputum. 4. Non-intact skin.* not: sweat

The nurse assesses a client being considered for thrombolytic therapy. Which question is most appropriate for the nurse to ask? (Select all that apply.)

1. Can you tell me the exact time your chest pain began?" 2. "Are you taking any medications to thin your blood? not: Did you have the flu and pneumonia vaccination?" rationale: it does not impact the use of thrombolytic therapy.

The nurse in the emergency department assesses the client diagnosed with Burns. Which observation most concerns the nurse? 1. Charred, waxy, white appearance ofskin on the left leg. 2. Reddened blotchy painful areas noted on the trunk

1. Charred, waxy, white appearance ofskin on the left leg. Rationale: this described a full thickness burn. All the skin is destroyed and the muscle and bone may be involved. the substance that remains is called eschar and it's dry to the touch. Full thicknesss burns do not heal spontaneously and required grafting. All functions of the skin are lost 2. Reddened blotchy painful areas noted on the trunk. (this describes a superficial burns. The skin appears to be pink and has increased sensitivity to heat. Healing occurs without treatment

he nurse assesses a yellow-brown coating on a client's tongue. Which assessment data will the nurse consider as the reason for this finding? 1. Client smokes cigarettes. 2. Client is recovering from hepatitis.

1. Client smokes cigarettes. not. 2. Client is recovering from hepatitis have their sclera and buccal mucosa turn yellow not tongue

The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). The nurse receives a prescription to transition the client from a regular insulin infusion to insulin glargine. Which action does the nurse take first? 1. Continue the insulin infusion for 1 to 2 hours after the glargine is started. 2. Check the client's blood glucose every 30 minutes for 24 hours. 3. Discontinue the insulin infusion as soon as the glargine is administere

1. Continue the insulin infusion for 1 to 2 hours after the glargine is started. rationale: Insulin glargine is a long-acting insulin that is given subcutaneously (SC). The onset of insulin glargine is 1 to 1.5 hours. Continuing the insulin infusion for 1 to 2 hours after the SC glargine has been administered allows for the long-acting insulin to begin to take effect before discontinuing the short acting (regular) insulin infusion and prevents hyperglycemia

a young client is admitted for catatonic schizophrenia. When the nurse places the clients hand over the head, it remains in that position. which appropriate action should the nurse implement? 1. Document the findings as wavy flexibility. 2. Administer benztropine to the client as prescribed,

1. Document the findings as wavy flexibility. rationale: the client is showing wavy flexibility, a form of abnormal postuirn seen in catatonic schizophrenia. wavy flexibility, is described as loss of animation and a tendency to remain motionless when placed in a position. not: 2. Administer benztropine to the client as prescribed,: this is used to treat extrapyramidal symptoms EPS, caused by antipsychotics. the client is not experiencing EPS.

The nurse identifies the condition of excessive fluid volume, impaired gas exchange and activity intolerance for a client with heart. Which finding validate these nursing diagnosis Select all 1. Dyspnea on exertion 2. Wheezes on auscultation 3. Crackles on auscultation 4. fatigue and weakness

1. Dyspnea on exertion 3. Crackles on auscultation 4. fatigue and weakness Not: 2. Wheezes on auscultation ( wheezing is not connected with fluid retention. Leaving indicates airway obstruction)

order for client to receive enteral feedings via gastrostomy tube and bolus. 1. Ensure the formula is at room temp 2. check for gastric residual volume 3. flugh gastrostomy tube with 30 ml water 4. assess daily intake and output 5. monitor pre-albumin levels

1. Ensure the formula is at room temp 2. check for gastric residual volume (determines if gastric emptying is delayed) 3. flush gastrostomy tube with 30 ml water (for bolus feedings flush before and after) and every 4 hours 4. assess daily intake and output (done daily) 5. monitor pre-albumin levels (lab values do not fluctuate on a daily basis)

The nurse delegates a task to an LPN/LVN. Which action will the nurse make that indicates delegation was appropriate? 1. The nurse follows up with the LPN/LVN to make sure the task was completed 2. The nurse has the LPN/LVN complete a task the LPN/LVN has completed once.

1. Following up with the LPN/LVN indicates appropriate supervision in a timely manner. not 2: the lpn only did it once

the nurse learns that an adolescent client's best friend has a driver's license and a new car. Which comment is the most appropriate for the nurse to make? 1. How often do you ride in the car with your friend? 2. what kind of driver is your friend?

1. How often do you ride in the car with your friend? rationale: the nurse should assess before counseling the adolescent about the importance of wearing seat belts and acting appropriately when riding with another adolescent. not: 2. what kind of driver is your friend?

The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is having difficulty clearing lung secretions. Which technique is best for the nurse to teach the client to perform? 1. Huff cough. 2. Postural drainage. 3. Chest physiotherapy. 4. Pursed-lip breathing.

1. Huff cough.

Client diagnosed with Bell's palsy for a health evaluation. Which client statement indicates the need for the nurse to provide additional teaching 1. I like to sleep with the window open 2. I tape my eyes shut at night

1. I like to sleep with the window open Rationale: the client should protect the face to prevent trigeminal hyperesthesia Not: 2. I tape my eyes shut at night ( appropriate action affected eye may not close completely)

The nurse provides care for a client who is prescribed level thyroxine. Which client statement in the case of a nurse a correct understanding of the medication therapy. Select all. 1. I will feel more energetic when this medication works 2. I will take this medication on an empty stomach when I wake up 3. This medication contains both T3 and T4 for hormones 4. If medication replaces the hormone I don't produce

1. I will feel more energetic when this medication works 2. I will take this medication on an empty stomach when I wake up 4. If medication replaces the hormone I don't produce Not: 3. This medication contains both T3 and T4 for hormones

The nurse counseld a Client about the west Nile virus during an outbreak. Which client statement required to follow up by then nurse 1. I will get an immunization for the west nile virus 2. I will use a few to repellent back that contains DEET

1. I will get an immunization for the west nile virus Rationale: There is no immunization for the west now virus infection Not: 2. I will use a few to repellent back that contains DEET (this product provides long lasting protection against the mosquito bite)

After attending a presentation on sexually transmitted infection an adolescent asks if the HPV vaccine as necessary if aperson is not sexually active which response for the nurse to make to this client select all that apply 1. Immunization are recommend to provide immunity before exposure 2. Use of condoms prevent the transmission of the sexually transmitted infection 3. The human papilloma virus can cause cervical or penilecancer

1. Immunization are recommend to provide immunity before exposure 3. The human papilloma virus can cause cervical or penile cancer Not: 2. Use of condoms prevent the transmission of the sexually transmitted infection (It can reduce the risk of STI but the virus can be transmitted to other parts of the body)

While administering an intravenous push medication to a client, the nurse notes that the color of the medication changed in the tubing. Which type of response will the nurse identify occurred with this medication? 1. Incompatibility. 2. Additive effect. 3. Synergistic effect.

1. Incompatibility. rationale:The change in color when the medication is administered indicates incompatibility. This is chemical response that occurs when medications or solutions that should not be mixed are given together.

The nurse receives a prescription for dobutamine to treat a client with heart failure, hypotension, and low urine output. Which information will the nurse provide to the client about the purpose of dobutamine?

1. Increases the strength of the heart's contraction, improving cardiac output. not: Reduces the workload of the heart, reducing fluid accumulation. thats what diuretics do

The nurse learns that a client was not prescribed a treatment for a disease process because of age. For which principle violation will the nurse bring this issue to the organization's ethics committee? 1. Justice. 2. Veracity. 3. Beneficence.

1. Justice The ethical principle of justice means that clients are treated fairly and receive fair treatment. Because the treatment was not prescribed due to the client's age, the ethical principle of justice is in question. not: beneficence which means to do good.

After being admitted and involuntarily to a mental health Facility a client with a history of assault calls from nurse aracist bigot. which action is the most appropriate for the nurse to take 1. Leave the room after informing the client of returning in 30 minutes. 2. That's another nurse of the same ethnic background of the client to provide care

1. Leave the room after informing the client of returning in 30 minutes. Rationale: The clients history makes him potentially violent. The nurse safety is a priority. The nurse should provide the client with time to calm down Not: 2. That's another nurse of the same ethnic background of the client to provide care. This is an appropriate and will validate the clients remarks and set the stage for staff splitting

The nurse provides care for a client who takes digoxin for heart failure. Which finding is a priority for the nurse to communicate to the health care provider (HCP)? 1.Intermittent nausea and loss of appetite. 2. Serum potassium level 3.8 mEq/L. 3. Weight gain of 2 pounds in one week.

1. Nausea, anorexia, and vomiting are early signs of digitalis toxicity. It is a priority to communicate this data to the HCP not: A weight gain of 2 lbs. in one week does not require immediate attention; however, this finding indicates the need further assessment.

The nurse provides care to a client in hypovolemic shock. Which intravenous solution will the nurse recognize as being an isotonic crystalloid solution? (Select all that apply.) 1. Normal saline. 2. Lactated ringer. 3. 0.5% normal saline. 4. 10% dextrose. 5. 0.45% dextrose in normal saline

1. Normal saline. 2. Lactated ringer.

The nurse provides care for a client on bed rest. The nurse determines that the client's right calf is swollen, red, and tender to touch. Which nursing action is most appropriate? 1. Notify the health care provider. 2. Teach the client to dangle legs.

1. Notify the health care provider. rationale: The assessment data indicates a possible thrombus; therefore, the priority nursing action is to notify the health care provider. 2) The client is taught to elevate legs to prevent venous stasis, not dangle the legs.

When performing a sterile dressing change, the nurse removes the saturated dressing, notes the wound is clean, applies a new dressing, and discards the used gloves. Which action does the nurse take next? 1.Perform hand hygiene. 2. Date and initial the new dressing.

1. Perform hand hygiene. rationale:After removing and discarding a saturated dressing and then removing the gloves, the nurse performs hand hygiene. then the nurse would open the sterile change kit, put on sterile gloves 2. date and initial is done last

The nurse provides care to a client with an epidural catheter for pain control with fentanyl MED after spinal fusion surgery. Which action will the nurse include when providing post-operative care to this client? (Select all that apply.) 1. Perform peripheral neurovascular checks every 2 hours. 2. Ambulate the client around the hallway. 3. Assess for bowel and bladder distention. 4. Keep the client at nothing by mouth status. 5. Monitor client for nausea and vomiting.

1. Perform peripheral neurovascular checks every 2 hours. 3. Assess for bowel and bladder distention. 4. Keep client NPO 5. Monitor client for nausea and vomiting.

The nurse prepares a client to receive a prescribed dose of cisplatin. For which laboratory values will the nurse withold providing this medication? select all 1. Platelet count 60,000 2. BUN 24 3. White blood cells 2,000 4. creatinine 2.0

1. Platelet count 60,000 3. White blood cells 2,000 4. creatinine 2.0 not: 2. BUN 24 (cisplating can be given if the blood urea nitrogen level is less than 25

The nurse notes that at 2200, a client is scheduled to receive 10 units of insulin glargine. The client also has a "now" prescription of 7 units of regular insulin. Which approach will the nurse use to administer these medications? 1. Prepare two separate injections. 2. Administer the regular insulin first.

1. Prepare two separate injections. rationale:Insulin glargine should not be mixed with any other insulin. This client will need two separate injections.

The nurse notes that a client diagnosed with Parkinson disease moves slowly, has difficulty dressing, and experiences bowel and urinary incontinence. Which intervention is appropriate for this client? (Select all that apply.) 1. Provide an elevated toilet seat. 2. Make modified clothing without buttons available. 3. Transfer to a skilled nursing facility. 4. Arrange for gait training. 5. Lower the dose of Parkinson medications.

1. Provide an elevated toilet seat. 2. Make modified clothing without buttons available 4. Arrange for gait training. Not: Transfer to a skilled nursing facility.

The community health nurse provides care for a client who is taking multiple medication for constipation. Which medication causes the nurse least concern 1. Psyllium hydrophilic mucilloid 2. Magnesium hydroxide

1. Psyllium hydrophilic mucilloid Rationale: this laxative is the safest even when taken on a routine basis. it is a fiber that works by increasing water absorption or retention with them to school increasing the bulk and stimulating peristalsis 2. Magnesium hydroxide: Chronic use of Celine laxative can significantly alter electrolyte balance causing dehydration and lead to laxative dependence

The nurse provides care for a client in the end stages of dying. The family asks the nurse how they can provide comfort to the client in the client's final hours. Which intervention will the nurse recommend the family implement? (Select all that apply.) 1. Reading to the client. 2. Encouraging the intake of fluid. 3. Giving a gentle massage. 4. Holding the client's hand. 5. Talking to the client.

1. Reading to the client. *3. Giving a gentle massage. 4. Holding the client's hand. 5. Talking to the client.

The nurse cares for a client diagnosed with recurrent depression. During the initial assessment based on the therapist recommendation for a cognitive approach to therapy which aspect is importance for the nurse to evAluate? 1. The clients use of language 2. The clients and insight into the depression

1. The clients use of language Rationale: cognitive viewpoint of depression sees it as stemming from errors in thinking which may be negative illogical and irrational. Language is used in thought as well as in speech. Speech and writing are used to express thoughts, and thereby are indicators of the clients automatic thoughts, their schemata or cognitive structure about themselves on the world and the cosmetic distortion Not: 2. The clients and insight into the depression ( The emphasis on insight is prominent place additional psychoanalytic and psycho dynamic therapy)

The nurse working with an AP receives mid-shift report, which report does the nurse respond first? 1. a client after a Billroth II procedure (gastrojejunostomy) wanted to lie down right after eating even after i told the client to sit up for atleast half an hour to let the food digest. 2. a client diagnosed with lung cancer keeps coughing, is on oxygen, and can hardly breathe, but asked for a cigarette.

1. a client after a Billroth II procedure (gastrojejunostomy) wanted to lie down right after eating even after i told the client to sit up for atleast half an hour to let the food digest. rationale: this requires immediate intervention, to prevent dumping syndrome and lying after eating is recommended in order to delay the gastric emptying process. Another measure that can be taken is eating lying down, or in the semirecumbent. The desire to lie down may be on of the early sysmptoms of dumping syndrome, as well as vasomotor disturbances of syncope. The client needs evaluation and clarification of proper procedure, and the UAP needs to be taught that this client situation is the exception to the rule of not lying down after eating. not 2. a client diagnosed with lung cancer keeps coughing, is on oxygen, and can hardly breathe, but asked for a cigarette. (the nurse should allow the AP to further express feelings. often it is difficult for staff to deal with clients who seem addicted to or intent to self destruction when the providers are intent on saving lives.

The nurse provides care to a client with the following assessment data: nonproductive cough, fever, lung crackles, headache, and myalgia. Which nursing concerns are appropriate? select all 1. acute discomfort 2. inefficient gas exchange 3. ineffective breathing pattern 4. potential for infection.

1. acute discomfort* rationale: related to inflammation in the lungs and muscle pain. 2. inefficient gas exchange 3. ineffective breathing pattern not: 4. potential for infection. not a concern the client already has an infection signaled by sings of respiratory systemic infection caused by pneumonia.

a client who had abdominal surgery 4 months ago experiences bloating, vomiting, cramping, and abdominal pain. which does the nurse suspect as the cause of the clients symptoms? 1. adhesions 2. contractures k-

1. adhesions rationale: adhesion is a band of scar tissue that forms between organs after a surgical procedure and can cause the symptoms of an intestinal obstruction not 2. contractures (may shorten the muscle or scar tissue, but they do not contribute to the abdominal symptoms)

a client recovering from a post-op discectomy/laminectomy. the client has a history of obesity of sleep apnea. the nurse administers diazepam 10 mg orally for pain reported as 9 out of 10 on a pain scale. which additional action is NOT appropriate for the nurse to take

1. administer narcotic analgesic as prescribed rationale: administering a narcotic is appropriate as it may worsen respiratory issues of the client.

the nurse caring for a 12 month old client is due to receive the first dose of measles, mumps, and reubella (MMR) vaccine. The nurse notes that the client has a low grade fever and signs of a minor respiratory illness. which action by the nurse is appropriate? 1. administer the vaccine on schedule 2. postpone the vaccination until the respiratory illness is gone.

1. administer the vaccine on schedule rationale: vaccinations should not be posponed unless they are allergic or immuno suppressed. the child is protected after birth by the mothers immunity provided during utero. but they require vaccinations to receive future immunity to prevent illnesses. not 2. postpone the vaccination until the respiratory illness is gone.

The nurse Staff at the pediatric hospital discuss instituting a community education program regarding intellectual disability particularly prevention, what is most beneficial for the nurse to empathize which area 1. alcoholism treatment 2. prenatal classes

1. alcoholism treatment Rationale: alcohol is the leading cause of preventable intellectual disability this is included in the fetal alcohol syndrome complex of system Not: 2. prenatal classes Focuses on the parents and the last trimester of pregnancy when any issues with the fetus may be already developed or no longer preventable or reversible

a client diagones with sudden fear of elevators, the nurse should take which action first? 1. allow the client to avoid the elevator 2. encourage the client to discuss the fear.

1. allow the client to avoid the elevator this will not increase the clients apprehension and andger not: 2. encourage the client to discuss the fear. (appropirate but its more important for client to avoid the elevator. phobias respond best to systematic desensitization.

the nurse performs a medical record review for modifiable risk factors of coronary artery disease (CAD). Which clients does the nurse identify as having a modifiable risk? (SELECT ALL) 1. an adult client who smoked for 25 years 2. an adult clietn who is 5'8 and weighs 242 lbs 3. an older adult client with a blood cholesterol of 255 mg/dl 4. an older adult client who plays gold four times a week

1. an adult client who smoked for 25 years 2. an adult clietn who is 5'8 and weighs 242 lbs 3. an older adult client with a blood cholesterol of 255 mg/dl not: 4. an older adult client who plays gold four times a week. (playing gold in an acceptable physical activity)

the nurse receives hand off report from an AP, which situation requires intervention by the nurse? 1. an african american female client whose hair is shampooed every day 2. a pakistani client on bed rest kneels on the floor several times during the day.

1. an african american female client whose hair is shampooed every day rationale: the hair of african american client may be dry. this necessitates application of oil rather than common shampoo, which will further dry out the scalp and make hair brittle. not: 2. a pakistani client on bed rest kneels on the floor several times during the day. (kneeling is part of an islamic ritual prayer that is done five times per day. the nurse should accomodate this practice to the best of the clients ability

client diagnosed with AIDS, is going to live with parents so that they can assist with care. which action does the nurse take first 1. ask the client about what kind of help is needed from the parents 2. assess if the client and parents understand the dosing schedule and side effects of the medication.

1. ask the client about what kind of help is needed from the parents rationale: the nurse shoudl first determine the clients needs and then assess whether the parents are able to meet the clients needs. After the assessment is complete the nurse can begin implementation not: 2. assess if the client and parents understand the dosing schedule and sideeffects of the medication.

the nurse provides care for a client diagnosed with cerebrovascular accident (cva) which action by the nurse is most important 1. ask the client to discuss perception of health status 2.. identify the client's strength and weaknesses.

1. ask the client to discuss perception of health status rationale: for teaching to be successful , the nurse should assess clients perception about the health problem first. not: 2.. identify the client's strength and weaknesses. (although important it would not precede assessing.)

the nurse admits a client daignosed with a cerebrovascular accident (CVA). Which actions are taken by the nurse to assess the client's neurological status? 1. ask the client to grasp and squeeze two fingers 2. determine client's orientation to person, place, and time 3. assess the client's pupillary response

1. ask the client to grasp and squeeze two fingers* rationale: assessing muscle strength and movement needs to be included when assessing the clients neurological status. 2. determine client's orientation to person, place, and time 3. assess the client's pupillary response

the nurse administers pain medication to a client with nausea, vomiting, adn upper right quadrant abdominal pain who is waiting surgery for acute cholecystitis. which action by the nurse is most appropriate? 1. assess fluid and electrolyte status 2. review the history for allergies to antibiotics.

1. assess fluid and electrolyte status rationale: due to hypokalemia and hypomagsemia being common with clients with cholecystitis or gallbladder disease. not: 2. review the history for allergies to antibiotics. (not the highest priority at this time).

the nurse determines that a client with a malnutrition is at risk for pressure injuries. which interventions will the nurse include in this clients's plan of care to decrease the risk? select all 1. avoid the use of donut-type devices 2. elevate the head of the bed no more than 30 degrees* 3. avoid prolonged periods of sitting in a chair

1. avoid the use of donut-type devices (promotes ischemia) 2. elevate the head of the bed no more than 30 degrees* rationale: elevating the head of the bed no more than 30 degree will decrease the chance of pressure injury development from shearing forces. 3. avoid prolonged periods of sitting in a chair

client who just had renal biopsy reports pain at the biopsy site that radiates to the front of the abdomen. Which complication does the nurse suspect the client is developing? 1. bleeding 2. renal colic

1. bleeding rationale: pain is starting at the procedure site and radiating to the flank area and around to the front indicates bleeding not: 2. renal colic: no data for this

the nurse provides care to a client receiving an epinephrine infusion following a cardiac arrest. which indicates that treatment is effective 1. bp of 130/67 2. apical hr of 99 beats/min 3. pupils constricted and equal 4. capillary refills less than 2 seconds

1. bp of 130/67 2. apical hr of 99 beats/min 4. capillary refills less than 2 seconds not:3. pupils constricted and equal (epi has no effect of pupils)

A client with lild preeclampsia will have which symptoms 1. bp of 150/96 2. urine output of 460ml in 24hrs 3. 4+proteinuria 5. ALT level 30

1. bp of 150/96 5. ALT level 30* rationale: Liver enzymes are normal in mild preeclampsia they are elevated in severe preeclampsia (HELLP syndrome) normal ALT is 10-40 not: 2. urine output of 460ml in 24hrs (low urine output is seen in severe, mild has adequate) 3. 4+proteinuria (1+ seen in mild, 3+ seen in severe)

the nurse discusses skateboard safety with a group pf parents. which statement is most important for the nurse to include 1. carefully check the surface where your child will be skateboarding 2. instruct the child to keep as close to the curb as possible

1. carefully check the surface where your child will be skateboarding rationale: the parents t should check for hole, bumps, rocks, and debris that can cause accident not: 2. instruct the child to keep as close to the curb as possible (child should never ride in the street or close to the curb.

a client prescribed furosemide should have which meals 1. cereal with a banana and orange juice 2. baked potato topped with chili 3. winter quash lasagna.

1. cereal with a banana and orange juice 2. baked potato topped with chili 3. winter quash lasagna. * all of these are high in potassium

the nurse provides care to a client receiving packed RBCs to treat anemia. Which action does the nurse take? select all 1. checks client name and blood product with a second licensed nurse 2. administer 0.9% sodium chloride solution after the transfusion 3. ensures the transfusion completes within 5 hours 4. monitors for signs of transfusion reaction or fluid volume overload.

1. checks client name and blood product with a second licensed nurse 2. administer 0.9% sodium chloride solution after the transfusion 4. monitors for signs of transfusion reaction or fluid volume overload. not: 3. ensures the transfusion completes within 5 hours (blood products should be transfused within 2 to 4 hours)

the nurse assesses assigned clients. Which cleint does the nurse identify as being the greatest risk for accident and injury? 1. client with a stroke of the right hemisphere 2. client recovering from a right hip replacement.

1. client with a stroke of the right hemisphere rationale: the client is often disoriented to time place, and person. this cleint will also have visual spatial defects and proprioception difficulties. Additional changes include impulsive behavior, poor judgment, decreased attention span, lack of awareness, or denial of neurologic deficits. all of these potential changes increase this clients risk for injury. not: 2. client recovering from a right hip replacement. (the client with a right hip replacement needs to have the legs abducted to prevent hip displacement. he is not at risk for injury

a client diagnosed with a myocardial infarction is prescribed iv morphine sulfate. which reason will the nurse use when explaining the purpose of the medication to the client? 1. decreases blood return to the right side of the heart and decreases peripheral resistance. 2. increases blood return to the right side of the heart and increases peripheral resistance.

1. decreases blood return to the right side of the heart and decreases peripheral resistance. morphine sulfate decreases preload and afterload pressures and cardiac workload. it causes vasodialtion and pooling of fluid in extremities and provides relief from anxiety. not: 2. increases blood return to the right side of the heart and increases peripheral resistance.

the nurse manager is informed that a client developed a central line-assoiciated bloodstream infection (CLABSI). The nurse manager collaborates with the risk manager during an investigation of the incident. which should she include (SELECT ALL) 1. determine if lack of supplies was a contributing factor 2. review nursing documentation to the CLABSI 2. Determine the method by which nurses access central lines.

1. determine if lack of supplies was a contributing factor* 2. review nursing documentation to the CLABSI 2. Determine the method by which nurses access central lines.

the nurse caring for a patient with peritoneal dialysis notes that the outflow appears red tinged. which action does the nurse take first 1. determine if the client is menstruating 2. continue with the peritoneal dialysis

1. determine if the client is menstruating rationale: becuas eof hypertonicity of the dialysate, blood from uterus can be pulled through the fallopian tubes into the effluent. this is common in premenopausal female clients during menstruation. no intervention is required not: 2. continue with the peritoneal dialysis 9 the pt should be assessed

which statement by the parents indicate that the family is ready for toilet training 1. diapers are usually dry when waking up from a nap 2. i am looking forwardto taking the next 2 weeks off. 3. sitting still for 2 to 3 minutes is not a problem. 4. dressing and undressing are a favorite activity.

1. diapers are usually dry when waking up from a nap 2. i am looking forwardto taking the next 2 weeks off. 4. dressing and undressing are a favorite activity. not: 3. sitting still for 2 to 3 minutes is not a problem. (client should be able to sit for 5-10 minutes without getting off for toilet training to be sucessful.

a client with NG tube, has a weak non-productive cough and dusky lips. which actions by the nurse is best select all 1. dicontinue the tube feeding 2. contact the health care provider 3. suction the clients airway.

1. dicontinue the tube feeding* feeding should be stopped as assessment data indicate possible aspiration. 2. contact the health care provider 3. suction the clients airway. (to clear any possible obstruction)

a school age client with eye inflmmation tells the school nurse that the parents refuse to take the student to a health care provider for medical atttention. Which action will the nurse take first? 1. discuss the condition of the child's eyes with the parents. 2. cleanse the drainage from the child's eyes.

1. discuss the condition of the child's eyes with the parents. rationale: the nurse to collect objective data and not just base care upon the child's report. The parents should be contacted first to learn more about the situation, including the possible cause of the condition. not: 2. cleanse the drainage from the child's eyes.

the spouse of a combat veteran asks the nurse how to respond when the client yells and wants to be left alone. which response by the nurse to the clients spouse is best? 1. do what is asked. make the environment quiet and keep your distance until your spouse is less upset. 1. approach your spouse calmly and slowly, saying your name and current location.

1. do what is asked. make the environment quiet and keep your distance until your spouse is less upset. (the client is probably having PTSD flashbacks. when a combat vet has a flashback, the vet is psychologically in war zone, reliving a trauma as if it were occurring now, and may misidentify people as a threat. the clients spouse should be directed to maintain a safe distance and limit stimuli. NOT: 1. approach your spouse calmly and slowly, saying your name and current location. (A calm, slow approach is useful when a client is diagnosed with PTSD, but approaching the client and talking slowly and calmly should not be done during a flashback. )

the nurse admits a client to the surgical unit for a mastoidectomy due to chroninc otitis media. which questio should the nursr first ask the client? 1. do you have problems with vertigo 2. do you have any questions about the procedure?

1. do you have problems with vertigo. rationale: the nurse shoudl anticipate the client willl experience vertigo. this will ensure client safety not: 2. do you have any questions about the procedure? the nurse should reinforce information presented by the surgeon., but not before asking about vertigo.

a young adult with history of frequenst nosebleeds that require health care intervention should be asked which question to assess risk factors? 1. do you use nasal sprays for allergies? 2. do you take aspirin on a regular basis?

1. do you use nasal sprays for allergies? frequent use of nasal spray causes atrophy of nasal membranes. not: 2. do you take aspirin on a regular basis?

which action by the student nurse assessing a neonate in a nursery requires intervention by the nurse? 1. documenting a negative red light reflex in a neonate who is two days old. 2. testing the rooting reflex by stroking the corner of the neonates mouth.

1. documenting a negative red light reflex in a neonate who is two days old. rationale: a negative absent red light reflex indicated a severe neurological deficit, possibly caused by increased intracranial pressure. it must be evaluated immediately. the infant should have a red reflex when assessing the eyes for retinoblastoma. not: 2. testing the rooting reflex by stroking the corner of the neonates mouth.

the nurse provides care to a client with recurrent gout attacks. the most important teaching 1. drink atleast 2000-3000 ml of fluid every day 2, decrease your intake of milk, cheese, and yogurt

1. drink at least 2000-3000 ml of fluid every day rationale: this can increase urinary uric acid excretion. not: 2, decrease your intake of milk, cheese, and yogurt (foods high in calcium can provide moderate protein and are appropriate to client)

a client diagnosed with substance abuse says "im having trouble sitting still, Am I bothering anybody, Maybe I should not come to these meetings." which action by the nurse is appropriate? 1. encourage the client to share problems with the group. 2. recognize this as manipulative behavior and encourage the client to remain in the group.

1. encourage the client to share problems with the group. rationale: this client is probably exhibiting mild level of anxiety. The nurse should reinforce and encourage the client to share feeling and attend the meeting. not: 2. recognize this as manipulative behavior and encourage the client to remain in the group.

a client in a semi-private rm is visited by a hospital employee to discuss the clients inability to pay for services. the client reports to the nurse his right to privacy was violated, which action does the nurse take first 1. escort the client to a private setting 2. contact the business office so the client can talk with the employee

1. escort the client to a private setting rationale: this further prevents future violation of client privacy while the nurse addressess the concern. not: 2. contact the business office so the client can talk with the employee (the nurse should speak with client in a private setting, then follow the chain of command and contact the nursing supervisor.

the health care provider informs the client she is pregnant. the client voices concerns to the nurse that this pregnancy is not well timed. which action should the nurse take first? 1. explain that ambivalence is a normal finding at this time 2. ask the client if shoe would like to have counseling about her options.

1. explain that ambivalence is a normal finding at this time, rationale: women feel ambivalence whether they planned their baby or not, it is important for the nurse to first normalize the clients experience. not: 2. ask the client if shoe would like to have counseling about her options. ( the nurse should first normalize the clients experience, she can address options at a later time.

the nurse admits a young adult client suspected of having acute glomerunephritis to the unit. Which question does the nurse ask first? 1. have you had a sore throat within the last few weeks? 2. have you have a decreased appetite within the last few weeks?

1. have you had a sore throat within the last few weeks? rationale: an infections occurs before the onset of accute glomerunephritis. a sore throat cause by grou a beta hemolytic strep is common cause of glomerunephritis not: 2. have you have a decreased appetite within the last few weeks? although common with glomerunephritis, the nurse should first asses the presence of infection

the nurse provides care to a toddler with epiglottis. which observation indicates to the nurse that the client is experiencing an early complication of hypoxemia? 1. heart rate of 148 beats per minute 2. bluish discoloration of the skin

1. heart rate of 148 beats per minute rationale: the heart rate correlates with hypoxemia and is an early finding, along with restlessness. 2. bluish discoloration of the skin (cyanosis is a late sign of hypoxemia)

which helath problem increases the risk of a client developing a crippling knee and join deformity? 1. hemophilia 2. celiac disease

1. hemophilia rationale: the knee id the most frequent site of bleeding is into muscle and joints. repeated bleeding episodes cause changes in bone and muscles, which can lead to crippling knee and joint deformities. 2. celiac disease

a 45 year old client presents to the emergency dept. with acute mid abdominal pain and acute vomiting. The health care provider wants to rule out pancreatitis. Which question does the nurse ask based on the clients differential diagnosis? 1. how much alcohol do you drink per day 2. do you have a history of peptic ulcer disease?

1. how much alcohol do you drink per day rationale: the clients symptoms indicate acute episode of pancreatitis. pancreatitis is associated with males ages 40 to 45 with a history of heavy drinking and females ages 50 to 55 diagnosed with biliary disease. as this is a 45 year old male client, askign about alcohol intake will help confirm the diagnosis. not: 2. do you have a history of peptic ulcer disease? peptic ulcer disease is associated with abdominal pain, but is not associated with vomiting. this assessment is not relevant at this time

the nurse caring for a client about to go under a adrenalectomy to treat pheochromocytoma will first monitor the client for

1. hypertention rationale:pheochromocytoma is a tumor within the adrenal gland that causes hypertension which can result in stroke or MI

the nurse cares for an older adult client. which age related change causes the nurse to carefully monitor the clients fluid and electrolyte balance? 1. hyponatremia 2. increases plasma oncotic pressures

1. hyponatremia rationale: an increase in antidiuretic hormone and atrial natriuretic peptide, and a decrease in renin and aldosterone, lead to decreased sodium reabsorption and increased water retention by the kidneys, which can cause low sodium or hyponatremia. not 2. increases plasma oncotic pressures(lack of protein causes this)

the nurse caring for a client receiving ranitidine twice daily should assess the client further if he says select all 1. i am going to have allergy test tomorrow 2. i like to smoke a cigarette before bedtime 3. i take an occasional ibuprofen if my knees hurt 4. i will take all of the medication in the bottle 5. i drink a glass of red or white wine every night

1. i am going to have allergy test tomorrow* rationale: the med is a histamine blocker and can cause false negative results on allergy skin testing 2. i like to smoke a cigarette before bedtime 3. i take an occasional ibuprofen if my knees hurt 5. i drink a glass of red or white wine every night not:4. i will take all of the medication in the bottle (he should take all prescribed meds)

the nurse provides care for the client diagnosed with hemophilia. The nurse intervenes if the client makes which statement. 1. i drink 2 beers every day after work 2. i receive intramuscular injections weekly. 3. i play golf on the weekends with my cousin. 4. i take meloxicam daily for arthritis pain.

1. i drink 2 beers every day after work 2. i receive intramuscular injections weekly. 4. i take meloxicam daily for arthritis pain.* rationale:this durg interferes with platelet agregation, increasing the risk for bleeding in a pt diagnosed with hemophilia. not: 3. i play golf on the weekends with my cousin.

the nurse asses a client diagnosed with seizure, migrained, and type 1 diabetes, mellitus. which client statement requied follow up by the nurse? SELECT ALL 1. i see fireflied aroudn my head 2. i cant seem to wake up today 3. my hands wont stop shaking 4. i usually sleep after a seizure

1. i see fireflied aroudn my head 2. i cant seem to wake up today 3. my hands wont stop shaking NOT: 4. i usually sleep after a seizure (Postical confusion and sleepiness in common)

the nurse plans teaching for a client receiving quinapril. The nurse determines further teaching is needed when the client makes which statement 1. i should increase my instake of broccoli and bananas 2. i should check my blood pressure weekly 3. i should take the medication at the same time each day 4. i shoud use salt substitute to season meals 5. i shoudl change positions slowly when standing 6. i should ask before takin otv medication.

1. i should increase my instake of broccoli and bananas* rationale: ace inhibitors block the release of aldosterone, which promotes potassium retention. the client should avoid foods high in potassium, such as broccoli and bananas. 4. i should use salt substitute to season meals rationale: salt substitutes contain potassium so the should not be used. . not: 2. i should check my blood pressure weekly 3. i should take the medication at the same time each day 5. i shoudl change positions slowly when standing 6. i should ask before takin otv medication

the nurse cares for a client with magnesium level of 0.8. the nurse interevenes if the new nurse makes which statement 1. i should look for a short QT interval on the EKG 2. I should keep lorazepam (Ativan) on hand 3. i may have to administer calcium gluconate 4. taking magaldrate has contributed to the clients problem

1. i should look for a short QT interval on the EKG (low mag will causes short QT interval) 3. i may have to administer calcium gluconate (this would be used in hypermagnesium not low) 4. taking magaldrate has contributed to the clients problem (lagadrate an antacid caused hypermag not hypo not:2. I should keep lorazepam (Ativan) on hand the client is at risk for seizure so the pt should have a seizur med available

the nurse instructs a client about trimethoprim/sulfamethoxazole. the nurse needs to intervene if the client makes which statements? select all that apply 1. i should take the medication with food 2. this med is safe during pregnancy 3. i should notify my healtcare provider if i develop nausea or abdominal pain

1. i should take the medication with food 2. this med is safe during pregnancy not: 3. i should notify my healtcare provider if i develop nausea or abdominal pain (this statement does not require the nurse to intervene. the development of hepatitis is a risk with this drug. signs of hepatitis include nausea and abdominal pain.

teh nurse is teaching clients ways to prevent falls. which client statement indicate the teaching is effective? 1. i started taking tai chi classes. 2. i have a new pair of athletic shoes with deep treads. 3. i had my vision checked 4. my health care provider reviewed all of my meds 5. i bought some new lamps for my home

1. i started taking tai chi classes.* rationale: exercise is one of the most important ways to decrease the chance of falling. Tai chi improves balance and coordination 3. i had my vision checked 4. my health care provider reviewed all of my meds 5. i bought some new lamps for my home not: 2. i have a new pair of athletic shoes with deep treads. (shoes with thin, nonslip soles are the safest to prevent falls. the client should avoid slippers and athletic shoes with deep treads.

the nurse provides care to a client 4 weeks after a kidney transplant. Which client statement require immediate follow-up by the nurse? select all 1. i take an antacid after meals, which helps with my indigestion 2. i found that a little wine in teh evening helps me sleep better 3. my feet were so itchy until my adult child told me to start using lotion twice a day 4. i worry that my new kidney will quit working 5. i saw that my blood pressure was up a little. i think i get nervous when i come to the office

1. i take an antacid after meals, which helps with my indigestion* rationale: indigestion is a symptom of a peptic ulcer, common when corticosteroids are used for immunosuppression after an organ transplant. 2. i found that a little wine in the evening helps me sleep better rationale: alcohol in contraindicated as the drug is hepatoxic. 3. my feet were so itchy until my adult child told me to start using lotion twice a day* rationale itchyness or pruritic rash on the palms of the hands or soles of the feet often mean the start of gradt-versus-host disease. the clients itching should be followed up. 5. i saw that my blood pressure was up a little. i think i get nervous when i come to the office rationale: cardiovascular disease, including hypertension, is a common problem after transplantation and needs immediate follow up. not:4. i worry that my new kidney will quit working

the school nurse teaches a group of school age and adolescent client s about menstruation with toxic shock syndrome (TSS). Which participant statement indicates to the nurse a need for additional teaching? 1. i use only super absorbent tampons when i am menstruating 2. if i begin to vomit or have diarrhea during my period, I will contact my health care provider.

1. i use only super absorbent tampons when i am menstruating. it has been found that super absorbent tampons increase vaginal dryness and can predispose the vaginal walls to damage. this can lead to the introduction of bacterial leading to toxic shock syndrome not: 2. if i begin to vomit or have diarrhea during my period, I will contact my health care provider. (this is an appropriate action. A temperature greater than 102, vomiting and diarrhea are symptoms of toxic shock syndrome and are to be reported immediately.

which statement by a breastfeeding mom will cause the nurse to intervene. select all 1.i wash my nipples with soap between feedings 2. i use breast pads with plastic lining

1. i wash my nipples with soap between feedings* rationale: soap cuases drying and removes protective oils. apply breast milk to nipples after feeding becuase breast milk has more healing properties. 2. i use breast pads with plastic lining raionale: breast pads with plastic lining retain moisture and can increase the risk for yest infectionn.

a client newly diagnosed with menire diseased is counseled about important dietary modifications. Which comment by the client best indicates to the nurse that teaching is successful? 1. i will avoid Chinese restaurants and fast-food places when i go out to eat 2. i can have corned beef and smoked fish, but now pickles or creamed sauces.

1. i will avoid Chinese restaurants and fast-food places when i go out to eat rationale: clients with Meniere disease require a low0sodium diet to decrease fluid retention (endolymphatic fluid, which is clear fluid on the inner ear). Many Chinese restaurants use MSG and soy sauce, both of which are high in sodium. fast food places should also be avoided as they have high sodium. not: 2. i can have corned beef and smoked fish, but now pickles or creamed sauces.( meat and fish products that are canned, smoked, pickled, or cured should be avoided because they are high in sodium, as are pickles and, often creamed sauces.

the nurse isntructs a client who is prescribed clozapine. Which client statement indicates to the nurse that the teaching session was successful? 1. i willl contact the doctor for a sore throat or fever 2. i am taking clozapine because i have an anxiety disorder

1. i will contact the doctor for a sore throat or fever ratgionale: clozapine can suppresee the bone marrow and cause agranulocytosis. this potentially fatal side effect occurs in 1 to 2% of clients not: 2. i am taking clozapine because i have an anxiety disorder (used for schizophrenia not anxiety)

the nurse should further teach client with chronic kidney failure if he makes which dietary statements 1. i will eat more oragnes and otehr foods with vitamin c 2. i should incease dairy products in my diet .3. i can no longer drink my prune juice in the morning 4. i shoudl add protein powder to my fruit smoothies

1. i will eat more oragnes and otehr foods with vitamin c* rationale: citrus foods should be voided as kidneys cannot excrete excess potassium 2. i should increase dairy products in my diet 4. i shoudl add protein powder to my fruit smoothies* not:.3. i can no longer drink my prune juice in the morning (dried fruits are high in potassium, the pt is right to say he will avoid it)

the nurse prepares a client diagnosed with cervical cancer for the insertion of an internal radiation implant. Which client statement requires immediate follow-up by the nurse? 1. i will get up only when i have to urinate, and then i will go right back to bed. 2. if it were not for my children, i would not be going through all of this.

1. i will get up only when i have to urinate, and then i will go right back to bed. rationale: the client will be on strict bed rest, supine with the head of the bed elevated no more than 20 degrees. movement is restricted and an indwelling catheter is inserted into the bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts. Severe radiation burns can result from a distended bladder or from the client attempting to go to the bathroom and void. not: 2. if it were not for my children, i would not be going through all of this. (although it requires further probing by the nurse to evaluate the client for depression, priority is risk of physical harm to the client.

the nurse instructs a client on how to collect a 24 hour urine specimen for a creatinine clearance test. which statement by the clietn would cause the nurse to intervene? 1. i will go to the lab after i work out in the gym 2. i will drink at least 1 cup of water hourly.

1. i will go to the lab after i work out in the gym rationale: creatinine is a waste product of muscle breakdown. a client should not engage in strenous exercise during or just before test. not: 2. i will drink at least 1 cup of water hourly. (this is approrpriate to make urine for test

a client diagnosed with glaucoma is correct to make which statement 1. i will schedule appointments with my physician in the morning 2. im glad the surgery will reverse damage caused by glaucoma.

1. i will schedule appointments with my physician in the morning rationale: intraocular pressure tends to be higher in the morning. an early morning assessment will be more accurate not: 2. im glad the surgery will reverse damage caused by glaucoma. (damage resulting in increased pressure is not corrected by surgery)

the nurse teaches a class on birth control options to a group of clients. which client statement indicated to the nurse that teaching was effective? select all 1. if i take an oral contraceptive, i may need to use additional measure to prevent pregnancy if i take the antibiotic rifampin. 2. if i use a diaphragm with a spermicidal gel, i need to inset the diaphragm 1 hour before i have sexual intercourse 3. the copper in my intrauterine device decreases the likelihood that sperm and ovum will unite. 5. the sponge prevents sperm from entering the uterus and releases a spermicide.

1. if i take an oral contraceptive, i may need to use additional measure to prevent pregnancy if i take the antibiotic rifampin. 3. the copper in my intrauterine device decreases the likelihood that sperm and ovum will unite. 5. the sponge prevents sperm from entering the uterus and releases a spermicide. not: 2. if i use a diaphragm with a spermicidal gel, i need to inset the diaphragm 1 hour before i have sexual intercourse (needs to be inserted up to 2 hours before having sex)

the home care nurse visits a client diagnosed with cardiomyopathy. the client asks the nurse, how do i know if i am overdoing it? the nurse best response is 1. if you feel fatigued, you have done too much 2. coughin uo more sputum is a good indication

1. if you feel fatigued, you have done too much rationale: fatigue is a useful guide in activity intolerance with decreased cardiac output not: 2. coughing up more sputum is a good indication

a 4 year old child will need which immunizations select all 1. inactivated polio IPV 2. Measles, mumps, rubella 3. rotavirus, 4. HIb, 5. Pneumococcal conjugate

1. inactivated polio IPV 2. Measles, mumps, rubella not: rotavirus, HIb, Pneumococcal conjugate

A client admitted to the ed after a motor vehicle accident. This client reports seeing sudden black dots and flashes of light and states that it feels as if a curtain is being closed over the right eye. Which action does the nurse take based on this data? select all 1. instruct the client not to get out of bed 2. have the cilent lie on the right side 3. prevent the client from eating or drinking.

1. instruct the client not to get out of bed 2. have the cilent lie on the right side* rationale: this prevents further detachment of the retina. 3. prevent the client from eating or drinking. rationale: clients with retinal detachment report light flashes, floaters, and a "cobweb", "hairnet", or ring in the field of vision.

the nurse prepares to administer hydroxyzine to a client. For which reason does the nurse use the z-track method when administering this medication? 1. is the safest and least painful way to give the injection 2. reduced irritation to the subq and skint tissues.

1. is the safest and least painful way to give the injection 2. reduced irritation to the subq and skint tissues.

the nurse reviews information about gabapentin before providing the medication to a client. Which information will the nurse include about this medication select all 1. is used for neuropathic pain 2. may cause drowsiness 3. may be used as an anti-seizure med 4. is prescribed for protherpetic neuralgia

1. is used for neuropathic pain 2. may cause drowsiness 3. may be used as an anti-seizure med* 4. is prescribed for prosthetic neuralgia

the nurse cares for a client with Gullain Barre syndrome. which statement by the family shows the nurse they understand the diagnosis select all 1. iv immunoglobulins are often used for treatment 2. the cause of the syndrome may be a virus my loved one's ability to walk will be affected 3. a feeding tube may be required for treatment

1. iv immunoglobulins are often used for treatment 2. the cause of the syndrome may be a virus my loved one's ability to walk will be affected* 3. a feeding tube may be required for treatment (they may not be able to swallow)

a client who fell off the roof of a house is examined by the nurse who determines he needs to open the airway. which procedure sohuld the nurse use to open the airway. 1. jaw thrust 2. head tilt, child lift

1. jaw thrust rationale: if a cervical spine injury is suspected, this maneuver can open the airway without further injury 2. head tilt, child lift (this produce hyperextension of the neck and could cause complication if a cervical spine injury is present

the hospital nurse educator plans an inservice for staff on the topic of working with interpreters. which statement is appropriate for the nurse to include 1. keep your question short and simple in structure and wording 2. focus primarily on the client's body language and tone of voice

1. keep your question short and simple in structure and wording rationale: make is easy for interpreter and client to understand and answer not: 2. focus primarily on the client's body language and tone of voice (the nurse shoudl focus on words as they are translate to the nurse so the nurse can formulate a new question. while the nurse should note the body language she should also know these vary accross cultures.

a client with pneumonia has a temp of 101.2, pulse of 112 beats/min, respirations of 22 breaths/min, and BP of 90/50. For which findings will the nurse notify the health care provider? select all 1. lactic acid level 5.0 2. WBC of 15,000 3. BP of 90/50 4. Apical heart rate of 112 bpm 5. oral temp of 101.9

1. lactic acid level 5.0 (normal is 0.5-2.2 2. WBC of 15,000 3. BP of 90/50 4. Apical heart rate of 112 bpm 5. oral temp of 101.9 rationale: an elevated lactic acids level and low bp indicate severe sepsis.

the spouse of a client diagnosed with multiple myeloma asks the hospice nurse for pain control suggestions since the prescribed medication makes the client sleepy. which responses by the nurse are appropriate. select all 1. let me show you some techniques of massage, which may help relieve the pain 2. please locate some of your spouse's favorite music and see if listening to it helps with relaxation. 3. i will contact the health care provider about changing the pain medication.

1. let me show you some techniques of massage, which may help relieve the pain 2. please locate some of your spouse's favorite music and see if listening to it helps with relaxation. not: 3. i will contact the health care provider about changing the pain medication. (the client needs to be assessed further before contacting the health care provider for a change in pain medication.

A client diagnosed with Crohn diseases has acute pain. Which action will the nurse teach to avoid discomfort? 1. lying supine with legs straight 2. Massaging the abdomen

1. lying supine with legs straight rationale: this position increases muscle tension in the abdomen, which aggravates inflamed intestinal tissue as the abdominal muscles are stretched. not: 2. Massaging the abdomen (massaging helps alleviate the discomfort associated with Crohn disease.

the nurse plans care for a client receiving peritoneal dialysis. which intervention is most important for the nurse to include in the plan of care? 1. maintain strict aseptic technique 2. monitor the client's level of consciousness.

1. maintain strict aseptic technique rationale: a major complication of the procedure, the most common and serious is peritonitis. Therefore, precise aseptic technique is required not: 2. monitor the client's level of consciousness.(does not have a high risk of altering cardiac output. Hemodialysis requires close monitoring of LOC)

when performing a triage, which client will the nurse see first? 1. multipara cleint at four weeks gestation reporting unilateral, dull adbominal pain 2. multigravida client at six weeks gestation reporting frank red vaginal bleeding with moderate cramps.

1. multipara cleint at four weeks gestation reporting unilateral, dull adbominal pain rationale: this client had signs of ectopic pregnancy and needs to evaluated immediately not: 2. multigravida client at six weeks gestation reporting frank red vaginal bleeding with moderate cramps. (vaginal bleeding early in pregnancy indicate signs of spontaneous abortion and should be instructed to save and count the pads).

which client statement requires follow up by the nurse? 1. my brother was just diagnosed with prostate cancer 2. lately, I just dont have as much desire to engage in sex.

1. my brother was just diagnosed with prostate cancer rationale: A middle aged male with a father or brother with this cancer increase the client's risk by 50%. Additional assessment is required. not: 2. lately, I just dont have as much desire to engage in sex. (shoudl be investigated for underlying causes but is not priority.

the home health nurse visits a cleint with diabetes and osteoporosis. the client lives with an adult child in a two-story home. which statement by the child most concernes the nurse? 1. my parent loves taking a hot bath with a scented bath oil 2. i am not sure what we are going to do once winter comes

1. my parent loves taking a hot bath with a scented bath oil rationale: hot bath and oils are saftey risk, due to slippery showers, hot bath can dry or damage the skin. not: 2. i am not sure what we are going to do once winter comes

A client receiving 50 mL/hr of continuous bladder irrigation fluid has a total output of 500 mL over 8 hours. Which action does the nurse take? . Notify the health care provider. 3. Manually irrigate the catheter for clots.

1. notify provider rationale:The client received 400 mL of bladder irrigation fluid over 8 hours with an output of 500 mL. The urine output for this time frame is 100 mL (12.5 mL/hr). Normal urine output is at least 30 mL/hr; therefore, the nurse notifies the health care provider.

a client is brought in by a family member, he reports a sudden onset f decreased LOC, blurred vision, headache, and slurred speech. which action does the nurse take 1. obtain a finger-stick glucose level 2. obtain a urine specimen from the client

1. obtain a finger-stick glucose level rationale: assessment of other underlying causes that can be quickly and easily corrected should be ruled out first. these include hypoglycemia, which may present with similar symptoms. the client symptoms are suggestive of a TIA or CVA. not: 2. obtain a urine specimen from the client

the nurse provides care for an older client 12 hours after a right total hip replacement. the client apprears disoriented to person, place, and time. Which action does the nurse perform first? 1. place an abductor pillow between the client's legs. 2. frequently orient the client to person, place, and time.

1. place an abductor pillow between the client's legs. rationale: the client who is confused may not follow disrections. abduction prevents dislocation of the hip while turning and is the priority intervention. Assess for pain, rotation, adn/or extremity shortening. not: 2. frequently orient the client to person, place, and time. (although appropriate, preventing dislocation of the replaced joint is the priority.)

due to a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the rive. which action should the nurse take next? 1. place an identification bracelet on each child. 2. notify the parents of the children's location

1. place an identification bracelet on each child. rationale: priority as it aids in communicaiton after rescue or recovery. This addresses a pertinent physical need not: 2. notify the parents of the children's location (psycho social need, not as important)

the nurse provides care for a client diagnosed with full thickness burns. in planning the debridement of the burn, the nurse gives priority to which actions 1. plan a time to perform the dressing change 2. prepare the client mentally for the procedural pain

1. plan a time to perform the dressing change rationale: this allows for client to be mentally prepared and for nurse to administer analgesic 30 minutes prior to wound care not: 2. prepare the client mentally for the procedural pain (not adequate, the nurse should plan time to offer pain meds before care

the AP ambulates a client ot the bathroom. The nurse overhears the AP ask a family meber to stand with the client while the AP cares for another client. Which reponse by the nurse to the AP is best? 1. please stay with the client and call me is the client becomes dizzy. 2. did the client ask you to leave?

1. please stay with the client and call me is the client becomes dizzy. rationale: the priority is for the nurse to instruct the AP to stay with the client. After the client is back in bed, the nurse can review safety expectaitons with the AP not: 2. did the client ask you to leave? the priority is client safety. the nurse needs to instruct the AP to stay with the client. After the client is saf,e the nurse can further explore why the AP asked a family member to stay with the client.

The office nurse meets with a high school graduate who will be starting at a residential college in the fall. It is most important for the nurse to address which immunizaitons. 1. pneumococcal 2. meningitis

1. pneumococcal meningitis rationale: vaccine is recommended for college freshmen, especially if the student will be living on campus in residence halls or dormitories. not: 2. pneumococcal vaccine is recommended primarily for older adults.

newborn with myelomeningocele should be placed in what position? 1. prone with the face turned to one side 2. left-side lying with a pillow behind the back

1. prone with the face turned to one side rationale: the prone position prevents pressure on the sac-like postrusion on the back. placing pressure on this area would result in increased pressure or it may rupture the sac, leading to an infection. the area should be covered with a moist sterile dressing. not: 2. left-side lying with a pillow behind the back (this places pressure on the sac-like protrusion on the back.

pt admitted 24 hours after an ischemic stroke has bp of 222/128, a radia pulse of 92 bpm, a respiration of 22 breaths/min, a temp of 98.9 and an oxygen of 96%. which actions are appropirate for the nurse to implement in this situation? select all 1. provide supplemental oxygen of 2l/min by nasal cannula 2. contact the health care provider 3. administer iv labetalol as prescribed 4. increase the iv flow rate to 100 ml/hr

1. provide supplemental oxygen of 2l/min by nasal cannula* rationale may increase the oxygent reaching damaged brain tissue. providing o2 is done for client with a CVA regardless of o2 saturation or respiratory symptoms 2. contact the health care provider rationale: he needs to be informed of the hypertension crisis 3. administer iv labetalol as prescribed (used for hypertensive crisis) not: 4. increase the iv flow rate to 100 ml/hr (potentiall unsafe as it can inceased blood volume.

the nurse supervises care of client at the local eye care center. the nurse determines that care of client immediately after intracaspular cataract extraction is appropriate if the unlicensed assistive personeel perform which action first? 1. raises the head of the clients bed 35 degrees 2. tapes the eye shield securely with paper tape.

1. raises the head of the clients bed 35 degrees rationale: raising the head of the bed 35 degrees prevents an increase in intraocular pressure, which is a major complication follwing the procedure. not: 2. tapes the eye shield securely with paper tape. (this is not withing the Ap's scope of practice)

The nurse provides care for clients in the pediactric clinic. The nurse performs as assessment of a toddler-age client. The nurse recognizes appropriate congnitive development when the client exhibits which behavior? 1. removes wet diaper and discards it. 2. Builds block castle with playmate.

1. removes wet diaper and discards it. rationale: toddlers are focused on autonomy not: 2. Builds block castle with playmate. does not occur until preschool

The intensive care nurse is caring for a client requiring mechanical ventilation. Which of the following are interventions the nurse should take to help prevent ventilator-associated pneumonia (VAP)? 1. reposition the client at least every 2 hours using lateral and horizontal positioning techniques. The head of the bed should be raised 30-45 degrees unless contraindicated. 2. use a nasogastric tube and high-calorie feedings 3. suction oral and pharyngeal secreitions and provide oral care at least every 2 hours. 4. Assess the client for sedation reductions and provide oral care at least every 2 hours 5. Perorm hand hygiene before and after care of the client and implement prophylactic intravenous antibiotic therapy

1. reposition the client at least every 2 hours using lateral and horizontal positioning techniques. The head of the bed should be raised 30-45 degrees unless contraindicated. 3. CORRECT: Oral care should be done at least every 2 hours. The removal of excess secretions is also an important element in the reduction of VAP. These secretions can cause aspiration, and can also be a perfect moist breeding ground for infection. 4. CORRECT: A reduction in the duration of mechanical ventilation and/or a reduction in sedation to assess readiness of weaning have been shown to decrease the development and incidence of VAP. No alteration in medication or weaning/extubation should be attempted without an order from the physician. The nurse can be proactive and encourage the progression of weaning through assessment and subsequent discussions with the physician. NOT: 2: A nasogastric tube can lead to sinusitis, which increases the likelihood of the client developing VAP. The use of an orogastric tube to aid in feeding and/or gastric decompression is recommended over the use of a nasogastric tube. 5. Although proper hand hygiene and the use of gloves have been shown to reduce the risk of VAP, prophylactic intravenous antibiotic therapy is not recommended. A broad-spectrum antibacterial oral rinse (chlorhexidine) has been used in conjunction with thorough oral care with good results.

a client with a previous history of transfusion related acute lung injury (TRALI) required another transfusion of red blood cells. which intervention will the nurse use to prevent the recurrence of TRALI 1. request for leukocyte-reduced red blood cells 2. give supplemental o2 during the tranfusion

1. request for leukocyte-reduced red blood cells ratioanle: the reaction to anti-lukocyte antibodies between donor and receipient leads to TRALI. Leukocyt reduced the risks not: 2. give supplemental o2 during the tranfusion does not prevent TRALI, not routinely used in a RBC transfusion

expected findings in client with Guillain-Barre syndrome 1. respiratory failure, flaccid paralysis, urinary retention 2. Diminished reflexes, pain, parasthesia

1. respiratory failure, flaccid paralysis, urinary retention rationale: the classic symptoms of Guillaun-Barre syndrome include respiratory failure caused by paralysys of the respiratory muscles, faccidity of the extremities due to paralysis of the muscles, and urinary retention due to loss of sensation. not:2. Diminished reflexes, pain, parasthesia (signs of peripheral nerve health problem)

the nurse provides care for a client diagnosed with a 3rd degree circumferential leg burn. The client is scheduled for an escharotomy. Which outcome does the nurse anticipate for the client? 1. return of distal pulses 2. formation of granulation tissue.

1. return of distal pulses rationale: the procedure is performed to alleviate the compartment syndrome that occurs when edema forms under nondistensible eschar in this type of burn circumferential leg burn. means the burn encircles the entire diameter of the limb, creating a tight leather like texture in 3rd degree burns, constricting blood vessels, and hindering blood flow. an escharotomy cuts thorugh this tough layer of the skin, releases the tissue, and permits the return of adequate blood flow which will be shows as improved peripheral pulse. not: 2. formation of granulation tissue. thi sis not the intent of this procedure

The nurse provides care for a client in the final stage of chronic kidney disease. The client's serum calcium level is 7.5 mg/dL (1.8 mmol/L) and the phosphate level is 6.0 mg/dL (1.9 mmol/L). Which priority nursing diagnosis does the nurse use to plan care for this client? 1. Activity intolerance. 2. Risk for injury

1. risk for injury raitonale: This client is experiencing both hypocalcemia and hyperphosphatemia. Normal range for serum calcium is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L), while the normal range for phosphate is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client in the final stage of chronic kidney disease is at risk for osteodystrophy due to bone mineral loss leading to an increased risk for fractures or osteoporosis. Due to this condition, the client is at risk for serious injuries during a fall.

client required to be on high protein, low sodium, low potassium diet. nurse should question which selections 1. roastbeef sadnwich, coleslwa, and baked beans 2. broiled chicken breast, spinach salad, and green beans 3. poached salmon fillet, broiled cabbage, and lemonade. 4. grilled chicken caesar salad and whole grain roll with iced tea.

1. roastbeef sadnwich, coleslwa, and baked beans (high protein but rest is high sodium) 2. broiled chicken breast, spinach salad, and green beans (high protein but spinach is high in potassium) 3. poached salmon fillet, broiled cabbage, and lemonade. (salmon is high in potassium) 4. grilled chicken caesar salad and whole grain roll with iced tea. (caesar salad is high in sodium and potassium)

the nurse teaches a new parent about childhood immunization for a 2 month old client. which immunization does the nurse include in this teaching. select all 1. rotavirus 2. diptheria, tetanus, pertussis. 3. haemophilus influenza type b. 4. inactivated poliovirus. 6. measles mumps rubella

1. rotavirus 2. diptheria, tetanus, pertussis. 3. haemophilus influenza type b. 4. inactivated poliovirus. not: 6. measles mumps rubella (done are 12 to 14 months and 4 to 6 years)

the nurse will implement which to insert an indwelling urinary catheter into a male client.

1. select an 18 french size cath 2. hold penis perpendicular to body* (this straightens the uretrhra for catheter insertion). 3. use sterile technique on insertion not retract and maintain the retraction of the fore skin: it should be replaced to prevent paraphimosis

a client with heart failure is prescribed IV chlorothiazid.e the nurse would question this order if she saw which lab values SELECT ALL: 1. serum sodium=128 mEQ 2. serum calcium=12 mg/dL 3. serum potassium =5.3 mEq 4. Serum pH=7.48

1. serum sodium=128 mEQ 2. serum calcium=12 mg/dL rationale: thiazide promote increased calcium, this calcium level is already high 4. Serum pH=7.48* rationale: loop diuretcs produce metabolic alkalosis because of urinary loss of hydrogen. NOT: 3. serum potassium =5.3 mEq (Thiazides promotes potassium loss, the pt would need this order

the nurse manager on the unit is fiscally responsible for meeting goals related to personnel and supply expenses. To meet budget expectations, it is important for the nurse manager to take which action? 1. share budget expectations with the personnel on the unit. 2. ensure that provider needs are met.

1. share budget expectations with the personnel on the unit. rationale: sharing the budget and monitoring activities with staff allows the staff to develop cost-conscious nursing practices. not: 2. ensure that provider needs are met. (when making budget decisions, make sure that client needs are being met. client needs are the priority over provider needs.

the client on a PCS pump with demand dosing of morphine has his vital signs taken by the nurse. He is startled and awakes saying "whoops, i keep forgetting to push this" and pushes the PCA pump button. Which response by the nurse is best? 1. show me on this pain chart the level of pain you are feeling 2. surgery and medication temporarily affect memory.

1. show me on this pain chart the level of pain you are feeling rationale: assessment of pain is needed to clarify the apparent discrepancy between patients ahving appeared comfortable and suddenly "remembering" pain. the patients response to nurse's question may lead to needed teaching. not: 2. surgery and medication temporarily affect memory. (although true this does not address the pts dangerous misunderstanding of how to use the pump.)

the nurse provides teaching to the parents of a newborn. Which parent statement is wrong. select all 1. since our baby seem to prefer formula to breastmilk, I will stop breastfeeding. 2. we will feed our baby formula until my breast milk comes in. 3. we will not give our baby a pacifier, due to an increased risk of SIDS 4. I will not worry is our baby's bowel movements are sticky and black at first.

1. since our baby seems to prefer formula to breastmilk, I will stop breastfeeding.* rationale: the nurse should recommend that the parents not offer formula is breastfeeding. The newborn may become confused and refuse breast milk. 2. we will feed our baby formula until my breast milk comes in. 3. we will not give our baby a pacifier, due to an increased risk of SIDS not: 4. I will not worry is our baby's bowel movements are sticky and black at first. (this is a correct statement describing meconium stools.)

the nurse is planning to discharge a client diagnosed with cancer and lymphedema. Which client statements alert the nurse to a need for home health services? select all. 1. sometime i dont get to the bathroom on time 2. my hands always shake when i try to pick things up 3. my denture dont fit so i dont wear them, ibut i eat just fine. 4. i cant feel a thing in my feet. Its been that way fro a while 5. im not able to get in the bathtub anymore

1. sometime i dont get to the bathroom on time* rationale: client should be assessed for durable medical equipment that might assist in using the bathroom. if incontinence is a problem, the client may need assistance with personal care. 2. my hands always shake when i try to pick things up* rationale: this client may need assistance preparing meals, managin medication administration 3. my denture dont fit so i dont wear them, ibut i eat just fine. rationale: sign that client has lost significant weight, and dietary refferal will ensure client has the home resources needed to eat a balanced diet. 4. i cant feel a thing in my feet. Its been that way fro a while not: 5. im not able to get in the bathtub anymore

the nurse staff an education booth during a community health fair. Which information does the nurse provide to the parents of an older school-age client as priority. 1. sports safety 2. water safety

1. sports safety rationale: bicycle and sports related injuries, along with proper nutrition, are the greatest concerns in school age clients. not: 2. water safety (more appropriate for toddlers and preschool age)

order in which to do a breast exam

1. stand in front of mirror and look for changes in breast and nipples. 2. standing in front of the mirror examine breast with arms raised above their heads. 3. lie down, placed pillow under their shoulders along with thier hands behind their heads. 4. used pads on middle 3 fingers to palpate the breast in circular motion.

the nurse assist a physicial while performing a thoracentesis in the client's room, which would be a sign of complication (Select all) 1. sudden dyspnea 2. decreased work of breathing 3. asymmetric chest excursion 4. acute abdominal pain 5. tachypnea

1. sudden dyspnea (sign of pneumothorax a potential complication) 3. asymmetric chest excursion (sign of pneumothorax a potential complication) 5. tachypnea* (sign of pneumothorax a potential complication) not: 2. decreased work of breathing (expected therapeutic result, if the client does not have to breathe as hard once both lungs can expand corrently) 4. acute abdominal pain (potential complication after paracentesis not thoracentesis.

the nurse provides care for the client diagnosed with rheumatoid arthritis (RA) which physical activities does the nurse recommend to the client? select all 1. swimming 2. tap dancing 3. yoga 4. jumping rope

1. swimming 3. yoga not: 2. tap dancing 4. jumping rope (high impact activitys should be avoided)

client who developed acute respiratroy distress dyndrome (ARDS) after a motor vehicle carash is being weaned from the ventilator. which ventilator mode will the nurse utilize to wean the client? 1. synchronized intermittent mandatory ventilation(SIMV) 2. positive end expiratory pressure (PEEP)

1. synchronized intermittent mandatory ventilation(SIMV) RATIONALE: the ventilator mode allows for spontaneous breaths at the client's owen rate and tidal volume between ventilator breaths this mode facilitates weaning NOT: 2. positive end expiratory pressure (PEEP)

the nurse assess ac lient who had a thyroidectomy eight hours ago. The nurse notes that the client has a weak voice and hoarseness. Which is the best action from the nurse? 1. tell the client this is likely due to edema 2. monitor the client for esophageal bleeding

1. tell the client this is likely due to edema rationale: initial hoarnesess occurs as a result of emeda or use of an endotracheal tube during surgery and will subside. persistent hoarseness may be due to laryngeal nerve injury. not: 2. monitor the client for esophageal bleeding. this ins unnecessary becasue the findings are unrelated to bleeding.

which statement requires further assessment from the nurse. select all 1. the baby's just so quiet and sleeps almost through the night 2. i sleep when the baby sleeps, and i cant get anything done. 3. im afraid of hurting my baby, and i cant keep my baby happy.

1. the baby's just so quiet and sleeps almost through the night rationale: lethargy is a sign of potential neonatal hyperbilirubenemia 3. im afraid of hurting my baby, and i cant keep my baby happy. rationale: feelings of anxiety and despair may indicate postpartum depression. not: i sleep when the baby sleeps, and i cant get anything done. (these are normal feelings for new parent, nurse should offer encouragement, and support

the nurse instructs a client with right sided-weakness how to use a cane. which client behavior indicates to the nurse that teaching is successful? 1. the client holds the can in the left hand, moves the cane forward followed by the right leg, and then the left leg. 2. the client holds the can in the left hand, moves the cane forward followed by the left leg, and then the right leg.

1. the client holds the can in the left hand, moves the cane forward followed by the right leg, and then the left leg. raitonale: this supports weight bearing on the weaker right leg. not: 2. the client holds the can in the left hand, moves the cane forward followed by the left leg, and then the right leg.

the nurse performs an assessmnet of a 9 month old, she expects which select all 1. the client sits unsupported 2. the client pulls self to a standing position 3. the client attempts to build a 2 block tower, 4. the client responds to simple verbal commands

1. the client sits unsupported 2. the client pulls self to a standing position 4. the client responds to simple verbal commands not: 3. the client attempts to build a 2 block tower, expected at 12 months, at 9 months they can compare 2 cubes.

which client are appropriate for the charge nurse to assign to the LPN on the unit. select all 1. the client with a colostomy whose appliance is leaking. 2. the client with a seizure history who is receiving gabapentin 3. the client who needs elastic comrpession stockings applie 4. the cleint with moderate low back pain who is restless 5. the cleint with diabetes mellitus who is due a dose of insulin

1. the client with a colostomy whose appliance is leaking. 2. the client with a seizure history who is receiving gabapentin 3. the client who needs elastic compression stockings applied 5. the client with diabetes mellitus who is due a dose of insulin not: 4. the client with moderate low back pain who is restless. (this clients pain is not controlled and requires assessment by the nurse.

the nurse performs a physical assessment on an adult client. Which findings does the nurse expect for this client? 1. the clients height has decreased by 1 inch 2. the client can perform full range of motion. 3. the client has diminished muscle tone 4. the client has join stiffness.

1. the clients height has decreased by 1 inch 3. the client has diminished muscle tone 4. the client has join stiffness. not: 2. the client can perform full range of motion. (an older client has diminished range of motion due to progressive deterioration of cartilage.)

the nure provides care fo an older client with bilateral cataracts. the client repeatedly asks the nruse "why did this happen to me? which statement by the nurse is the best response? 1. the lenses of the eyes gradually lose moisture and increase in density as you age 2. the retina becomes detached from the inner part of the eye

1. the lenses of the eyes gradually lose moisture and increase in density as you age rationale: cataract are partial or total opcaity of the normally transparent lens. this occurs because they become less hydrated and more denser. not: 2. the retina becomes detached from the inner part of the eye. (Cataracts is not a detached retina)

a nurse is preparing a client for a fecal occult guaiac test which should be used. select all 1. the nurse ask about taking vitamin C in the past several days 2. the nurse asses for a blue color change 3. the nurse collect a sample from two different areas of the stool specime.

1. the nurse ask about taking vitamin C in the past several days (taking vitamin c is contraindicated for 3 days prior to taking the specimen) 2. the nurse asses for a blue color change (positive result) 3. the nurse collect a sample from two different areas of the stool specimen.

the nurse plans care for a client with dementia. which should she include 1. use simple, short phrases when speaking with the client 2. Plan a regular exercise program

1. use simple, short phrases when speaking with the client rationale can enhance a clients ability to process information given. not: 2. Plan a regular exercise program (helpful to decrease anxiety, but not for dementia clients)

the nurse provides care for a client receiving albuterol (tow puffs) and beclomethasone (two puffs) through inhalers. which instruction does the nurse include when counseling the client 1. use the albuterol inhaler and then us the beclomethasone inhaler 2. use the beclomethasone inhaler and then use the albuterol inhaler

1. use the albuterol inhaler and then us the beclomethasone inhaler rationale: albuterol is a bronchodilater that opens tghe passageways so the steroid medicatio, beclomethatsone, can get into the bronchioles not: 2. use the beclomethasone inhaler and then use the albuterol inhaler (steroids will not be able to penetrate unless the bronchioles are opened by the bronchodilator first.

a client scheduled for a CT scan says to the nurse. "The health care provider had me sign that form the scan. I thought i understood what was said, but now Im not so sure." which is the best response by the nurse? 1. what is it that you are not sure you understand 2. ill contact the health care provider so that you can get your questions answered.

1. what is it that you are not sure you understand rationale: this addresses the clients concerns so they can be addressed. the nurse can clarify questions after the HCP has explained benefits and risks of the procedure to the client not: 2. ill contact the health care provider so that you can get your questions answered. ( the nurse should idenitify the clients concerns and try to address them)

steps for z track im injection

1. with draw the needle 2. administer the drugs IM in the dorsalgluteal 3. Release the skin 4. Displace the skin lateral to the injection site

a client prescribed to receive a dose of nifedipine has a pulse rate of 50 beats per minute. Which action is the most appropriate for the nurse to take? 1. withold the medication 2. administer the medication.

1. withold the medication rationale: nifedipine is calcium channel blocker used as an antihypertensive. Bradycardia is an untoward effect of this medication. The nurse should withold the medication and notify the healthcare provider of the client's pulse rate. not: 2. administer the medication.(the medication could cause the heart rate to be eve slower and would be dangerous.)

a full-term newborn is transferred to the nursery. which observation concerns the nurse the most? 1. yellow coloration over the bridge of the nose when blanches 2. irregular area of blue-gray pigmentation over the sacrum

1. yellow coloration over the bridge of the nose when blanches rationale: jaundice apprears first on the head and progresses cephalocaudal (from head to toe). jaundic during the first 24 hrous indicates hemolyptic diease of the newborn not: 2. irregular area of blue-gray pigmentation over the sacrum. (mongolian spots spots can be found on any part of the body.

a client crying hysterically, calls the nurse at the prenatal clinic. she reports that shes a few days late for her period, has a positive pregnancy test, and just noticed a scant amount of blood on the tissue when she voided. she is afraid she is having a miscarriage. how should the nurse response? 1. you seem really upset, take some slow deep breaths 2. bleeding from implantation is expected at this time

1. you seem really upset, take some slow deep breaths rationale: the response reflects the clients feelings. it also gives the client the opportunity to verbalize concersn and thoughts. not: 2. bleeding from implantation is expected at this time.(the nruse should talk in terms that the client understands due to her current emotional state, this is not the most appropirate response.

The nurse observes the AP prodividing care for a client with shingles. which action by the UAPrequires the Nurse to intervene 1.ambulating the client to the nurses station 2. Donning gown and gloves prior to entering the client room 3. Refusing to answer the classroom due to a personal positive titer 4. Performing hand hygiene upon entering the clients room 5. Using the unit equipment to monitor the clients vital signs

1.ambulating the client to the nurses station * Rationale: the client requires to be in isolation with a private room to reduce the risk of infection or other for me not be immune 3. Refusing to answer the classroom due to a personal positive titer* 4. Performing hand hygiene upon entering the clients room* Rationale: The UAP is the new towbar with Varicella chicken pox based on the positive titer 5. Using the unit equipment to monitor the clients vital signs Not: 2. Donning gown and gloves prior to entering the client room (this would be an appropriate action for contact precautions in shingles)

the nurse teaches the client about a new medicatio for hypertension. which client statement indicates that further teaching is needed select all. 1.i should not take acetaminophen with this medication 2. i do not need to stop smoking now that i have this medication

1.i should not take acetaminophen with this medication* rationale: there are no interactions noted between acetaminophen and antihypertensives 2. i do not need to stop smoking now that i have this medication

a client sustained a crush injury to the trachea in a motor vehicle crach (MVC). in the ED the pt had a cuffed tracheostomy inserted. several hours after admission, the nurse enters the clients room and finds the client in respiratory distress. which action does the nurse take first? 1.listen to the clients breath sounds 2. check the client for retractions

1.listen to the clients breath sounds rationale: changes in breathsounds will help the nurse identify what is causing the respiratory distress. not: 2. check the client for retractions: (this assessment is a sign of respiratory distress but the nurse already knows the client is in respiratory distress

When initiatin iv therapy in 89 year old pt what angle should be used

10 degrees

NormL range of phenytoin (dilantin)

10-20

a client diagnosed with bulimia nervosa, requires and immediate referral to the health care provider 1. bilateral parotid gland enlargement 2. A hoarse voice that is barely audible

2. A hoarse voice that is barely audible rationale: client with a hoarse voice is at high risk for tracheosophageal fistula from esophageal tear secondary to forceful vomiting. Laryngitis is a danger sign. not: 1. bilateral parotid gland enlargement is a hallmark sign of chronic vomiting as the glans become clogged with foreign matter. not a priority

The nurse admits several clients during the day shift. Which room assignment is most appropriate for the nurse to make? 1. Assign the client who is returning from an appendectomy to a room with a client who had an incision and drainage of a leg wound earlier today. 2. Assign the client who is returning from a total knee replacement to a room with a client diagnosed with pancreatitis. 3. Assign the client diagnosed with streptococcal pneumonia to a room with a client diagnosed with staphylococcal pneumonia.

2. Assign the client who is returning from a total knee replacement to a room with a client diagnosed with pancreatitis. rationale: Neither client is infected. Pancreatitis is an inflammatory process of the pancreas and not an infectious disease. not 3: Clients who are diagnosed with two different infectious organisms should not be placed in the same room.

The nurse plans care for a client diagnosed with dementia. Which nursing intervention is the priority 1. Encourage the family to perform activities of daily living for the client 2. Assume a face-to-face position when speaking to the client

2. Assume a face-to-face position when speaking to the client The nurse maximizes verbal and nonverbal cues. The nurse should use short simple words and phrases and speak slowly to give the client time to process information Not: 1. Encourage the family to perform activities of daily living for the client ( The nurse said encourage the client to do as much as possible.

The nurse prepares to document care given to clients. Which areas will the nurse include in complete and accurate documentation? (Select all that apply.) 1. Subjective nursing observations. 2. Client symptoms and response to treatments. 3. Nursing care given. 4. Explanation of a medication error. 5. Medications and treatments.

2. Client symptoms and response to treatments. 3. Nursing care given. 5. Medications and treatments. not: 4. Explanation of a medication error. that belongs in incident report not in clients record

What does the first measure for the tires and I for implement during a low census client care shift 1. Keep all staff to provide care for new admissions 2. Contact the hospital supervisor with staffing information.

2. Contact the hospital supervisor with staffing information. Rationale: exccess staff may be floated to another unit that requires additional personnel. Only the supervisor will have this information. The charge nurse may not make make unit staffing changes without consideration of the rest of the hospital Not: 1. It's all staff to provide care for new admissions. (unless the charge nurse has accurate information that additional clients are about to be admitted this is not cost-effective)

The nurse provides care to a client who is at a high risk for falling. Which medication will the nurse identify that increases the client's risk? (Select all that apply.) 1. Acetaminophen. 2. Hydrocodone. 3. Diphenhydramine. 4. Lorazepam. 5. Lisinopril.

2. Hydrocodone. 3. Diphenhydramine. 4. Lorazepam. 5. Lisinopril.

A client admitted to the hospital for an acute MI. The client spouse states, "There has been an issue with heavy drinking for years. Based on this data, the nurse observes the client for which symptoms? 1. watery eyes, cramps, mild tremors. 2. Hyperalertness, easily startled, anorexia.

2. Hyper-alertness, easily startled, anorexia. (early symptoms of withdrawal) not: 1. watery eyes, cramps, mild tremors. (symptoms of withdrawal)

the nurse in the outpatient psychiatric clinic is meeting in a room with a client. Another client diagnosed with antisocial persoanlity disorder comes into the room and sits down. Which response by the nurse is most appropriate? 1. Is there something you need? 2. I am talking to this client. Please return to the waiting room.

2. I am talking to this client. Please return to the waiting room. rationale: this sets limits on the inappropriate behavior in a nonjudgemental way. not: 1. Is there something you need? clients with antisocial personality firm limit setting is required. the nurse shoudl not allow the client to infringe on others's rights.

A client is a continuous positive airway pressure (CPAP)during the night to assist with sleep apnea. Which clients statement indicates that a nurse but need for additional client teaching 1. I will cover my nose and mouth with a face mask to sleep 2. I can't smoke in my bedroom fan fair is combustible

2. I can't smoke in my bedroom fan fair is combustible Rationale: CPAP and uses room air not oxygen and is not combustible. It is used with spontaneous ventilation to keep the alveoli open and decrease hypoxia Not . I will cover my nose and mouth with a face mask to sleep ( The nose and mouth are covered with a face mask when CPAP is used during sleep. The client should be instructed to avoid alcohol and medications that depress the upper airway)

the nurse provides teaching to a pregnant client about varicose vein preventions. which client statement indicates that the client needs further teaching? 1. i cross my ankles 2. I wear tight socks

2. I wear tight socks: rationale: tight fitting socks that leave marks on the skin increase the risk of varicose veins. the nurse will re-teach the client to wear support hose or elastic stocking and apply them before getting out of bed each morning. not: 1. i cross my ankles (the client should not cross legs at the thighs. crossing legs at the ankle is acceptable.

The nurse provides care for a client experiencing supraventricular tachycardia (SVT). Which action by the nurse is appropriate when giving adenosine? 1. Inject over 1 minute, followed by a normal saline flush (NS). 2. Inject over 1 to 3 seconds, followed by a normal saline flush.

2. Inject over 1 to 3 seconds, followed by a normal saline flush. rationale: should be pushed in 1-3 seconds (MARK says 8) then followed by a normal saline flush

While performing post-mortem care the spouse of a client who died unexpectedly enters the room and demands that the nurse remove all tubes and medical equipment from the client. Which response will the nurse make to the spouse? 1. "I will take the tubes out immediately." 2. "I am very sorry. It has to be difficult to see your spouse this way, but I have to leave everything in place for an autopsy.

2. Most states require all tubes to remain in place until the autopsy is completed. The nurse is acknowledging the difficulty of the situation with the spouse. not1. : When an unexpected death occurs, most states require all tubes to remain in place.

The nurse caring for a group of high school parents at a local fair would need to give further instructions to which parent. (select all) 1. my teenanger is very independent and doesnt need constant supervision after school 2. My teenanger can be impulsive at times, but is improving on problem solving skills. 3 It is important to consistently tell my teenanger what to do every day.

2. My teenanger can be impulsive at times, but is improving on problem solving skills. rationale: impulsiveness should be explored in greater detail in case it leads to risk taking behaviors 3. It is important to consistently tell my teenanger what to do every day. rationale: needed constant directions does not contribute to an ideal level of development of independence which is important for with this age group. not: 1. my teenanger is very independent and doesnt need constant supervision after school (assurance of healthy developmental growth does not require constant supervision of teenagers and does not require follow up.

The nurse identifies the nursing diagnosis of Stress Urinary Incontinence related to weakened pelvic musculature for a client. Which goal is most appropriate for this client? 1. Engage in a bladder retraining program. 2. Reduce the frequency of urinary incontinence episodes through exercises

2. Reduce the frequency of urinary incontinence episodes through exercises not: Bladder retraining is appropriate for reflex urinary incontinence.

A client's IV alarm sounds. A nurse states, "I'll get it! That alarm has been beeping all shift. Maybe it's broken." During client rounds, the charge nurse finds the IV pump alarm button covered with a heavy layer of tape. Which immediate action by the charge nurse is appropriate? 1. Report evidence of "alarm fatigue" among staff to the unit manager. 2. Replace the pump, label the current pump, and send it for repairs.

2. Replace the pump, label the current pump, and send it for repairs. rationale: Focus the immediate action on the client and the safe use of equipment. Arrange for the replacement or repair of the pump that is alarming continuously.

The nurse observes two staff members that have been in frequent conflict for the last several days. The nurse schedules a meeting with both staff members after observing them argue while putting a client back to bed. When meeting with staff members which statement by the nurse is most appropriate 1. One of you will speak first and the other personal refrain from commenting and until first person is done 2. Summarize what you hear the other person saying. The other person will then validate the summary

2. Summarize what you hear the other person saying. The other person will then validate the summary Rationale: summarizing enhances communication each party is actively listening and heats the other person perspective Not 1. One of you will speak first and the other personal refrain from commenting and until first person is done (if one person speaks freely for an extended period the other person may feel attacked and become more defensive frequently exchange or feedback and more appropriate

The nurse observes a six-year-old client playing in the clinic playground which activity shows appropriate musculoskeletal development for this age 1. The child walks up and down the stairs 2. The child hops and skips.

2. The child hops and skips. Not 1. The child walks up and down the stairs (this is appropriate for a child of two through four years of age

During an admission interview a client called the nurse about a six year history of heart failure. Was assessment finding requires an immediate intervention by the nurse. 1. The client feet are cool with 2+ pitting edema 2. The client has a productive cough of pink tinged sputum

2. The client has a productive cough of pink tinged sputum Rationale: this finding indicates fluid in the lungs which decreases the ability of a lungs to exchange oxygen and carbon dioxide. as a threat for breathing this may be immediately life-threatening this is a priority concern Not: 1. The client feet are cool with 2+ pitting edema this indicates a lack of adequate perfusion 50 extremity assist concerning but not as important as fluid in the lungs

A tornado has just leveled the housing division near the hospital. The nurse working on postpartum/pediactric considers which client is ready for discharge? 1. a postpartum client who delivered 4 hours ago and has an intact perineum. 2. a 3 day old breastfeeding neonate with a total serum bilirubin of 14

2. a 3 day old breastfeeding neonate with a total serum bilirubin of 14 rationale: this client is stable. phototherapy is considered for the neonate with bili greater than 15 at 72 hours of age. therefore the current level does not indicate that therapy is needed. not:1. a postpartum client who delivered 4 hours ago and has an intact perineum.( this is the second most stable client. the client still has a potential risk of bleeding postpartum.

pt on cardiac monitor notes elevated T waves. Which client is likely to have this appear on the ECG? Select all 1. a client with cushin syndrome who has hypertension and a pathologic fracture of the spine 2. a client with alcholic liver cirrhosis who has a severe ascites and shallow respiration 3. a client who was in a house fire and suffered extensive burns on the arms, trunk, and face

2. a client with alcholic liver cirrhosis who has a severe ascites and shallow respiration rationale: liver failure will cause ascites witch build up of Co2 and respiratory acidosis, which is associated with hyperkalemia 3. a client who was in a house fire and suffered extensive burns on the arms, trunk, and face rationale: cell destruction from the burns casue increased pottasium not: 1. a client with cushin syndrome who has hypertension and a pathologic fracture of the spine (elevated twaves mean hyperkalemia. cushings diseases has high glucose, sodium, and low potassium.)

who does the nurse see first 1. client with MI whose monitoring shows 4 to 6 premature ventricular beats per hour 2. a client with pneumonia who is increasingly confused and has a temp of 104.

2. a client with pneumonia who is increasingly confused and has a temp of 104. rationale: the high temp just means the pneumonia is getting worse, but confusion indicate hypoxia. Fever increases the oxygen demand, and combined with confusion indicates the client's condition may worsen quickly. not: 1. client with MI whose monitoring shows 4 to 6 premature ventricular beats per hour (the nurse would only be concerned if there was 4 to 6 pvc per minute.

who should the nurse see first. 1. a preschool age client, underweight for height, whose parent screams profanities at the child. 2. a school age client, small for age, whose parents are unemployed and are strict vegans.

2. a school age client, small for age, whose parents are unemployed and are strict vegans. rationale: vegan diet is low in essential fats, complete proteins, iron, and B12 does not support growth needs during childhood. this child is at risk for malnutrition, a type of physcial neglect. physiological threat take precedent over types other problems not: 1. a preschool age client, underweight for height, whose parent screams profanities at the child. (psychological abuse is important to assess and resolve, physical abuse takes priority.

the nurse supervises and AP. which task is appropriate for the nurse to delegate to the AP 1. elastic bandage application 2. abdominal binder application.

2. abdominal binder application. rationale; the AP can do this as long as the nurse assesses the area the binder will be applied to and the clients comfort level after its applied not: 1. elastic bandage application (cannot be delegated to AP, the nurse most assess distal pulses, skin color, and skin temp to ensure the bandage is not too tight.

a client reports stabbing facial pain and twitching facial muscles a week after having a toothache. The client is diagnosed with trigeminal neuralgia. Which nursing action does the nurse implement when providing care to this client? select all 1. teach isometric exercises for facial muscles. 2. administer oral carbazepine as prescribed. 3. teach to chew on opposite side of mouth

2. administer oral carbazepine as prescribed. 3. teach to chew on opposite side of mouth not: teach isometric exercises for facial muscles. (isometric exercises are appropriate for Bell Palsy. This client has trigeminal neuralgia.)

during the admission assessment, an older adult exhibits poors kin turgo, dry lips, and an open sacral wound with reddedned edges and malodorous drainage. the nurse observes the client has poor hygiene and a withdrawn affect. Which actions will the nurse implement? select all 1. bring the clients caregiver into the room. 2. alert the nursing supervisor to possible elder abuse 3. obtain a thorough skin assessment. 4. perform an elder mistreatment assessment. 5. conduct a mini mental status exam.

2. alert the nursing supervisor to possible elder abuse* rationale: nurses are mandated reporters. 3. obtain a thorough skin assessment. 4. perform an elder mistreatment assessment. rationale: protocols for elder mistreatment should be followed. This will include documentations and photographs. not; 1. bring the clients caregiver into the room. (a client should be interviewed alone to promote disclosure. most clients are afraid to speak freely in the presence of their possible abuser. 5. conduct a mini mental status exam. (there is not indication of need for further cognitive assessment at this time.

which client with the nurse in an ED dept would see first? 1 . a young adult with asthma and a productive cough 2. an older adults client with one episode of fainting.

2. an older adults client with one episode of fainting. rationale: the fainting episode may be the result of an irregular cardiac rhythm or rate change, and this requires an immediate cardiac evaluation to prevent cardiac and respiratory arrest. not: 1 a young adult with asthma and a productive cough (productive cough is indicative of a probable upper respiratory infection. Eventhough this is is a breathing issue with a potential to become an airway issue, this is not the highest priority.

after a major power outage, a confused client with an unsteady gait arrives at a portable emergency response station. Which action does the nurse take first? 1. assess the client's level of consciousness 2. assist the client to the nearest chair.

2. assist the client to the nearest chair. not: 1. assess the client's level of consciousness rationale: the client has an unsteady gait and is at risk for falling. The nurse should ensure client safety before beginning assessment.

What teaching will the nurse provide about feeding an infant to his parents. 1. sweeten foods with honey, not sugar. 2. avoid use of non-spill cups that require sucking.

2. avoid use of non-spill cups that require sucking. rationale: these cups to not encourage infant to learn to drink from a cup. Also they allow juice or milk to be in constant contact with teeth, increasing the risk for dental caries. not: 1. sweeten foods with honey, not sugar. (honey is avoided to prevent infantile botulism)

client diagnosed with acute renal failure secondary to severe kidney infection. During the oliguric phase, which assessment finding does the nurse expect to observe 1. urine specific graviti 1.039 2. azotemia 3. nausea 4. serum potassium is 6 meq 6. pruritus

2. azotemia* rationale: classis sign of renal failure, is the buildup of nitrogen waste in the bloodstream resulting in high BUN and increased creatinine 3. nausea* rationale: build up of metabolic waste product may casue nausea and vomiting 4. serum potassium is 6 meq* 6. pruritus* rationale: itching may occur during buildup of urea 1. urine specific graviti 1.039 (during oliguric state urine specific gravity decreases or remains in normal limits)

the nurse cares fro a patient with an exacerbation of ulcerative colitis. the nurse determines teaching is effective when the client makes which dietary choice? select all 1. a multigrain sandwich with lean turkey and alfalfa sprouts 2. canned green beans and applesauce 3. grilled cheese sandwich on white bread with creamed tomato soup 4. roast beef mashed potatoes

2. canned green beans and applesauce* rationale: eat a low-residue diet. canned, cooked, and seedless vegetables without skins are permitted on a low-residue diet. this dietary choice indicated understanding by the client. 3. grilled cheese sandwich on white bread with creamed tomato soup 4. roast beef mashed potatoes* rationale: a client with exacerbation of ulcerative colitis should eat a low-residue diet. meats and cooked skinless veggies are permitted. not: 1. a multigrain sandwich with lean turkey and alfalfa sprouts (a client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. whole grains and raw vegetables, such as sprouts, are contraindicated. this dietary choice indicates that the client needs additional teaching.

the nurse administer a bolus of 0.9 % normal saline to a client diagnosed with severe sepsis. to evaluate the effectiveness of this fluid therapy, which parameter is important for the nurse to assess? 1. blood pressure and oral temp 2. central venous pressure and output.

2. central venous pressure and output. CVP is the measurement of blood pressure in the right atrium and vena cava. normal reading is 2-8. high reading=fluid overload, heart failure low reading=hypovolemic shock and dehydration. not: 1. blood pressure and oral temp (temp is not a reliable indicator of the clients fluid volume status.

the nurse in daycare center observes a toddler squatting and panting after chasing a ball. what should the nurse do first? 1. remove the child from the playgroun and encourage rest 2. check for sweating, color, and tachycardia

2. check for sweating, color, and tachycardia rationale: squatting, or knee-chest position, increases pulmorany blood flow adn improves systemic arterial oxygen satutation. the child may squat to relieve hypoxia. the nurse should confirm signs or symptoms of hypoxia first as this may be an emergency situaiton. 1. remove the child from the playgroun and encourage rest ( the nurse should first assess the child for hypoxia and underlying perfusion issuee before deciding a course of action)

the nurse provide care for a client with an abdominal abscess draining into a build suction device. which is the most important ata for the nurse to assess when monitoring drainagE? 1. amount 2. color

2. color Rationale: noT: 1. amount

the nurse provides care to an older adult client with partial and full thickness burns over 75% of the body. Which assessment indicated to the nurse the client is developing shock? 1. widening pulse pressure and bradycardia 2. cool, clammy skin, and tachypnea

2. cool, clammy skin, and tachypnea. rationale: the body responds to early hypovolemic shock by adrenergic stimulation. vasoconstriction compensates for the loss of fluid and causes cool, clammy skin and rapid rate of breathing. not: 1. widening pulse pressure and bradycardia (occurs in cardiac disorders)

client diagnosed with known history of substance abuse with opioids is recoverign aftery a hysterectomy, the nurse will do which 1. notified the health care provider that the opioid prescription if twice the normal dose 2. determines what type and amount of opioids the client uses 3. administer opioid around the clock 4. provide nonopioid methods of pain relief.

2. determines what type and amount of opioids the client uses (the nurse will try to avoid the opioid that was abused) 3. administer opioid around the clock (to prevent withdrawal) Not: 1. notified the health care provider that the opioid prescription if twice the normal dose rationale: opidoids prescribed as pain for opioids users with be higher, this is normal 4. provide nonopioid methods of pain relief. rationale: witholding meds would lead to withdrawal

a client reporting sadness and exhaustion is interested in taking st. johns wort. which of these meds would the nurse be concerned about. select all 1.hydrochlorothiazide 2. digoxin 3. nifedipine 4. simvastatin 5. escitalopram

2. digoxin 3. nifedipine 4. simvastatin* 5. escitalopram not: 1.hydrochlorothiazide

a client seeks medical attention after experiencing an eye injury while working at a welding plant. Which question is the most important for the nurse to ask to begin providing this client with care? 1. can you tell me exactly what happened? 2. do you know what type of material entered your eye?

2. do you know what type of material entered your eye? rationale: since the client works in a welding plant, it is essential to know what material might have caused the injury. Some materials, such as copper, iron, and steel, can result in an intense inflammatory reaction. Knowing the material that entered the eye assists the nurse to determine the extend of the injury. not: 1. can you tell me exactly what happened? finding out what caused this injury is not necessary to determine the client's immediate needs. (finding out what caused the injury is not necessary to determine the client's immediate needs.)

the nurse supervises an client receiving enteral feeding through an NG tube. Which observations indicate to the nurse that the care being provided by the AP is appropriate?(Select all) 1. aspirate and measures the amount of the gastric aspirate 2. elelvates the head of the bed 30 degrees. 3. warms the feeding to room temp. 4. measures the ph of the gastric aspirate. 5. clamps the proximal end of the feeding tube at the end of the feeding.

2. elelvates the head of the bed 30 degrees. 3. warms the feeding to room temp. 5. clamps the proximal end of the feeding tube at the end of the feeding. not: 1. aspirate and measures the amount of the gastric aspirate 4. measures the ph of the gastric aspirate. both should be done by a nurse

a university sponsors a trip abroad for students majoring in international law. At 0300, a student awakens the nurse to report frequency, urgency, and dysuria. Because of safety concerns, night travel is prohibited. Which action should the nurse take first? 1. obtain the student's temperature 2. encourage the student to drink large volumes of fluid

2. encourage the student to drink large volumes of fluid rationale: the clients symptoms are consistent with a urinary tract infection, and fluids will help flush the system and may relieve some discomfort. A warm sitz bath may also help relieve discomfort. Antibiotics, the treatment of choice for a UTI, can be obtained after curfew. not: 1. obtain the student's temperature (the student is exhibiting the symptoms of a urinary tract infection (UTI). Fever is a rare manifestation of UTI.

what is the most characteristic diseases of hodkin lymphoma 1. enlarged, painful inguinal lymph nodes 2. firm, painless, and movable adenopathy in the cervical area.

2. firm, painless, and movable adenopathy in the cervical area. not: 1. enlarged, painful inguinal lymph nodes (when they are in the neck they will be painless)

the nurse provides care for clients in the psychiatric unit. The nurse is concerned if a client receiving phenelzine sulfate eats whic h menu item? 1. boiled fish and whole milk 2. grilled cheddar cheese on wheat bread.

2. grilled cheddar cheese on wheat bread. rationale: phenelzine sulfate (nardil) is an MAOI, and eating aged cheese may cause hypertensive crisis. 1. boiled fish and whole milk (these are good choices, the nurse advises the client to avoid alcoholic beverages such as beer, red wine due to tyramine.

a pt about to undergo an MRI, nurse should be most concerened with 1. report claustrophobia, 2. has an aneurysm clip

2. has an aneurysm clip, rationale: the heat can dislodge clip and cause hemorrhage or death. not: report claustrophobia, these pts can be sedated or use an open MRI

The nurse provides care for a client diagnosed with prerenal acute kidney injury. The nurse recognizes that which cause likely led to this diagnosies? 1. ureteral obstruction 2. hypovolemia

2. hypovolemia rationale: decreased cardiac output or hypovolemia is the cause of acute kidney injury not: 1. ureteral obstruction (this is the cause of postrenal , acute kidney injury

a client being treated for diarrhea requres follow up if he says 1. i am taking an over the counter probiotic pill 2. i am taking azithromycin

2. i am taking azithromycin rationale: azithromycin is a macrolide anti-infective agent, may cause diarrhea, nausea, and abdominal pain. th elcient should consult a health care provider for diarrhea management, which may include changing the medication 1. i am taking an over the counter probiotic pill (otc pills or powders add healthy bacteria to the gi tract, which aids in digestion and helps prevent diarrhea.

the nurse talks to c child who was sexually abused by a family member. the child asks the nurse not to tell anyone his secret. which response by the nurse is best? 1. i will not tell your mom and dad. 2. i cannot keep this information a secret.

2. i cannot keep this information a secret. rationale: the nurse cannot keepvital info a secret in order to keep him safe. not: 1. i will not tell your mom and dad. (the nurse cannot promise that the parents wil not be informed of this info.

the nurse calls the mother of a school-aged child diagnosed 1 day ago with rubella. Which statement by the mother will the nurse respond to first? 1. my child feels very warm. i am goign to give my child some aspirin to decrease the fever. 2. i have heard measles can cause serious complications. i do not know how to protect my child

2. i have heard measles can cause serious complications. i do not know how to protect my child rationale: administering aspirin to a child can cause Reye syndrome. Acetaminophen is effective in reducing the fever and is the preferred antipyretic for children. 1. my child feels very warm. i am going to give my child some aspirin to decrease the fever. (The nurse should reassure the mother that complications are rare)

the nurse evaluates comprehension of teaching to a client schedules for surgery. which client response is the most important for the nurse to report to the health care provider 1. sometimes i feel so claustrophobic i want to run 2. i hope they keep the operating room cool. my grandfather died during surgery when he got very hot.

2. i hope they keep the operating room cool. my grandfather died during surgery when he got very hot. rationale: not: 1. sometimes i feel so claustrophobic i want to run (the statement about feeling claustrophobic indicates the need for anxiety-reduction interventions. This information is not a priority to share with the heath care provider.

a client diagnosed with peptic ulcer disease asks if an over-the-counter antacid can be taken instead of esomeprazole because of the cost. Which responses by the nurse are appropriate? 1. try the antacids for a few days. if you start to feel worse, call your healthcare provider? 2. i will call your pharmacy and find out the cost 3. esineorazole helps reduce stomach acid, and you will need to take it for several weeks to achieve healing 4. here is information about smoking cessation classes available in your area 5. notify your health care provider if you have stools that are black and tarry.

2. i will call your pharmacy and find out the cost* rationale: promotes advocacy for the client to receive appropriate treatment for the health problem 3. esomeprazole helps reduce stomach acid, and you will need to take it for several weeks to achieve healing* rationale: acts to reduce stomach acid, the desired meachanism to help heal the ulcer 4. here is information about smoking cessation classes available in your area* rationale: nicotine inceases stomach acid. smoking cessation info is appropriate. 5. notify your health care provider if you have stools that are black and tarry. not: 1. try the antacids for a few days. if you start to feel worse, call your healthcare provider? peptic ulcers are not treated by peptic ulcers

the nurse cares for a client receiving fluoxetine. the nurse determines that teaching is effective when the client makes which statement? 1. i should take a missed dose as soon as i remember 2. i will chew sugarless gum frequently 3. i will sit on the side of the bed before standing 4. i will use sunscreen when i go outdoors.

2. i will chew sugarless gum frequently* (minimizes dry mouth) 3. i will sit on the side of the bed before standing 4. i will use sunscreen when i go outdoors.* (drug leads to photosensitivity) not: 1. i should take a missed dose as soon as i remember (the client should omit that dose and return to the regular dosing schedule is missed)

Which instructions should the nurse include in the teaching of atorvastatin 1. schedule an annual physical exam 2. increase intake of fiber

2. increase intake of fiber rationale: increasing fiber can reduce cholesterl levels by up to 10% not: 1. schedule an annual physical exam: (this is part of general helath maintenancy not specific for clients with hyperlipidemia

The school nurse observing a basketball game. Two cheerleaders are tumbling and hit eachother in midair. One of the cheerleaders begins to cry and says. "I think my arm is broken." Which action should the school nurse take first? 1. immobilize the arm 2. inspect the affected arm.

2. inspect the affected arm rationale: the nurse should remove clothing and inspect fro bleeding, swelling, or deformities not 1. immobilize the arm

the nurse provides care to a client with a sore throat and fever. A throat culture indicates group A beta-hemolytic Streptoccocus infections. Urinalysis reveals protein and numberoud RBC. Antibiotics are prescribed. The client is leaving soon for a 6 week internation conference. which action should the nurse take next ? 1. determine if the clietn is allergic to penicillin 2. instruct the client to schedule an appointment before leaving the country.

2. instruct the client to schedule an appointment before leaving the country. rationale: follow up appointment before leaving and upon return are required to determine the clients kidney status due to the symptoms of acute glomeruneprhitis (common cause is strep throat) not: 1. determine if the client is allergic to penicillin (allergies would have been determined before the antibiotic was prescribed. the primary focus is determining client is in good health and able to attend the conference.

an older asia american client reports nausea and anorexia since taking isoniazid for 4 months. which action will the nurse take first? 1. inspect the hard palate 2. instruct the client to stop taking the medication

2. instruct the client to stop taking the medication raitonale: isoniazid can effect liver function signs of ealy jaundice are observed on the hard palate of asian descent. even the sclera in asian clients can have pigments that mimic jaundic not: 1. inspect the hard palate( the nurse needs to assess and validate the signs of hepatoxicity before directing the client to alter the med)

the nurse provides care to a client who is vomiting brown material that has a fecal odor. Which condition does the nurse suspect is causing this type of vomitus 1. obstruction below the pylorus 2. intestinal obstruction

2. intestinal obstruction rationale: a bowel obstruction is indicated with vomitus that is brown with a fecal odor as described. not: 1. obstruction below the pylorus (the vomitus would be bile-stained green if there was an obstruction belowe the pylorus)

The nurse assess a toddler diagnosed with acute diarrhea related to gastroenteritis. there is no evidence of dehydration. which recommendation is the most important for the nurse to make to the cleint parent 1. bananas, rice, and toast are effective for decreasing diarrhea 2. its best to start your child on the usual diet right away, offering food as tolerated.

2. its best to start your child on the usual diet right away, offering food as tolerated. rationale: once rehydration has occured or no evidence of dehydration the childs normal diet should be resumed. reintroducing of nutrients as in a normal diet is without adverse effects, decreases the duration and severity of the illness, and improves weight gain compared to gradually reintroducing foods. not: 1. bananas, rice, and toast are effective for decreasing diarrhea (has very low nutritional value)

the nurse provides care for a client in isolation. Which item must be marked as biohazardous when removing in from the room? select all 1. bed linen 2. lab specimen 3. discarded syringes

2. lab specimen 3. discarded syringes not: 1. bed linen (linens that are removed from an isolation room are to be placed in a plastic bag and taken to the area designated for soiled linens. No special handling precautions are required.

a client diagnosed with a seizure disorder is taking carbamazepine and oral hormonal contraceptive and levothyroxine. which response by the nurse is most importat 1. do you take the medication at the same time eveyr day>: 2. lets talk about other forms of contraceptives

2. lets talk about other forms of contraceptives rationale: carbamazepines interferes with the action of hormonal contraceptive. the client should use another form of birth control to be effective against pregnancy. not: 1. do you take the medication at the same time every day: (each med shoudl be taken on the same schedule to maintain blood levels but they do not have to be taken at the same time)

the client diagnosed with anorexia nervosa has which priority goal in the care plan? 1. gain one fourth pound per week 2. maintain potassium between 3.5 to 5.0

2. maintain potassium between 3.5 to 5.0 rationale: the client with anorexia is at risk fro fluid and electroly imbalance, especially hypokalemia which should be closely monitored not:1. gain one fourth pound per week (this is a physical need however, it is not a higher priority than cardiac functioning.

the nurse cares for a client after an ileosotmy. the most importat action for the nurse to perform is 1. empty the ileostomy bag from the bottom 2. measure the output from the ileostomy

2. measure the output from the ileostomy rationale: the output from an ileostomy is liquid and usually copious in amount. include the amount of intake and output to help keep the client balanced. 1. empty the ileostomy bag from the bottom (it should be emptied when its 1/3 full)

the nurse completes a medication history with a cleint experiencing a bleeding duodenal ulcer. which prescribed medication reported by the client causes the nurse concern? 1. ranitidine hydrochloride 150 mg by mouth. 2. metoclopramide hydrochloride 15 mg by mouth

2. metoclopramide hydrochloride 15 mg by mouth rationale: stimulates motility of the upper gi tract and is contraindicated in a client with a possible hemorrhage of the gi tract. the med is used to treat nausea associated with chemotherapy. bleeding from the duodenal ulcer can be a medical emergency and actions should be taken to prevent further bleeding or irritation. not: 1. ranitidine hydrochloride 150 mg by mouth. (this drug is used for short-term treatment of duodenal and gastric ulcers).

the cardiac monitor of a client who is awake and aler and has a peripheral pulse shows ventricular tachycardia with a rate of 160 beats/min. which actions are appropriate for the nurse to implement? 1. defibrillate using 200 joules 2. monitor blood pressure 3. aler the rapid response team 4. obtain a 12 lead ekg 5. prepare to administer adenosine by slow iv push

2. monitor blood pressure 3. aler the rapid response team 4. obtain a 12 lead ekg not: 1. defibrillate using 200 joules: awake client should receive cardioversion of 100 joules if medication fails to convert rhythm. 5. prepare to administer adenosine by slow iv push

the nurse obtains a history from a client who is prescribed rosuvastatin. Which client report is most important for the nurse to report to the health care provider? 1. abdominal pain 2. muscle tenderness

2. muscle tenderness rationale: eventhough it is rare, one of the greatest risk to a client taking rosuvastatin. (crestor) is myosistis or muscle inflammation, that can progress to rhabdomyolysis. therefore a client report of muscle tenderness is the priority for the nurse to report to the health care provider. not: 1. abdominal pain and gi distress is a common side effect that should be reported but is not the greatest risk for injury.

the nurse calls the mother of a child who was diagnosed with rubella 1 day ago. which statement by the mother does the nurse respond to first 1. i have heard measles can cause serious complications. i do not know hot to protect my child 2. my child feels very warm. i am going to give my child aspirin to decrease the fever

2. my child feels very warm. i am going to give my child aspirin to decrease the fever rationale: giving aspirin to a child can cause Reye syndrome. acetaminophen is used to reduce fever. not: 1. i have heard measles can cause serious complications. i do not know hot to protect my child (inform mom complications are rare)

the nurse notes that a client experiencing dull pain in the anterior and posterior neck, has full neck range of motio and no throat redness or enlargement of the head or lmph node. which assessment will the nurse do next 1. examination of the ears 2. palpation of the liver

2. palpation of the liver rationale: the right neck and flank are common areas of refereed pain from liver should be examined when dull pain in the anterior and posterior neck 1. examination of the ears

the nurse reviews telephone messages in the pediatric clinic. which message will the nurse return first? 1. parent states that a 4 day old newborn has had one stool per day for the past 2 days. 2. parent states that the umbilical cord stump of a 5 day old newborn is moist at the base and slightly red

2. parent states that the umbilical cord stump of a 5 day old newborn is moist at the base and slightly red RATIONALE: sign of infection, the cord should be dry and with no redness NOT: 1. parent states that a 4 day old newborn has had one stool per day for the past 2 days. (one stool per day is a normal pattern for a newborn of this age.)

the nurse prepares to asses a client with right -sided heart failure. which symptom will the nurse expect to observe? 1. increased respiration with exertion 2. peripheral edema and anorexia

2. peripheral edema and anorexia (because of congestion of gastric veins, anorexia develops as well all ascites) noT: 1. increased respiration with exertion (sign of chronic lung disease)

a nurse caring for a client with a hemoglobin of 6.8. which intervention should the nurse perform first 1. draw type and crossmatch for 2 units of packed red blood cells 2. place the client on 2 liters of oxygen per nasal cannula.

2. place the client on 2 liters of oxygen per nasal cannula. rationale: normal hemoglobin is 12-16, when low less oxygen circulates. not 1. draw type and crossmatch for 2 units of packed red blood cells

a client diagnosed with siezure disorder asks what needs to be done when having to travel for work 1. travel with a person experienced in handling health problems 2. place your medicatio in your carry on bag.

2. place your medicatio in your carry on bag. rationale: the client should carry meds in carry on as luggage can get lost. not: 1. travel with a person experienced in handling health problems (the cient does not need constant supervision but a medical bracelet can help)

the nurse teachign a new nurse about the prevention of acute respiratory distress syndrome (ARDS) Which action is the nursing priority in ARDS prevention? 1. early mobility for clients with pneumonia 2. prevention of client aspiration.

2. prevention of client aspiration. rationale: aspiration is one of the most common causes of ARDS. Prevention of it is priority to reduce risk not: 1. early mobility for clients with pneumonia (early mobility promotes ventilator weaning. it has not been shown to prevent ARDS.

the nurse is caring for a client with a cast on the left leg. which exercise will the nurse tell the client to do? 1. active range of motion exercises of the unaffected limb 2. quadriceps setting of the affected limb

2. quadriceps setting of the affected limb. rationale: this is an isometric exercise. it is done by contracting the muscle without moving the joint. this exercise maintains muscle strength while the limb is in a cast. not: 1. active range of motion exercises of the unaffected limb (it is more important to maintain the muscle strength of the limb with the cast)

client diagnosed with deep vein thrombosis DVT is prescribed warfain. which info would require nurse to hold the medication and contact the health care provider? 1. history of catacts removal one month ago 2. recent diagnosis of peptic ulcer disease 3. regular consumption of up to six beers per night 4. current treatment with aspirin therapy 5. colonoscopy one week ago that revealed polyps

2. recent diagnosis of peptic ulcer disease 3. regular consumption of up to six beers per night* regular alcohol consumption lowers action of warfarin 4. current treatment with aspirin therapy* when combined with aspirin, warfarin will have an even larger risk of bleeding. not:1. history of catacts removal one month ago 5. colonoscopy one week ago that revealed polyps discountinuation would occur before surgery not after or at diagnosis

the nurse answers a call light for a client reporting pain at the IV access site. Upon assessment, the nurse note the IV insertion site is pale, cool to the touch, and mildly swollen. it is most important for the nurse to take which action. ? 1. stop the infusion and notify the health care provider 2. remove the iv cath and place the clients arm on a pillow `

2. remove the iv cath and place the clients arm on a pillow rationale: the client is experiencing an infiltration of the iv access site. the nurse will remove the iv cath and elevate the extremity to increase the rate of re absorption of the fluid. not: 1. stop the infusion and notify the health care provider the client with infiltration needs to have the catheter removed and the extremity elevated to increase the rate of reabsorption fo the fluid.

the nurse is caring for a child with suspected sickle cell disease. Which laboratory result does the nurse expect to be increased in sickle cell disease? 1. white blood cell count 2. reticulocyte count

2. reticulocyte count rationale: these counts are elevated in children diagnosed with sickle cell disease because the lifespan of their sickled red blood cells is shortened. not: 1. white blood cell count (wbc is not count is not impacted by sickle cell disease.)

older client received mouth care from UAP. the nurse would need to intervene if she sees which 1. applying petroleum jelly to the clients lips 2. rinsing the clients mouth with a glycering-based mouthwas

2. rinsing the clients mouth with a glycering-based mouthwash rationale: glycerin causes dehydration and iiritation of the oral tissues. the nurse should intervene and provide the UAP and client with non-glycerin mouthwas not:1. applying petroleum jelly to the clients lips (this is appropriate)

the nurse provides care for a client diagnosed with pneumonia. the client has a history of type 2 diabetes. the client in an older adult and is malnourished. for which type of shock does the nurse monitor for? 1. cadiogenic 2. septic

2. septic rationale: older adults with chronic diseases who are malnourished or debilitated are at great risk for septic shock not: 1. cardiogenic (no mention of cardiac problems)

the nurse provides care for a client with suspected scabies. the nurse expects which assessment finding? 1. small pink bumps with a raised surface on the chest and limbs. 2. several wavy or straight thread like lines beneath the skin.

2. several wavy or straight thread like lines beneath the skin. not: 1. small pink bumps with a raised surface on the chest and limbs.

a client receiving phenelzine sulfate is diagnoses with cushin syndrome and found to be hypokalemic. which diet selection is appropriate for this client 1. banana and fruit salad with raisin 2. spinach ad tuna salad

2. spinach ad tuna salad rationale: diet is high in potassium and does not connect tryramine not: 1. banana and fruit salad with raisin (bananas are high in potassium but are also high in tyramine.

the nurse instructs a client receiving olanzapine. which statemenet made by the client to the nurse required further teaching? 1. this medication will help my thought and behavior 2. stiffness and tremors are expected for the first 2 weeks

2. stiffness and tremors are expected for the first 2 weeks rationale: these symptoms are extramypyramidal and should be reported immediately. not: 1. this medication will help my thought and behavior this med is an atypical antipsychotic med, this is accuarate

a client with history of chronic urinary tract infections who is experience urolithiasis. the nurse expects the cient developed which type of stone 1. uric acid 2. struvite

2. struvite rationale: referred to as infection stones because they form in urine that is alkaline and rich in ammonia. not 1. uric acid (occur with gout)

the nurse provides care for a client diagnosed during the acute phase of a cerebrovascular accident (CVA). in which position will the nurse maintain the client? 1. lateral, with the head of the bed elevated 30 to 45 degrees 2 supine, with the head of the bed elevated 15 to 30 degrees

2. supine, with the head of the bed elevated 15 to 30 degrees rationale: this position facilitates venous drainage from the brain, reduces intracranial pressure, and maintain the head in midline position. not: 1. lateral, with the head of the bed elevated 30 to 45 degrees (this position is used to help with drainage secretion not patient post CVA

an older client has a medical history that includes hypertension. a public health nurse visists the client regularly. which finding does the nurse expect for this client? 1. temp 99.8, pulse 90 beats/min, respirations 20 breaths/min bp 150/90 2. temp 98.8, pulse 80 beats/min, respiration 20 breaths/min, bp 160/90

2. temp 98.8, pulse 80 beats/min, respiration 20 breaths/min, bp 160/90 raitonale: the temp is usually lower in the older adult client due to decrease in the basal metabolic rate. the be is expected with a history of hyptnsn, especially since there is no indication the high bp is being controlled with meds. not: 1. temp 99.8, pulse 90 beats/min, respirations 20 breaths/min bp 150/90 (the nurse would not expect high pulse and temp.)

The nurse provides care to a client with second-degree heart block. Which equipment will the nurse place at the client's bedside? 1. respirator 2. temporary pacemaker

2. temporary pacemaker: pacemaker placement. is needed to provide a stimulus for cardiac contractions. In second-degree heart block, only some of the impulses from the atria are conducted to the ventricles. The client may require a pacemaker to a ensure a steady rhythm and adequate cardiac output. not: 1. respirator: a respirator is used for clients with difficulty breathing.

a client reporting severe pain in the missing limb should be told 1. is the residual limb bleeding or does it have unusual odor? 2. that kind of pain is common after an amputation. does the client have pain medication available?

2. that kind of pain is common after an amputation. does the client have pain medication available? rationale: phantom limb pain cuased by the nerve endings becoming pinhced in the scar tissue and the brain stil has an image of the missing limb. not: 1. is the residual limb bleeding or does it have unusual odor? the client is experiencing pain in the missing portion of the limb. the residula limb pain will not address the current problem

the charge nurse will intervene is she sees 1. the LPN assigned to medicatio administration argues loudly with a client with bopolar disorder who is refusing to take prescribed med. 2. the UAP placed personal care items in reach of a client with Alzheimer disease and then leaves to fill the wash basin with water.

2. the UAP placed personal care items in reach of a client with Alzheimer disease and then leaves to fill the wash basin with water. rationale: the Alzheimer client is at risk for choking on inedible items such as soap, lotions, and caps of smaple bottles. not: 1. the LPN assigned to medication administration argues loudly with a client with bipolar disorder who is refusing to take prescribed med. (the LPN's behavior needs addressing. the client may have the right to refuse medication. This is not priority over the choking risk for the client with dementia

a clien with an ileal conduit would concern the nurse if she saw which 1. bleeding from the stoma when the appliance is change 2. the client has abdominal pain and a temp of 100.4

2. the client has abdominal pain and a temp of 100.4 rationale: fever, abdominal regidity and pain are indication of peritonitis. urine may have leaked into the peritoneal cavity and is an in risk of harm wihthout medical intervention 1. bleeding from the stoma when the appliance is change (Expected finding) instestinal mucosa bleeds durign changing at this stage due to collection pouch not fitting properly

the triage nurse prioritizes clients for evaluation. which client does the nurse determine should be seen first? 1. the client receiving dialysis who missed a treatment the day before and reports swelling in the feet and ankles. 2. the client with a history of chronic alcohol use who reports tremors, confusion, and feeling like the heart is racing.

2. the client with a history of chronic alcohol use who reports tremors, confusion, and feeling like the heart is racing. RATIONALEl: chronic alcohol use is the most common cause of hypomagnesemia which may result in cardiac arrest. the manifestations include neuromuscular irritability, tremors, tetany, and seizures. the clients symptoms put the client at an actual risk not: 1. the client receiving dialysis who missed a treatment the day before and reports swelling in the feet and ankles. (he will likely require dialysis, he may have altered electrolyte. Actual risk takes precedence over potential risk.

the pediatric nurse assess an adolescent male client. which finding requires immediate intervention. 1. the clients scrotum appears swollen, and a soft mass is palpated. the nurse is unable to insert a finger above the mass. 2. the clients scrotum appears enlarged and red. the nurse palpates a thickened and swollen spermatic cord.

2. the clients scrotum appears enlarged and red. the nurse palpates a thickened and swollen spermatic cord. rationale: these findings indicate torsion of the spermatic cord. this is very painful and emergency situaiton requiring surgical repair. this is caused by hypoxic injury ot the testicle. not: 1. the clients scrotum appears swollen, and a soft mass is palpated. the nurse is unable to insert a finger above the mass. (this finding is inguinal hernia, the nurse should refer the client to the doctor for evaluation.

the nurse provides care for a client with a head injury who is placed on a volume-cycled ventilator. which action by the nurse best indicates an understanding of proper management of a client on a meachanical ventilator? 1. water is added to the tubing to provide for humidification of inspired air 2. the sigh setting on the ventilator is adjusted to occur every hour.

2. the sigh setting on the ventilator is adjusted to occur every hour. rationale: the setting on the ventilator should be set for 1.5 times the tidal volume and adjustment should occur every 1 to 3 hours not: 1. water is added to the tubing to provide for humidification of inspired air(no water should be in the tubing. the tubing is assessed for the presence of water, which is removed. A humidifier of the oxygen is used.

the client with genital herpes says "i do not know how i keep getting reinfected because i am really careful. which response by the nurse is best 1. what do you mean, i am really careful? 2. the virus remains in your body in a dormant state

2. the virus remains in your body in a dormant state rationale: the client should not engage in sexual activity while the lesions are present. to prevent the spread, the client should abstain from sex or use a condom. not: 1. what do you mean, i am really careful? reinfection does not occur by reinfection. the client may shed the virus even though there are not symptoms, so the client may give the disease to others.

a nurse cares for a newborn who was just diagnosed with allergy to cows milk. the nurse discusses the adaptive measure to take. which statement by the infants parent to the nurse indicated a correct understanding of how to proceed? 1. I am glad there are so many variety's of soy-based formulas 2. those predigested formulas sound like a good choice.

2. those predigested formulas sound like a good choice. rationale: formulas that use enzymatic hydrolyis to break down or predigest the casein protein into its amino acids are recommended for infants with cows milk allergies not: 1. I am glad there are so many variety's of soy-based formulas (not recommended for infants with cows milk allergy due to cross reactivity to soy

A nurse care for a client 1 day after a bypass graft (CABG) he is found sitting in the chair. He is cool pale and responds only to loud verbal stimuli. Which action should the nirse do first? 1. administer oxygen per nasal cannula 2. transfer the client back to bed with assistance

2. transfer the client back to bed with assistance Rationale: The cool, pale client experiencing decreased levels of consciousness needs to be reclining in bed to increase the prefusion to the heart Not: 1. administer oxygen per nasal cannula May not be needed Nurse should assess pt after putting in bed

the nurse provides care to a client receiving sulfamethoxazole-trimethoprim. Which observation indicatd that the clietn is experiencing a common side effect of this medication? 1. loss of hearing 2. urticaria

2. urticaria rationale: a mild to moderate rash is the most common side effect of suldfa a urinary tract anti-infective not: 1. loss of hearing (aminoglycosides are ototoxic not sulfa)

the nurse prepares to give a newborn the first bath after birth. which action does the nurse take first 1. remove the vernix from the newborn's body 2. use a pH neutral soap for cleansing the newborn.

2. use a pH neutral soap for cleansing the newborn. rationale: will minimize injury to the skin. not: 1. remove the vernix from the newborn's body. the white cheesy substance provide protection to the skim against bacterial. the nurse should leave as much on the skin as possible.

the nurse provides care for a client diagnosed with peripheral artery disease (PAD). The client reports leg pain occurs frequently when walking. Which action doe the nurse advise the client to take? 1. Lie down with feet elevated above the heart when experiencing pain. 2. walk until experiences pain,rest, and then resume walking.

2. walk until experiences pain,rest, and then resume walking. rationale: exercise increases collateral circulation and should be encouraged. Stopping and resting will usually relieve the pain, and then the client can continue to walk walking is both a cure and cause to pain with PAD. not: 1. Lie down with feet elevated above the heart when experiencing pain. (a client with PAD, elevating the legs above the heart decreases arterial flow to legs. This will increase, not relieve, the pain.

the parents of a preschool child bring their child to the ER during flu season, due to the child's complain of abdominal pain, nauseated and vomiting, and refuses to eat. which is the most important question for the nurse to ask? 1. how long has your child been feeling like this? 2. which came first the pain, or the nausea and vomiting>?

2. which came first the pain, or the nausea and vomiting>? rationale: the sequence is the most reliable info from the history to assess for possible appendicitis. in acute appendicitis the pain usually comes prior to nausea and vomiting. if the nausea and vomiting come before abdominal pain then it indicates gastroenteritis not: 1. how long has your child been feeling like this? although important, not most important

a child prescribed digoxin is sleepign and has a regular heart rate of 80 bpm. which action does the nurse take 1. give the medication and document heart rate 2. withold the medication and immediately notify the health care provider

2. withold the medication and immediately notify the health care provider rationaleL: a normal hear rate for infants is 120-140. bradycardia is 80-100. the nurse should withold the medication if rate is between 90 to 110 bpm. excessive slowing heart rate may indicate dig toxicity. 1. give the medication and document heart rate

an adolescent asks the school nurse what to do when a parent has a panic attack every time the parent attempts to leave the shouse. which statement is the best response for the nurse to make? 1. have your parent practice deep breathing and relaxation techniques before leaving the house 2. you are concerned fro your parent, but more help is needed than you are able to provide.

2. you are concerned for your parent, but more help is needed than you are able to provide. Rationale: the student is describing a phobic disorder that is treated with behavior therapy and medication that can reduce or block the panic attacks. phobias are an extreme expression of anxiety, apprehension, or helplessness when confronted with the phobic situation or feared object. the person avoids the situation in which the symptoms have occurred and restricts life in ways that become problematic as the original phobic object. NOT: 1. have your parent practice deep breathing and relaxation techniques before leaving the house (this makes the student responsible for the parent's care. the parents anxiety apprears pathological and requires professional help.)

A nurse prepares to perform a venipuncture on a client with Crohn's disease. The client becomes upset enough what are you really going to be injecting into my veins? which is the best response by the nurse 1. Nothing I'm just going to draw some blood 2. you sound frightened what are your specific concerns?

2. you sound frightened what are your specific concerns? Rationale: allows client to verbalize feelings I'm concerned Not: 1. Nothing I'm just going to draw some blood

how soon can a colostomy start to function post op

3-6 days after surgery, cannot irrigate before then

The nurse receives a prescription to start an IV dopamine infusion for a client with hypotension. Which action does the nurse take next? 3. Check to see if the client received volume replacement. 4. Attach the client to an oxygen saturation monitor.

3. Check to see if the client received volume replacement rationale: Adequate fluid volume must be achieved before vasopressors are given because this vasoconstrictor results in further reduction in tissue perfusion without volume.

The nurse provides care to a client who is unconscious. In which position will the nurse place the client to provide oral care? 3. Side-lying. 4. High Fowler.

3. Side-lying. rationale:When performing oral care to an unconscious client, the nurse should place the client in a side-lying or lateral position to facilitate the flow of secretions by gravity to prevent aspiration during the procedure. The nurse can also keep the head of the bed lowered

The nurse provides care to a client with an internal radiation implant. Which intervention will the nurse include in the plan of care? 2. Placing the client in a semiprivate room at the end of the hallway. 3. Wearing a lead apron when providing direct care to the client. 4. Keeping all linens in the room until the implant is removed.

3. Wearing a lead apron when providing direct care to the client. 4. Keeping all linens in the room until the implant is removed. not: 2. A private room with a private bathroom is essential to prevent the exposure of others to radiation.

A client with a newly casted lower leg reports to the nurse that the foot feels numb. Which action will the nurse take firs? 1. assess for pain 3. notify the hcp

3. notify the hcp rationale:Compartment syndrome begins with edema and increased pain. It progresses with decreased perfusion, causing a change in skin color and weak pulses. Numbness is a later sign that could indicate tissue necrosis. This is an emergency that should be reported to the health care provider. not:1. assess for pain that can be done after provider is called.

the wound care nurse assess a group of clients. The nurse determines that which client is receiving appropriate care? select all 1. the client one day pos-operative after an appendectomy with a hydrogel dressing over the surgical site 2. the cleitn with necrotic areas on both heelse covered by sterile gauze and tape 3. the client with a stage 3 pressure injury whose hydrocolloid dressing is changed weekly 4. the client wit a spinal cord injury who has a non-blanching reddened aread coverd by a foam dressing. 5. the client whose poorly healing led wound is being treated with a negative pressure wound vacuum system

3. the client with a stage 3 pressure injury whose hydrocolloid dressing is changed weekly 4. the client wit a spinal cord injury who has a non-blanching reddened aread coverd by a foam dressing.* (a foam dressing will protect a sage 1 pressure injury,) 5. the client whose poorly healing led wound is being treated with a negative pressure wound vacuum system not: 1. the client one day pos-operative after an appendectomy with a hydrogel dressing over the surgical site (not absorbent enough for a surgical incision. this client is not receiving appropriate care) 2. the cleint with necrotic areas on both heelse covered by sterile gauze and tape (sterile gauze will no provide the debridement needed for necrotic wounds)

The therapeutic range for heparin

30-90 Rationale; 1.5 -2 times the control level Lowest Normal range (20) X 1.5=30 Highest normal range (45) x 2=90

A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level indicates. Which information does the nurse provide to the mother?

A neural tube defect. not: lung maturity, An amniocentesis is used to determine lung maturity.

The nurse provides care for a client diagnosed with systemic lupus erythematosus (SLE). Which finding will the nurse find most concerning? 1. Blood pressure reading of 152/90 mm Hg. 2. Blood urea nitrogen (BUN) level of 40 mg/dL.

Blood urea nitrogen (BUN) level of 40 mg/dL. rationale: A BUN of 40 mg/dL is well above the normal range of 10 to 20 mg/dL. Nephritis is the most common renal problem; however, the potential for renal disease must be managed aggressively and early to prevent kidney failure. not: Hypertension since it is an expected cardiac side effect; pericarditis is the most common cardiac finding.

Infant of 32 weeks of gestation has 4lbs motttling of the skin and acrocyanosis with irregular respirations of 60 breaths per minute. which newborn problems does the nurse suspects the client is experiencing

Cold stress

frost bite treatment

Elevate extremity after rewarming, provide adequate anelgesia, provide continuous warm water soaks. Allow wounds to dry after rewarming before applying loose non adherent sterile dressing . Momitor for compartment syndrome

The lab values of a patient that reveal the presence of hepatitis B surface antigen is a hepatitis B antibodies which of these resuls should the nurse also expect to see

Elevated serum transaminate (ALT) and AST, and Prolonged Prothombin(PT)

the nurse provides care for a client who had epidural morphine following a cesarean birth. Which intervention does the nurse include in the client's plan of care for the first 24 hours after the delivery?

Encourage increased fluid intake. Not: Determine patellar reflexes. Rationale: the client can prevent constipation by increasing fluid intake, and fiber

Wavelike flank pain in urolithiasisis

Expected

Low urine output for the first 24 hrs post op is expected or emergency

Expected ( due to fluid restriction before op)

Pt in hemodialysis with acute kidney injury with potassium of 6.2

Expected findind in acute kidney injury, is being addressed by dialysis

A pt discharge with an o2 tank and nasal cannula should use vaseline for dry nose true or false

False! It is flammable use water soluble lubricant instead

Blood sugar level fasting and non fasting

Fasting; 199 and non fasting 125

risk for cholelithiasis (gall stonges)

Fat, Female, Forty, Fertile, Fasting for religious reasons (decreases gall bladder movement) Not: african american but Hispanic, native american, US south western

which statement is wrong if said by a pt with latent TB

I'm glad i dont have to take any medication rationale:if latent TB if not effectively treated, can become active later and cause disease. not: latent Tb is not contatigous, the immune system stopped TB from growing, it can become active if not treated

What drug can cause increased wheezing in asthmatic patient

Ibuprofen

What type of drug should a pt on lithium avoid

Ibuprofen (NSAID) Rationale; acetaminophen is better option as it does not decrease renal blood flow leading to toxicity

The montoux skin test shows what about TB

If the pt has been infected with tb

Implanted port

Inserted under skin and then brought out under subq tissue and attached to the catheter which is threaded into this superior vena cava examples Mediport and Port-A-Cath

Older couple say they can manage alone just need help going grocery shopping and housekeeping these are

Instrumental activities of daily living

Position: Modified Trendelenburg

Interesting as the time is for shock prevention n treatment

The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which finding indicates to the nurse that the client is experiencing cor pulmonale?

Jugular vein distention indicates cor pulmonale (right-sided heart failure)

which intervention will minimize the risk of increasing ICP

Keep the clients head from flexing or rotating, elevate the HOB 30 degrees, and avoid frequent suctioning. not: maintain liquid diet, perform traech suctioning, and turning client every 2 hrs

The nurse plans care for a client diagnosed with left sided paralysis and slurred speech. which direction is most important to give an AP? 1. Turn the client every 2 hours 2. Keep the head of the bed elevated to 30 degrees

Keep the head of the bed elevated to 30 degrees rationale: facilitates venous drainage from the brain and reduces ICP. not" 1. Turn the client every 2 hours (not as important as cerebral tissue perfusion

The nurse suspects that a newly admitted client might be a victim of elder physical abuse. Which is the nurse's priority action? 1. Call the local police precinct. 4. Notify the health care provider. View Explanation

Notification of the health care provider is essential for comprehensive assessment. not. 1 it it not the nurses responsibility

2 signs of impending labor

Passage of a thick mucus plug from the cervix and rupture of the amniotic membranes

What test should be done for a pt with allergies from an unknown cause

Patch test

Irritable bowel syndrome sign

Pattern of alternating diarrhea and constipation

A pt 32 weeks gestation went into cardiac arrest. What is the best intervention

Perform chest compressions slightly higher on the sternum -the uterus should also be displaced to the clients left to reduce pressure of the vena cava and aorta

Patient taking propranolol and furosemide should be assessed for

Peripheral edema: verapamil and antihypertensive can cause hypotension and heart failure

Elderly pt with confusion, mood lability, inpaired communication, and lethargy. Nurse should question

Placing him in trendelenburg as it is used in pts with varicose veins

The nurse provides care for a client who is confused and reports a headache. The client's vital signs are as follows: temperature 101.0°F (38.3°C), BP 150/64 mm Hg, pulse 58 beats/min, and irregular respirations of 12 breaths/min. Which action does the nurse take next? 1. Administer morphine 4 mg intravenously. 2. Prepare for a head computerized tomography (CT) scan.

Prepare for a head computerized tomography (CT) scan. rationale:The client is demonstrating signs of increased intracranial pressure (ICP) and Cushing triad. A head CT scan is indicated. not morphine:Morphine alleviates pain but may mask neurological symptoms.

a 36 week-old prima gravid client with history of diabetes mellitus us is admitted with preeclampsia which of the following actions should the nurse take first

Prepare the client for childbirth

Pt with left femur cast can exercise by

Quadriceps setting of the affected limb(isometric exercise) maintains strength in affected limb

The nurse observes a student nurse perform closed urinary catheter irrigation on a client with decreased urinary output. Which observation indicates that the student requires additional teaching to perform the procedure correctly?

Quickly instills the sterile saline. - The solution should be instilled slowly to help loosen clots and sediment and to prevent trauma to the bladder wall. not:Clamps the urinary drainage tubing below the irrigation port. (Correct action)

Which is primary risk for hypertension

Race(African american) Note: low serum lipids associated with lower risk

The nurse plans to delegate a task to a new nursing assistive personnel (NAP). The nurse discovers that the NAP has never performed the task and changes the assignment. Which right of delegation does the nurse follow in this scenario?

The right person rationale: is choosing the correct personnel to complete the task. The NAP had not performed the task before, so the nurse decided to not delegate that task to the NAP.

rinne test

The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal not: when the stem is held at the middle of the forehead that would be The Weber test.

Older a client diagnosed with pneumonia is admitted to the medical surgical what other clients should the nurse place with him

The still recovering alcoholic or cellulitis on the right foot Rationale; Both clients have infections

The nurse provides care for a client diagnosed with deep vein thrombosis. The client receives warfarin therapy. Which laboratory test result indicates to the nurse that treatment is successful?

The warfarin dose is within therapeutic range when the client's international normalized ratio (INR) is 2 to 3. not: 1-2

Client with Kaposis sarcoma virus secondary to HIV wants to be an organ donor

Theyre illness prevents them from being donors

A patient with impending sense of doom myocardial infarction confirmed by 12 lead ECG you and a stroke one month ago should not have which medication

Thrombolytic therapy Rationale: contraindicated in clients with a history of recent (past 3 months)

the nurse of ICU needs to admit a client with head trauma for assessment. There are no empty beds, which client does the nurse anticipate as being the most stable for a transfer to the step-down neurological unit.

a client diagnosed with stroke 4 days ago who is exhibiting confusion. rationale: after 4 days the risk of this client having a second stroke is significantly reduced. therefore the focus of care is rehabilitation. 2. A client with a head injury who is having seizures 3. a client diagnosed with bacterial meningitis and a glasgow coma scale of 7 (under 8 is comatose)

what pt is at risk for pressure injury

a client with skeleton traction who is diaphoretic, a premature neonate with nasogastric feedings* not: and infant to had surgical repair of an umbilical hernia ( infant should be mobile after repair) not: a client with reddened areas that blanch on the elbows. (not pressure problem

A client with a history of intravenous drug abuse experiences a low-grade fever, cough, night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum. Which transmission-based precaution will the nurse use for this client?

airborne: rationale: The client's history and signs suggest pulmonary tuberculosis, which is spread by airborne pathogens (M. tuberculosis). Airborne transmission-based precautions should be initiated immediately.

after abdominal surgery the client reports abdominal gas pain. the nurse should

ambulate the client frequently raitonale:promotes the return of peristalsis and faciliates the expulsion of flatus, reducing gas pains. not: teach how to splint the abdomen during activity: it does nothing to increase peristalsis after surgery. will alleviate stress on the surgical site but not relieve gas

client with ataxia should be supervised during

ambulation ataxia means poor coordination (like they are drunk)

The nurse assists with a cardiac arrest for a client in ventricular fibrillation. Cardiopulmonary resuscitation is in progress and 1 mg of epinephrine was just given. The nurse is likely to give which medication next?' 1. amiodarone or atropine

amiodarone not atropine: Atropine is no longer indicated in cardiac arrest, only in symptomatic bradycardia.

compound fracture

an injury in which a broken bone pierces the skin, causing a risk of infection.

Malignant hypothermia initiated by

anesthetics such as (desflurane, isoflurane, halothane) and succinylcholine (paralytic for general anesthesia.

who should the nurse see first a client with a loose tooth with epilepsy or a client reporting the arm cast feels too tight.

arm cast, loose tooth is potentical problem

older client has glaucoma, hard of hearing, and experiencing abdominal pain for the past 24 hrs. the most appropriate nurse action is to

ask if the client wears hearing aids (nurse should determine if the client can hear what is being asked before finding out pain scale. Asking if hearing aids are in place comes before pain scale not: rate pain on pain scale.

nurse administerign medications to a client on a psych unit. the client says i dont usually take a pink pill. what should the nurse do

ask the client for a list of routine medications, and then confirm the prescription with the heath care provider. not: check mar, determine its correct, and tell the client to take the med. as it does not include client as a partner in the clients care

24 hour urine analysis should

ask whether the collection container contains a preservative . Urinary catherers not necessary unless incontinent.

intervention for preschool child with characteristics of autism

assign the same nurse to the clients care each day rationale: continuity of care is important in any child but especially with autistic children.

haldol adverse effects

bloody dyscrasia and extrapyramidal symptoms

Biophysical profile include which assessment

breathing movement muscle tone amniotic fluid volume

range of motion assist elder clients in

carrying out ADLS (Prevent muscle contractures and maintain joint mobility) not: muscle strength

lice teaching

comb hair daily, repeat permethrin rinse if nits are still present after 7 days, wash clothes with hot water

client with aluminum hydroxide. nurse should look out for which side effects

constipation: may need laxatives or stool softener

resiratory syncytial virus (RSV) precaution

contact precations,

if the family of a client is calling because the clien had midsternalchest pain but refuses to seek medical attention the nurse should first

contact the client and report being asked to visit by a family member. rationalE: The client needs to give permission for nurse to enter home not ask the family member if there are color changes and dyspnea. the client needs to be assessed directly not through info given by family member.

nurse has order for D5W 100 mL with 80 mEq KCL to infuse in 30 minutes. what action does the nurse take

contact the health care provider the rate of IV administration should not be more than 10 /hr. (20-30 may be allowed in specialized setting and only through a central venous line) not: order lidocaine, these combinations are avoided

Adolescent that fell and lost consciousness has persistent headache unrelieved by acetaminophen the nurse should

contact the health care provider: sign of skull fracture

client had been admitted for 24 hrs and shows signs of withdrawal. the hcp has prescribed chlorpromazine im the nurse should

contact the healthcare provider: rationale: the nurse should get an order for benzodiazepine to sedate and calm nuerological irrability not administer: chlropromazine and antipsychotic antiemetic not a med to treat withdrawal symptoms

positive treatment sign of client receiving treatment fro myxedema

discuss the family finances with a spouse. hypothyroidism causes slowed mental functioning, discussing financial affairs indicates improves thought processes and improvement in health status.

alzheimers clietn wanders into clients room the nurse shoudl

encourage the client to assist with sorting linen rationale: this option preserved dignity, does not block wandering but uses it constructively while protecting other clients from intrusion not :place the client in a geriatric chair with a clipboard to complete a puzzle; a geriatric chair is a form of restraint, they will not be able to complete a puzzle.

priority after applying restraints

ensuring they were applied correctly not: hydration status

the stoma and ties of a patient with a tracheostomy should be cleaned and dressed

every 8 hrs, the ties every 24 hrs

moisture in ventilaiton tube expected or priority

expected

pt with raynauds disease with throbbing and tingling in fingers expected or priority

expected

Pt with thrombocytopenia and petechiae on arms expected or priority

expected sign of platelet under 150,000

umbilical cord of day old newborn is dry and hard to the touch priority or expected

expected, non expected:swelling

dialysis graft for hemodialysis access has new onset pain and redness priority or expected?

expected: they are prone to infection, the pt it assesed for erythema, graft tenderness, fever and tachycardia but not priority

priority for adolescent with bilateral pelvic pain about to have a pelvic exam

explain procedure priority over collecting urine.

pt with right femur fracture placed in thomas splint and pearson attachment is at risk for

fat embolism

3 days after extracaspular cataract extraction with intraocular lens implantation the nurse would be concerned with

i am feeling really good. when i get off the phone i an doing to the vacuumin and then play golf. rationale: gold involves too much hand jerking movements and golf too much flexion and rapid movement which can cause tissue damage to operative site. not: hair shampooing and being tilted back is fine

a client with cervical cancer and a cesium 137 implant needs further instruction if she says

i will abstain from sexual intercourse and not use tampons for 2 weeks. rationale: she can resume normal activities after discharge, she is instructed to avoid sexual intercourse and tampons until a follow up visit with the health care provider which is 6 weeks after discharge. not: i cannot lift either of my children for 2 months, (it does not require further teaching)

the nurse insructs a primagravida woman during the third trimester about the signs and symptoms of impendind labor which statement inidacted to the nurse the teaching was effective?

i will call the HCP when my contraction occur every 5 minutes for an hour.

further teaching is required for advanced stage of liver cirrhosis

i will increase the amount of fat and sodium in my diet -i will incease the amount of fluids* they should decrease the amount of fluids to help prevent or manage ascites

successfult teaching of chlorpromazine is

i will take extra care to do proper mouth cleaning: rationale: dry mouth is common, important to keep moist with frequesnt brushing, flossing, and sucking on hard candy not: this med may cause eyes to tear: the med may cause dry eyes so use artificial tears

which should not be given to a graves pt

iced tea: rationale: its a caffeinated beverage stimulant that would increase metabolic rate. the graves pt

correct teaching for nicotine patch

if you smoke while you are using the nicotine patch, you are at risk of having a heart attack.

client undergoing Billroth II procedue can minimize complications if the nurse instructs the client to

increase consumption of fat protein rationale: avoid dumping syndrome associated with surgery by decreasing carbs and increasing fat and protein

NG Tube use with medication

indicated when pt is NPO, medications cannot be given by mouth at this time and would required nurse to check if they can be crushed or givne in liquid form. -after giving medication through NG tube, nothing else shoudl be provided through the tube for atleast 30 minutes. -they should not be givendirectly into the enteral feeding. due to proper documentation of when it was given and if the client received all of it. -the nurse should flush the tube with 15 to 30 ml of warm sterile water between each medicatio to keep the tube clear. 60 ml would lead to overload. -the nurse should clamp the tube for 30 minutes after administering the medications to enhance absorption and prevent interactions with enteral feedings. -ph gastric ocntects should be less than 5

an infant admitted with pyloric stenosis, his parents ask how they can avoid the condition to happening to another child

inform them its a structural problem, not a reflection of their parenting not: it is an inherited condition, not your fault rationale: answer has better therapeutci communication

group of clients have been exposed to hazardos chemical who does the nurse see first between a client that swallowed the chemical or one that inhaled the chemical

inhalation: rationale: results in immediate absorption and can impair oxygen exchange. he should be assessed for airway and adequacy of breathing not: swallowing: GI exposure is serious but not as life threatening as impaired gas exchange.

instruction on houw to use an incentive spirometer 1. inhale thorugh the mouthpiece and hold your breath for 3 seconds exhale into the spirometer for 3 seconds

inhale thorugh the mouthpiece and hold your breath for 3 seconds exhale into the spirometer for 3 seconds

what is the proper way to suction a client with endotracheal tube after he was ventilated

insert sterile catheter, begin to withdraw, apply suction, and continue to withdraw while rotating the cath. note: suctioning while inserting decreases the oxygen in the airway. no saline solution necessary

a client takin iodine I-130 to treat hyperthyroidsm. the nurse should monitor for which complication 1)lethargy, sensitivity to cold, dry skin, weight gain, depression 2)irritability, weight loss, nausea, vomiting, postural hypotension.

lethargy, sensitivity to cold, dry skin, weight gain, depression not: irritability, weight loss, nausea, vomiting, postural hypotension. (related to primary adrenal insufficiency.

newborn with myelomeningocele. the most important nurse action is 1. monitor for elevated temp, irrtability, and lethargy 2. apply lotion to helathy skin and gently massage the skin

monitor for elevated temp, irrtability, and lethargy raitonale: the newborn is at risk to develop an infection called meningitis because of the myelomeningocele sac. change the dressing every 2-4 hours using aseptic technique. monitor the temp and the infant for sing of increased irritabilty not: 2. apply lotion to helathy skin and gently massage the skin. (although necessary, this is not priority over infection.

a nurse teaching a parent of a 4 month old client about to receive Haemophilus influenza type b(HIB) vaccine should be told

monitor your child for signs of allergic reaction for a few hours after the vaccine purpose:preven HIB disease, which can cause meningitis, brain damage, and deafness.

intervetnion for client with command hallucinations

nurse should ask what are the voices saying rationale: ensures safety not: administed antipsychotic med

The nurse provides dietary teaching to a client with an acute kidney injury. Which menu selection made by the client indicates to the nurse that teaching is effective? 1. Potatoes. 2. Raisins 3. Pasta.

pasta: A client with an acute kidney injury is at risk for hyperkalemia. Pasta is not a good source of potassium and should be selected. Pasta is also good to meet caloric requirements and spare using protein for energy.

client with radium implant with have which precaution

place the client on a low-residue diet to cecrease bowel movement not: check the position of applicator every 2 hours (it should be 8)

how scd stockings are applied

placing the antiembolism stocking on before wrapping and securing the sleeves

priority car in pt with hypoparathyroidism

plam measure to deal with cardiac dysrhythmias due to low serum calcium

client with radium implant the nurse should implement plan care to decrease the time spent in the clients room wear lead-lined apron when providing care for the client

plan care to decrease the time spent in the clients room not: wear lead-lined apron when providing care for the client (it is not required for routine care)

sign of hypocalcemia

positive trousseaus sign, circumoral numbness, hyperreflexia

medications that require blood glucose monitoring in diabetes pt

prednisone, estrogen, atenolol

client with trigeminal neuralgia is takine carbamazepine for

relieve of agonizing pain rationale: trigeminal neuralgia creates shocklike facial pain, difficult to manage,

when would you call rapid response

resp rate of under 8 or more than 28, sustained change in loc for 10 minutes, H.R under 40 or higher than 130/min, systolic bp under 90mm hg, o2 under 90 even with oxygen

client with prescription for warfarin and atrial fibrillation. the nurse give priority to which diagnosis

risk for injury rationale: anticoagulation therapy puts clients at greater risk if injury occurs not: risk for imbalanced fluid volume: not associated with anticoagulant therapy

pt care for a client who underwent supratentorial craniotomy to remove a brain tumore. the nurse should place client in which position

semi-fowler, headmidline, minimal hip flexion not left lateral: as he should be place on non affected side and affected side was not noted in question

A client with osteoarthritis is being taught how to decrease pain and stiffness in the joints before begining the daily routine

take a warm bath and then rest for a few minutes. rationale: heat reduces pain, spasms, stiffness in joint. Ice may be helpful for acute inflammation not exercise:it would be painful

most important teaching for client sent home with positive VDRL

take all of the medication.

priority teaching for TB pt to prevent the spread of disease

take your medication as prescribed. rationale: correct therapy lead clients to become non-contagious. if they dont they will develop drug resistan TB.

a child with right ankle fracture can prevent skin breakdown by

teach client to perform isometric exercises of the right leg

client was sexually assaulted the nurse should first care for all urgent medical problems or document contusions and laceration of perineum and cervix?

teat all urgent medical problems rationale: stabilizing client is most important, documentation next

client with delusion says he is the head of hospital system says he is working undercover to discover client abuse, initially the nurse should say

tell me what you mean about being head of the hospital system gathering info. rationale: initial approach is to clarify meaning, after clarification the delusions should not be discussed or argued as they may reinforce them.

medication nurse would question for pt with angle closure glaucoma

tetrahydrozoline contraindicated: cuases vasoconstrictor

client with conversion reaction would have

the client is experienceing blindness withou an identified physical cause not: the client is experiencing delusions of messianic grandeur

client diagnose with empysema arrives to the emergency dept with family. he is short of breat and ashen. his respiratory rate is 36 breathes/min. oxygen is started what observation is the most concern

the clients skin color is pink within the first 20 minute of oxygen. rationale: color of COPD pt with hypercapnia due to emphysema, will be ashen then pink then apneic or goes to respiratory arrest. remember: *pink puffer* mnemonic

the home health nurse visits a client who was hospitalized with chronic kidney disease and sent home on continuous ambulatory peritoneal dialysis (CAPD) which statement made by the client most concerns the nurse

the fluid draining out has looked cloudy the last couple of days. raitonale: cloudy or opaque dialysate is the earliest sign of peritonitis, a major complication of peritoneal dialysis. the normal outflow is clear and light yellow. not: sometimes i forget and carry the groceries on my left arm there is no need to avoid use of an arm in peritoneal dialysys, rather than hemodialysis.

client with pneumothorax has a chest tube connected to a 3 chamber water seal drainage system with 20 cm suction. the nurse determines the lung has re-expanced if which observation is made

the fluid in the water seal chamber does not fluctuate with respirations rationale:sign that not more air leaking into pleural space. not: continuous bubbling: sign of air leak.

client with closed head injury is oriented and reports a slight headache at admission. which symptom woudl require immediate intervention by the nurse

the headache worsens and LOC decreases rationale: increase in headache and decrease in LOC req immediate attention such as CT scan, dexamethasone to help with cerebral edema, inserting ICP monitor not :single vomiting episode and continued slight headache. as vomiting once or twice is a normal response to monitor a head injury.

how is hemophilia transferred to a child

the mother transmits the gene to her son rationale: it is a sex linked disorder: mother to son, father to daughter

who is more urgent a multipara who gave birth to a 6lb baby and has a recent substance use history or a multipara who give birth a 5lb 9 oz baby afer 2.5 hours of labor

the mother who gave birth in 2.5 hours rationale: risk for shock and hemorrhage while the the other mother will need to be assessed for withdrawal within 1 to 2 days of being hospitalized.

which is a priority: a primagravida with baseline fetal heart tones 136 bpm with decelerations to 116 bpm independent of contractions or a multigravida with baseline fetal heart tones of 150 bpm increasing to 170 bpm mirroring uterine contractions

the primagravida: sing of repetitive variable decelerations, which indicates umbilical cord occlusion that need immediate response

the home care nurse visits a client daignosed with cerebal palsy. the clients primary caregiver has been experienceing diarrhea secondary to viral gastroenteritis. which observation indicates a need for follow up by the nurse

the primary caregiver prepares a sandwich for the client. rationale:prevent the spread of gastroenteritis

the nurse should stand directly infront of a pt with menieres syndrome because

the pt does not have to turn the head to see her rationale: decrease vertigo attacks

the nurse preparing to administer a tb skin test to a pregnant client. which is true

the reaction is measured in millimeters of the induration and read 48 to 72 hours after administration

a client with type 1 diabetes not willing to perform blood glucose, he tests his urine for glucose and acetone. the nurse knows blood glucose monitoring is preffered ove urine test for which reason

the renal threshold for glucose is elevated in the elederly

which is a priority a pt with cataract exraction 3 days ago reporting nausea or client with spinal cord injury at the level of C6 reporting a headache

the spinal cord injury rationale: severe headache indicative of autonomic dysreflexia in the client with a high level spinal cord injury. autonomic dysreflexia involves a high blood pressure and if untreated can result in intracranial bleeding and death. not: the cataract exraction he would be 2nd as vomitin increases intraocular pressure.

the client develops a post op infection and receives creftriaxone sodium iv every day. the nurse should monitor for which changes

the surface of the tongue rationale: long term use of cephalosporing can cause overgrowth of organishm

adolescent client reports a missed dose of a norethindrone estradiol pill yesterday and the day before. what do you instruct her

use another method of birth control for the remainder of your cycle. -she should also take 2 tabs/day for the next to days then regular doses afterward. -if she had only missed one pill then the nurse would of just instructed her to take 2 pills the next day and continue the normal dose afterward.

The nurse teaches a client about complications of venous insufficiency. Which complication will the nurse include as the most serious complication?

venous ulceratnions Not: Neuropathic ulcers rationale: they are associated with diabetes, not venous insufficiency.

Clients with receptive aphasia should be instructed with

visual aids and hand gestures Not: hand written since they cant interpret spoken or written language

intervention for peritoneal dialysis

warm dialysate solution

client comes in reporting tingling and weakness in the lower extremities that started when getting out of bed. the symptoms seem to be progressin upwar, most important thing for nurse to consider it

we have been in the final preparations for a trip overseas. rationale: immuniziations may hav been given prior to this trip and could have triggered Gullain Barre syndrome which are acute and start at feet but can go toward head. emergency condition with potential to compromise respiratory muscle. not polio: an infectious disease vs. inherited

client at 38 weeks of gestation lies should be instructed to

wear low heeled shoes to decrease back pain not: lie on back with feet elevated as it can compress the vena cava and decrease supply to the fetus

graves diases pt expected to have

weight loss of 10 lbs in 3 weeks due to increase metabolic rate

when a medication error occurs, the nurse should document ______ in the clients medical record but not the _____. the incident report should be completed in ____.

when a medication error occurs, the nurse should document THE EVENT in the clients medical record but not the INCIDENT REPORT WAS COMPLETED. the incident report should be completed AS SOON AS POSSIBLE. Not: 48 hours after the event.

immunization of client in 3rd trimester of pregnancy

you are not immune to rubella and will get immunized after your baby is born -if need you can get the tetanus vaccine while you are pregnant* -while pregnant, you should receive the influenza vaccine during flu season not: the pertussis vaccine should not be taken while you are pregnant. Rationale: inactivated vaccines such as those for tetanus, hep B, and influenza are safe for women who have a risk for developing these diseases.

subcutaneous emphysema at the chest tube priority, expected

the nurse should asses for a popping sound, palpate for crackling sensation but is not a big priority it is air that leaks into the tissue surrounding the chest tube insertion. usually a small amount and reabsorbs spontaneously.

priority assessment for client ordered promethazine hydrochloride iv push

the patency of the clients vein

client refuses to let a student nurse care for him saying "they are going to hurt me" which response by student nurse is wrong.

-dont worry, weve never killed anyone, -we often look pretty scary, -the nurse will assist you with your bath instead.*

client with a transection of the spinal cord at t-5 after a mvc will concern the nurse if he states what 1) i emptied my bladder 7 hours ago 2) i smoke 2 packs of cigarettes pers day

i emptied my bladder 7 hours ago rationale: bladder retention will cause autonomic dysreflexia

nurse would be most concerned if pt with history of gastric ulcer and current symptoms of nausea, vomiting, and diarrhea for 2 days says

i have been drinking more fluids to keep from getting dehydrated, but i am urinating less than I thought i would. rationale: lack of urine output can be first stage of shock. with clients ulcer it can be bleeding, and combined with diarrhea and vomiting it could mean hypovolemic shock.

endotracheal tube sucitoning done by

insters the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn. Never suction longer than 10-15 seconds

Order in which to administer red blood cells to a client

1) verify order 2)assess client had blood bank id band 3)explain procedure 4)obtain vitals 5)prime bag wuth 0.9 sodium chloride 6)obtain blood from blood bank 7)bedside identification with 2 nurses

Interventions to promote comfort and rest for a client diagnosed with left sided heart failuref

1)Take on walks to increased mobility and circulation 2) raise the head of the bed. 3) offer stress reduction strategies

Fhr during prenatal

120-160 bpm

Adult erikson stage

19-34 yrs old Intimacy vs isolation. 35-64 yrs old generativity vs stagnation Dilemma: feeling life is meaningless

preciptous labor is priority or non-priority

priority: risk for early post partum hemorrhage and amniotic fluid embolism. rationale: preciptous labor is labor pattern that progresses quickly and ends less than 3 hours after it began. Especially in multipara

client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago. expected or priority

priority: asthma exacerbation may require repeat nebulizer every 20 minutes, or continuous nebulization for 1 hr to

pt with sudden onset "the worst headache of my life" non-priority or priority

priority: sign of subarachnoid intercerebral bleed. emergent condition caused by rupture of vessel has a high mortalioty rate

a client being treated for fear of heights, the nurse know that phobias involve which behaviors

projection and displacement projection: attributing ones thoughts or impulses to another) displacement: shifting emotion concerning person or object to another neutral less dangerous person or object not reaction formation which is development of concious attitured, and behavior patterns into opposite of what one really wants to do and symbolization something represents something else.

client with diabetes type 2 with order for glimepiride. nurse should question which meds

propanolol; can mask symptoms of hypoglycemia, ibuprofen, ginseng, gemfibrozil: increases hypoglycemic event, not gingko bilboa

soft spot on the head of newborn feels elevated when the baby sleeps

should be immediately assessed; indicates increased intracranial pressure expected: soft and flat

pt with concussion should/should not receive aspirin

should not: can prolong bleeding. acetaminophen can be give every 4 hrs

comatose pt should be in which position

side lying with the bed flat so saliva runs out of the mouth instead of being aspirated by lungs

pt with histroy of chronic hypertension exhibiting epitaxis and blurred vision is

sign of hypertensive encephalopathy: medical emergency. hypertensiver crisis creates cerebral edema and ICP, can be life threatening requires immediate assessment

Guillain Barre pt given priority when

signs and symtoms are affecting diaphargm not when they are affecting lower extremities

The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom should the nurse immediately report to the healthcare provider?

slurred speech rationale: sign of possible stroke expected sign: cyanosis of tongue, jaundice, slow cap refills

Infant with Fetal alcohol syndrome are born with

small head, underdeveloped cheek bones, low birth weight, learning disabilities, not: hypertension

left sided cerebral infacrt with affect

speech, math, analytical thinking

lyme disease precaution

standard

a client in a halo vest traction with a sutained an injury 2 days ago. the nurse is most concerned about which client statement

it hurts when i chew rationale: if jaw pain movement occurs 24-48 hours after halo traction is applied, it may indicate the skull pins have slipped onto the thin temporal plate. notify the health car provider immediately not: i have a headache tightened screw of halo can cause headache that can be treated with anagesics

client with pulselessness and asystole should be treated with

iv epinephrine, o2 with bag mask, chest compressions

intervention for a nurse caring for client with acute confusion and delirium

keep the room organized and clean not: keep lights in the room dimmed during the day. rationale the room should be well lit during waking hours to promoted adequate sleep at night

low income option for protein needs

legumes

breast feeding mom with diabetes will require more insulin or less

less, it has an antidiabetic effect

client with hypercalcemia will have which risk factor

malignant neoplasm rationale: most common causes are malignancies and hyperparathyroidism. not: hypomagnesemia rationale: clients with hypomagnesemia are at risk for hypocalcemia

the nurse prepares to administer influenza vaccine to the client. which will the cause the nurse to question giving the vaccine

medication for Rimantadine* and Zanamivir rationale:both may effect the efficacy of influenza vaccine: not:Acyclovir

baby found with curdlike patches in oral mucosa requires

medication, nystatin to treat thrush. not: dont let baby sleep with bottle

best fluids to offer a toddler admitted for lead poisoning

milk: as calcium binds to lead and inhibits its absorption

arterial line is used for

monitoring blood pressure, heart rate, obtaining blood gasses and other lab samples

sign a pt has a complication of autonomic dysreflexia

severe pounding headache, profuse sweating, nasal congestion

priority nursing intervention for a client who was in a car crash and unresponsive

-assess the client for a carotid pulse -find clients glascow coma scale -place a hard cervical collar on the -remove the client from car and onto a backboard

factors that contribute to sleep apnea

1. Obesity 2. Short neck 5. Smoking

A pt receiving cimetidine iv reports headache and dizziness what should the nurse do first 1.stop 2. Assess vitals

1. Stop(will cause lease harm)

The nurse provides care for a client diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the client. When will the nurse administer this medication?

1. Twice a day within 1 hour before morning and evening meals.

malpractice elements

injury, causation, duty, and breach of duty not: intention

indwelling catheter size for pediatric client

8 french

effective way to use timeout

Time-outs can be used when appropriate but should not exceed 1 minute for each year of age.

Airborne precautions

MTV or My chicken hez tb = measles, TB varicella(chicken pox) Herpes zoster/shingles

Normal alcohol level

O%, to drive :Legal limit of intoxication is 80 mg/dL (0.08 g/dL)

changs that occur shortly after birth to faciliate a newborn's adaption to extrauterine life

-decrease in pulmonary vascular resistance -closur of the foramen ovale* -closure of the ductus arteriosus -closure of the ductus venosus

Before defibrelating a nurse should

Apply pads, make sure space is all clear, continue chest compressions untilready to deliver shock

Breast self exam and american cancer society

BSE not recommended as a screening tool for breast cancerA

BIPAP adverse

Change in LOC

walkers are good for

not recommended at any age (concerning finding)

First signs of sepsis and burn clients

Disorientation and fever

Hematocrit

Male-42-50, female 40-48%

which pt can be given to a nurse from another unit

a client diagnosed with an MI and reports burning on urination. NOT: a pt with a glasgow coma scale of 7 as under 8 indicate severe brain damage

contrainidication of cardiac catheterization

allergy to shellfish

a sign of intestinal obstruction

distended abdomen, with reports of pain, nausea, vomiting,

The graduate nurse attends an orientation to the oncology unit. Which statement indicates that the graduate nurse understands the teaching? 1. "Angiogenesis is only accomplished by malignant cells." 2. "Everyone diagnosed with cancer will die from it." 3. "Cancers metastasize through lymphatic spread to organs."

"Cancers metastasize through lymphatic spread to organs." rationale:Cancers metastasize primarily by spreading cancerous cells through the lymph system. not: Angiogenesis is the creation of a blood supply. The human body does this for many reasons; it is not unique to tumors.

which scenarios require the completions of an incident report

-client fell at 9:00 getting out of bed -levofloxacin 500 mg prescribed, 750 mg was given -client left facility before signing ama form -vesicant med infusing. client IV site warm to touch, reddedned and swollen*

The nurse instructs a client being discharged about home oxygen therapy. Which client statement indicates that further teaching is needed?

"I know I can turn up the rate of oxygen flow if I get short of breath." o2 is "My family members who smoke promise not to smoke in my room." no smoking anywhere in the room "We have a gas fireplace so I won't be breathing smoke from burning logs." rationale:Gas stoves or heaters are a fire hazard in the home of a client receiving oxygen.

The nurse teaches a new parent about umbilical cord care. Which statement by the parent requires follow-up teaching by the nurse?

"I will call my child's doctor if the cord becomes brownish black in color."- normal occurence not: Purulent drainage, redness, or edema at the cord base may indicate infection and is to be reported to the HCP

The nurse provides care for a client diagnosed with multiple myeloma. The client's new pain management regimen includes timed-release oxycodone and immediate-release oxycodone. The client asks the nurse how to schedule these new medications. Which response by the nurse is best? "Schedule both medications so that your pain is relieved all day." not:Take the immediate-release medication any time that you are hurting."

"Schedule both medications so that your pain is relieved all day." not:Take the immediate-release medication any time that you are hurting." This response does not address the schedule for the extended-release narcotic.

The parents bring their 4-month-old infant to the clinic for a wellness visit. They report trying to give the infant prepackaged baby food a couple of weeks ago, but the infant stuck out the tongue and would not take the food. Which response by the nurse is appropriate?

"That's a natural reflex; it will soon disappear and then your baby will be ready for solid foods." rationale: The tongue extrusion reflex is a natural reflex for an infant who is not developmentally ready for solid foods. This reflex disappears at about 4 to 6 months when solid food can be safely introduced into the diet. Not: Try introducing another food. Your baby probably doesn't like the taste of what you tried."

Aan observer tells the nurse that a client with suicidal ideation took off running. In what oder should the nurse do the following: -Notify security with client description -notify the nurse manager -Notify unit staff -ask observer in what direction the client went

-ask observer in what direction the client went -Notify unit staff Notify security with client description -notify the nurse manager

Priority with Newborn with spontaneous jerky movements

(Sign of hypoglycemia) determine blood glucose

ovulating signs

-basal temp will elevate for 2 days then decrease after ovulaiton -regular cycles will be fertile for 14 days after the begining of her period

client with ECG needs additional teaching if he says

-*i will wrap the device with plastic wrap before taking a shower (avoid showering while being monitored) -i will contact the healthcare provider is i experience light headedness, i will decrease my fiber during monitoring not: using safety razor: it is correct because the alternative using electric razor will interfere with monitoring

An AP is helping a client with right sided cervical vascular accident resulting in oral pharyngeal displacia. What action by the ap should the nurse intervene

-Adding milk to mashed potatoes to make it more liquid (risk for aspiration) -putting straw in fruit smoothie( straw cause increased swallowing difficulties and risk for choking controlling drink from a cup is easier)

BEST indicator that diuretic therapy in heart failure pt is improving

-Increase in urine output: -Less(reduction or elimination) crackles heard on auscultation Not: diminished as that would mean atelectasis pr decreased airflow

post mortem care

-Leave dentures or put in to restore pts structure. Its hard to do when rigormortis sets in

which assesment for pt in post anesthesia care unit requires the nurse to contact the HCP

-The client experiences coarse, crowin respiration -Respirs at 10 breaths/min -client is disoriented and has oliguria -client is restless and shouting -core temp is 94.8 not bp of 110/69

a pre-op pt is npo the night prior to surgery in the am. No medications are prescribed to be withheld before surgery. Which medication will cause the nurse to question is administration prior to surgery

-Triamterene 50 mg once daily for asthma (a diuretic are witheld prior to surgery, as they increase the risk for hypovolemia and hypokalemia) -Dabigatran 75 mg given daily for atrial fib (anticoagulants are witheld prior to surgery in order to preven excessive bleeding intraoperatively)

which factors would contribute to a false high BP reading

-Using a handcuff that is too short -repeating the assessment to quickly -positioning the brachial artery below the heart* -deflating the cuff to quickly not: using a cuff that is too wide: it may cause a low reading

preventives measures for client at risk for developing deep vein thrombosis

-compression stockings, --sequential compression devices -low molecular weight heparin

a client receiving thrombolytic therapy for blood clot in the lower extremity. which finding shows effective treatment signs

-dorsal pedal pulse +1 bilaterally, (sign of adequate blood flow) -affected foot slightly pink, - client reports feeling pinpricks on the great toe (indicates circulation is present) rationale: DVT causes pain or absence of sensation.

a pt is intubated on mechanical vent with worsening cerebral edema from icp what intervention can reduce intracranial pressure

-hyperventilating before suctioning (Induces vasocontriction), -maintaining a quiet dark envieonment, -maintain head of bed neutral midline Not: suction for 30 seconds to remove traech secretions. Maximum is 10 seconds as needed prolonged suction can increase ICP

pt with CVAD device being treated for osteomyelitis, requires further instruction

-if the dressing over this catheter gets lose, ill tape it back down, -if the catheter falls out, i will gently reinsert it, - ill put all these supplies in the trash as soon as im done with them. not: washing hands before touchign the catheter it is correct to wash hands if i see blood in the catheter, i will call my nurse, is correct, it can cause the infusion to slow or stop.

teaching for above the knee amputation (AKA)

-phantom limb pain is common after extrmity amputation -maintain the prone position several times daily. -anti-seizure medication may help with phantom limb pain (neuropathic pain)

client with abdominal surgery, has 3 staples that have dislodged and the wound edges are separating, the nurse will

-place sterile saline dressing over the wound -place the client in a semi-fowlers position with knees bent* not: encourage deep breath or coughing to avoid strain on abdomen.

Steps to remove bulb suction in order

1. Release suction 2. Remove sutures using sterile removal kit 3. Instruct client to breathe deep and evenly 4. Remove drain in continuous smooth motion 5. Assess the exit site for irrigation and drainage 4.

diabetes mellitus pt with anblood glucose of 200 at 0700. Should have it recheched at

0200 or 0300 when expecting rebound hyperglycemia

voluntary control of anal and urethral sphinters begins

at about 18-24 mothns of age not: 30 months

before starting physiotherapy nurse should do what first (do before meals, or auscultate breathe sounds)

aucultate breathe sounds before and after

The client just indicated a wish to commit suicide. The client asked the nurse not to tell anyone with action by the nurse is best

Report this to staff members in order to protect the client

Steven Johnson Syndrome (SJS)

Severe skin integrity issues blistering and skin shedding, high risk for infection

Expected diabetic Ketoacidosis sign

Shallow breathing 32/min

Albumin is use for

Shock blood loss low protein levels due to surgery or liver failure

which assessment will help the nurse determine the estimated date of delivery

auscultation of the fetal heartbeat can be heard at 12 weeks

Pediactric pt who just had tonsillectomy should be placed in which position

Side lying (Faciliates drainage from mouth)

Steps to administer blood products safely

1)verify client consent 2)check clients baseline vital signs 3) check physicians order 4)identify a stable vein and needle with proper gauge 5) set up equipment and start IV 6) and save her a spot for that from blood bank 7) verify client ID a double check the second nurse 8) hang blood 9) we can transfer you going to flow rate 2 milliliters per minute 10) Monitor clients vital signs and lung sounds for the first 15 minutes and there 11) after 15 minutes increase rate of infusion 12) Monitor pts vital signs and lung sounds for one hour after transfusion is complete 13) **** him and all activities and the clients medical record

who does the nurse see first 1) 54 year old with hypertension reporting headache and blurred vision 2) 72 year old with parkinson disease who is suddenly unable to get up out of bed

1) 54 year old with hypertension reporting headache and blurred vision, could be hypertensive crisis, not: 2) 72 year old with parkinson disease who is suddenly unable to get up out of bed (common in advanced parkinson disease

A pt with sickle cell anemia can prevent future crisis by

1) Avoid strenuous exercise (provokes hypoxia) 2) take pain medication as prescribed 3) avoid tight clothing (restricts circulation)

The nurse aspirates a central venous catheter prior to drug administration but is not able to verify blood return. The nurse does not feel resistance when flushing or see any fluid leakage, swelling, or redness around the catheter site which of these are the appropriate next step 1) Plus the cost of Celine using a 10 mL syringe and push. 2) request that the client cough and re-attempt aspiration 3) administer IV medication and observe for signs and symptoms of catheter malfunction 4) Play client in trendenburg position while attempting to aspirate blood 5) follows this is an a protocol to initiate a D clotting protocol

1) Plus the cost of Celine using a 10 mL syringe and push. 2) request that the client cough and re-attempt aspiration 5) follows this is an a protocol to initiate a D clotting protocol

A child biking to school and falls, he tells the nurse he thinks his leg is broken. The nurse should first 1) check the appearance of leg, 2) ask what happened

1) check leg

In what position should the nurse place a client with a prosthetic hip implant

Side lying with the affected hip in a position of abduction Avoid: adduction and internal rotation in early stage

A client with NG tube and dementia who keeps trying to pull out ng tube has an order for restraints. Which is most appropriate 1. Tie restraints to bed frame 2. Do Range of motion exercises daily

1. Tie to bed frame will allow sidecrails to move up n down. (ROM excercises should be done every 2-4 hours)

A pediatric client who just had tonsillectomy is in pacu what intervention should the nurse use 1. Institute measures to minimize crying 2. Cough n deep breathe hourly

1. Minimize crying (will cause the lease harm)

Client Positioning for thoracentesis

Sits up places arm over table, encourages to remain still

The nurse provides discharge instructions to an adult client hospitalized for pneumococcal pneumonia. Which instruction does the nurse include in the teaching plan? (Select all that apply.) 1. "Finish all of the antibiotics, even if you start to feel better." 2. "Continue doing your breathing exercises and using the spirometer." 3. "Report any cough or mucous production to your health care provider." 4. "Avoid large crowds because your immune system is weakened." 5. "Report any increase in shortness of breath to your health care provider."

1. "Finish all of the antibiotics, even if you start to feel better." 2. "Continue doing your breathing exercises and using the spirometer." 4. "Avoid large crowds because your immune system is weakened." 5. "Report any increase in shortness of breath to your health care provider." not: Cough and mucous production are expected outcomes with resolving pneumonia.

The nurse prepares teaching for a client prescribed alendronate sodium. Which information will the nurse include in this teaching? (Select all that apply.) med 1. "Take this medication with at least 8 ounces of water." 2. "Take this medication while ingesting the first bite of food in the morning." 3. "Wait 30 minutes after eating before taking this medication." 4. "Sit upright for at least 30 minutes after taking the medication." 5. "Take this medication 30 minutes before food or other medications."

1. "Take this medication with at least 8 ounces of water." 2. taken on an empty stomach 3. The best time to take this medication is upon awaking in the morning and 30 minutes before eating breakfast. 4. "Sit upright for at least 30 minutes after taking the medication." 5. "Take this medication 30 minutes before food or other medications."

treatment fr hiatal hernia

1. Avoid chocolate and carbonated drinks. 2. Stay in an upright position after meals. 3. Elevate the head of the bed six inches.

The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to the LPN/LVN to provide care?

1. Client with an erythrocyte sedimentation rate of 10 mm/h. rationale:CORRECT - An elevated sedimentation rate indicates an inflammatory process. The normal value for males under 50 years is less than 15 mm/h. For males over 50 years, it is less than 20 mm/h. For females under 50 years, it is less than 25 mm/h. For females over 50 years, it is less than 30 mm/h. This client can be delegated to the LPN/LVN. not: 4) The INR level monitors the effectiveness of warfarin. The therapeutic range is 2 to 3.5, based on the diagnosis and the reasons for taking warfarin. An elevated INR indicates that the warfarin dose is not therapeutic. The client is at high risk for bleeding and should be monitored by the nurse.

a client schedules to receive a hemodialysis treatment. the nurse will hold which meds? select all 1. Doxazosin 2. captopril 3. tramadol 4. vancomycin

1. Doxazosin (antihypertensives are held unitl after dialysis to prevent hypotension from when dialysate fluid is removed). 2. captopril (Ace inhibitor) used to treat hypertension and CHF. 4. vancomycin (antimicrobials are removed with dialysate solution and should be held until after the procedure is completed. not: 3. tramadol (non-narcotic analgesic is not contraindicated)

A healthcare provider notifies the charge nurse of an inpatient unit that the city major is being admitted. He states that one of the nurses on the unit is disheveled and unkempt and asked that she be reassigned during the mayors hospitalization. Which response does the charge nurse provide? 1. I am on able to comply with your request. 2. I have not had any complaints from any other clients.

1. I am on able to comply with your request. Rationale: this is an inappropriate request by the HCP. The charge nurse is in the best position for us that's the needs of the client and make appropriate assignment based on her knowledge of and abilities of staff number Not: 2. I have not had any complaints from any other clients.

the nurse teaches a breastfeeding class for expectant and new mothers. Which antibody does the nurse explain is passed through breastmilk to the infant? 1. IgG 2. IgM

1. IgG/: NOT: 2. IgM is produced by the child's body in response to the exposure to an antigent. it is not passed through the breastmilk.

nurse should include which information to a client in 1st trimester about nausea select all 1. Nausea may be linked to the mother's acceptance of the pregnancy 2. nausea should diminish by the 14th week of pregnancy. 3. eating a dry carbohydrate immediately upon arising is recommended. 4. Avoid fried, spicy, and greasy foods.

1. Nausea may be linked to the mother's acceptance of the pregnancy* 2. nausea should diminish by the 14th week of pregnancy. 3. eating a dry carbohydrate immediately upon arising is recommended. 4. Avoid fried, spicy, and greasy foods.

The nurse performs an intermittent urinary catheterization for a client who is 2 hours post surgery. Which client observation indicates that the procedure was effective? 1. Rests quietly. 2. Notes distention above symphysis pubis. 3. Voids 30 mL every 15 minutes.

1. Rests quietly. rationale:- Urinary retention can cause anxiety and restlessness. Resting quietly indicates that the client is comfortable. not: Voids 30 mL every 15 minutes. Urinary frequency can indicate urinary retention.

The nurse provides care for a client receiving chemotherapy and radiation who has several bruises. Which nursing intervention will be part of the care plan to prevent further injury? (Select all that apply.) 1. Shave with an electric razor. 2. Allow the client to be up without supervision as tolerated. 3. Avoid enemas and suppositories. 4. Administer stool softeners.

1. Shave with an electric razor. 3. Avoid enemas and suppositories.* 4. Administer stool softeners.

The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). Which intervention does the nurse expect the health care provider to prescribe? 1. Short acting intravenous (IV) insulin. 2. Isotonic intravenous (IV) fluids. 3. Hourly intake and output. 4. Finger blood glucose every four hours

1. Short acting intravenous (IV) insulin. 2. Isotonic intravenous (IV) fluids. 3. Hourly intake and output not: 4. Finger blood glucose every four hours (too long an enterval

Client admitted for myasthenia gravis should receive which test

1. Tensilon test 2. Nerve conduction studies 3. electromyography (EMG)

Which action by the AP requires intervention Selecy all 1. The AP Applies elastic compression stockings to the client after the client returns to bed after breakfast 2. The AP assist a418 pound client diagnosed with lower extremity weakness to the bathroom 3. The AP wears a gown and gloves on assisting a client just admitted with meningitis to change into a hospital gown

1. The AP Applies elastic compression stockings to the client after the client returns to bed after breakfast 2. The AP assist a418 pound client diagnosed with lower extremity weakness to the bathroom 3. The AP wears a gown and gloves on assisting a client just admitted with meningitis to change into a hospital gown* Meningitis of droplets of caution she should also wear a mask prior to entering in the clients room

The nurse observes the parent of an adult client crying in the waiting area. The parent says to the nurse my father died of meningitis and it was awful. Now my children may die of the same thing. Which is the best initial response by the nurse. 1. The outlook for meningitis is better now than it was then. 2. This must be bringing back a lot of memories

1. The outlook for meningitis is better now than it was then. Rationale: this response offers factual information of which the parent maynot have been aware this may help alleviate some distress Not: 2. This must be bringing back a lot of memories

client at risk for development of pneumonia select all 1. a client diagnosed with cystic fibrosis 2. a client with a fracture rib due to an auto accident 3. a client in buck traction due to fractured hip

1. a client diagnosed with cystic fibrosis* rationale: underlying lung disease is a risk factor for pneumonia. cystic fibrosis causes chronic obstructive pulmonary diseases and excess mucous production 2. a client with a fracture rib due to an auto accident 3. a client in buck traction due to fractured hip

a client diagnosed with type 2 diabetes mellitus DM is treated for hypertension with propanolol. The history reveals that the client is diagnosed with glaucoma and is allergic to sulfa. Which prescribed medication requires an immediate intervention by the nurse? 1. acetazolamide 2. timolol maleate

1. acetazolamide: rationale: clients with sulfa allergy should not take acetazolamide, as an allergic reaction can occur not: 2. timolol maleate

a client admitted for an adrenalectomy to treat cushing syndrome should receive which intervention most important 1. monitor the clients glucose 2. obtain the client weight

1. monitor the clients glucose not: 2. obtain the client weight

when intervening with a client who is in a state of crisis, which statement by the nurse is most effective? 1. what have you done before when you felt this anxious 2. it seems as if this situation is very stressful for you

1. what have you done before when you felt this anxious rationale: for crisis intervention, the priority is to establish coping methods that have helped in the past. Crisis intervention focuses on finding the clients inner strengths to deal with the problem at hand. not: 2. it seems as if this situation is very stressful for you (this is an appropriate reflective statement, but in a crisis, it is more important to determine coping methods used in the past to give the client tools to move forward

the parent of a toddler says he has many house plants, and that the toddler gets into everything all the time and drives him to distraction. Which response is best? 1. what kind of plants do you have? 2. who is available to care for you child when you need a break?

1. what kind of plants do you have? rationale: this addresses the safety issues related to a toddler. some plants are poisonous. the nurse should address the physical safety concern. 2. who is available to care for you child when you need a break? legitimate concern but first should be addressing safety.

Specific gravity of urine

1.010-1.030

The nurse plans to teach a local community group about chronic obstructive pulmonary disease (COPD). Which information does the nurse include? (Select all that apply.) 1. Uncontrolled COPD can lead to cardiac disease. 2. Asthma in childhood leads to COPD later in life. 3. Cigarette smoking is the leading COPD risk factor. 4. More females are affected by COPD than males. 5. Co-existing illness may cause COPD exacerbation.

1.Uncontrolled COPD can lead to cardiac disease. 3. Cigarette smoking is the leading COPD risk factor 5. Co-existing illness may cause COPD exacerbation. rationale: 2.There is no evidence that childhood asthma leads to COPD in adults. 4. More males than females are affected by COPD.

which food choices provide the client with 15 grams of oral carb

1/2 cup of plain past, 1/2 cup of canned fruit, 125 ml of apple juice not: whole milk it contains 11 grams of carb

Quickening occurs

17-19 weeks first fetal movement

client at risk for developing with hypernatremia 1) vomiting 2) diabetes insipidus

2) diabetes insipidus rationale: with DI, fluid is excreted from the body before sodium levels can adjust, thereby losing fluid and retaining sodium. if the client does not experience thirst, cannot respond to thirst, or fluid are excessively restricted they will have too much sodium. not: 1) vomiting (increases risk of hyponatremia)

most effective method of non-pharmacologic birth control 1) coitus interrupts 2) symptothermal method

2) symptothermal method rationale: combines cervical mucus evaluation and basal body temp evaluation. any combination method increases the rate of effectiveness not: 1) coitus interrupts (lease reliable)

a nurse would need to intervene if a newborn with phototherapy lights has which 1) a lab tech turns off phototherapy lights to draw the newborns blood 2) the jaundice observed around the newborns eyes and nose has begun to dissappear

2) the jaundice observed around the newborns eyes and nose has begun to dissappear rationale: indication eye patched are not adequately placed or are not opaque. When theyr are not covered, and exposed to light, it cold result in eye damage, especially the retina not: turning off lamp for blood draw, removing eye patches for feeding, or frequent loose, green stools and increased urine output (sign phototherapy is working as bili is being excreted)

The newly-licensed nurse states to the nurse preceptor, "I am so frustrated. I take so long to pass medications, and I make administration errors nearly every day. Because I am so slow, I have to stop to get my other tasks done. " Which advice by the preceptor best addresses the nurse's concerns? 1. "Slow down and prepare the medications for only one client at a time." 2. "Interruptions can cause errors, so let's talk about how to stay focused." 3. "When you make an error, reflect on what went wrong and how to fix it."

2. "Interruptions can cause errors, so let's talk about how to stay focused."

The nurse provides care for a client who is status post for a cardiac catheterization. The client is also diagnosed with type 2 diabetes mellitus (DM) and renal insufficiency. Which statement is most important for the nurse to include in discharge teaching? 1. "Remember to adhere consistently to a cardiac prudent diet." 2. "You should not take your metformin for the next 48 hours.

2. "You should not take your metformin for the next 48 hours. rationale: Post cardiac catheterization, best practice includes withholding the metformin for 48 hours to prevent lactic acidosis. Metformin is excreted via the kidney. A client diagnosed with renal insufficiency has an increased risk for lactic acidosis.

the charge nurse is making client assignment for the nursing team. which client will the charge nurse assign to the LPN. 1. A client diagnosed with psychosis. 2. A client in skin traction

2. A client in skin traction rationale: client with an expected outcome. not: 1. A client diagnosed with psychosis. (this client is unstable and should be assigned to an RN.

the charge nurse is making assignments. Which client is appropriate to assign to a float nurse from the med-surge unit? (select all) 1. a client with an intravenous infusion of epinephrine for heart failure. 2. A client scheduled for insertion of an implantable cardioverter-defibrillator device. 3. a client receiving albumin and blood transfusion for hypotension 4. a client receiving intermitent iv cefazolin for endocarditis.

2. A client scheduled for insertion of an implantable cardioverter-defibrillator device. 3. a client receiving albumin and blood transfusion for hypotension 4. a client receiving intermitent iv cefazolin for endocarditis. not: 1. a client with an intravenous infusion of epinephrine for heart failure. (IV cardiac meds are used in unstable clients at high risk for changes and complications. this client requires continuous monitoring by an individual trained for use of epinephrine and care of the unstable client. this assignment is not appropriate for a float nurse.

The nurse notes that a client's T-tube has drained 425 mL of dark green thick fluid. Which action does the nurse take next? 2. Document the amount on the output sheet. 3. Notify the health care provider immediately.

2. Document the amount on the output sheet.

a client ask the nurse what causes type 1 diabetes the nurse should respond 1. corticoid steroid use stimulates glucose secretion by the liver 2. pancreatic beta cell destruction causes decreased insulin production

2. pancreatic beta cell destruction causes decreased insulin production not: 1. corticoid steroid use stimulates glucose secretion by the liver

the nurse provides care to a client diagnosed with chronic heart failure (HF) and an acute bacterial infection. The client's medication include furosemide 40 mg PO faily aspiring 81 mg PO daily. Which new prescriptions cause the nurse to seek clarification from the health care provider? select all 1. potassium chloride 40 mEq PO daily 2. vancomycin 2 g IV pigguyback every 12 hrs 3. Digoxin 0.25 mg PO daily

2. vancomycin 2 g IV pigguyback every 12 hrs 3. Digoxin 0.25 mg PO daily rationale: dig toxicity increased when furosemide and dig are taken not: potassium chloride 40 mEq PO daily (furosemide is a potassium wasting drug, it is indicated to take KCl

the nurse provides care to an adult client who sustained a T3 spinal cord injury 2 days ago. The nurse suspects a developing emergency based on which assessment finding? select all that apply 1. respiratory rate of 18 breaths/min 2. warm, dry, flushed skin 3. blood pressure of 88/42 4. hear rate of 88 beats/min

2. warm, dry, flushed skin 3. blood pressure of 88/42 rationale: sign of nuerogenic shock. not: 1. respiratory rate of 18 breaths/min (within normal range, with neurogenic shock the respiratory rate may increase) 4. hear rate of 88 beats/min (normal hear rate ranges from 60 to 100 beats/min, with shock bradycardia may or may not be present)

an older adult client asks the nurse to explain therapeutic massage the doctor recommended as treatment. the nurse says 1. it decreases hypertension 2.it improves circulation and muscle tone

2.it improves circulation and muscle tone not: 1. it decreases hypertension (does not affect hypertension

the nurse schedules a patient for a myelogram. which teaching will the nurse provide to prepare the client for this test? (select all) 1. a trained radiology technician will perform the procedure 2.jewelry and metal objects will need to be removed 3. an informed consent form will need to be signed 4. food and fluids will be restricted for 4 to 8 hours before the procedure. 5. the procedure will take about 45 minutes

2.jewelry and metal objects will need to be removed* 3. an informed consent form will need to be signed 4. food and fluids will be restricted for 4 to 8 hours before the procedure. 5. the procedure will take about 45 minutes* not: 1. a trained radiology technician will perform the procedure ( a health care provider will perform the procedure

The client is placed on cephalexin prophylactically after surgery which foods will the nurse encourage the client to eat 1. Egg white and lean meats 2.yogurt and acidophilus milk

2.yogurt and acidophilus milk Rationale: Will help maintain normal intestinal Flora which may be altered by cephalexin Not; 1. Egg white and lean meats (Not necessary)

Normal ptt

20-45 seconds Note:used in heparin

client with depressed mood should have activities schedules at which time so that client has the greates chancess of success in activities that require psychic and physical energy

during the am hours rationale: as day progresses energy declines

6 month old immunizations

3 doses of diptheria, tetanus, and pertussis vaccine

a newborn infant should feed every 3 hrs or 4

3 hrs, if hes sleeping she should wake him to eat. 4hrs is wrong mothers breast should feel soft after feeding not firm

There should be _______ finger spce between the pads and axilla

3-4

The nurse is assisting in the care of a client with ventricular fibrillation. The "code" leader called to shock the client uses a biphasic defibrillator. The nurse sets the defibrillator at which energy level? 2. 100 to 110 Joules. 3. 120 to 200 Joules.

3. 120 to 200 Joules.

The nurse provides care for a client diagnosed with lymphoma. The client has a large tumor. Which intervention by the nurse is most important in preventing tumor lysis syndrome? 1. Record vital signs every 2 to 4 hours. 2. Send a urinalysis test every 6 hours. 3. Administer a high rate of intravenous fluid.

3. Administer a high rate of intravenous fluid

The nurse provides care for a client who reports mid-back discomfort. Which technique does the nurse use to determine if the pain is coming from the kidneys

3. Blunt percussion. not:2. Light palpation. It is not possible to identify the kidneys using light palpation.

The nurse prepares a client for a contraction stress test using nipple stimulation. Which measure does the nurse include in the plan of care? 1. Cleanse abdomen with an iodine solution. 2. Place client on an internal fetal monitor. 3. Place client in reclining chair with a slight lateral tilt.

3. Place client in reclining chair with a slight lateral tilt. rationale: Placing the client in a reclining chair with a slight lateral tilt optimizes uterine perfusion and avoids supine hypotension. other options not needed

The nurse is caring for a client with a shoulder injury. Which intervention will the nurse delegate to nursing assistive personnel (NAP)? . 1. Direct the client to the shower. 2. Provide back care as part of a partial-care bath.

3. Provide back care as part of a partial-care bath. rationale: because of the shoulder injury, the client most likely will not be able to wash the back and buttock area. A partial-care bath is appropriate for this client.

the nurse provides care for a client who requires neurological checks every 2 hours. the nurse identifies which components as part of the Glasgow coma scale (GCS)? Select all 1. eye-opening response-partially. 2. best motor response-unsteady gate 3. best verbal response-confusd 4. eye-opening response-none 5. best verbal response-incomprehensible sounds 6. best motor response-localizes pain

3. best verbal response-confusd 4. eye-opening response-none 5. best verbal response-incomprehensible sounds 6. best motor response-localizes pain not:1. eye-opening response-partially. 2. best motor response-unsteady gate (not a component of the GCS.)

correct understanding of chlorpromazine select all 1. it is important to brush my teeth 3 times a day 2. it may take 6 weeks for my medication to work* 3. i need to have a blood drawn regularly for a few months 4. i should not be concerned if my urine turns pink*

3. i need to have a blood drawn regularly for a few months (risk of leukopenia) 4. i should not be concerned if my urine turns pink* expected side effect

The nurse receives a prescription to provide aspirin to a client with an emergent acute myocardial infarction. What is the best method to administer aspirin to this client 3. Give sublingually, times three doses. 4. Have the client chew non-enteric coated ASA.

4) CORRECT - To maximize immediate antiplatelet action of aspirin across the buccal mucosa, it is best to be chewed. not:3. In acute myocardial infarction aspirin is given once, not in three doses.

Pt constipated in the bathroom. What order should the nurse do the following: 1) offer fluids 2)notify provider 3)offer prn medication orally 4) use gloved hand with lube to assess fecal impaction and stimulate rectal wall to loosen fecal matter

4) assess 3)med 2)notify provider 1)offer fluidsq

Rewarming pt with a core temp of 94.1 using a Bear hugger

4, cleanse the plug with an alcohol wipe 2, compress the evacuator 3,replace the plug in the evacuator 1, dispose the bloody drainage 5, document the amount, odor, and consistency of the drainage

The nurse assesses a client with obsessive compulsive personality disorder. Which finding will the nurse expect to observe? (Select all that apply.) 1. Requires excessive support from others when making decisions. 2. Believes is able to know what others are thinking. 3. Possesses exaggerated feelings of helplessness when alone. 4. Demonstrates unwillingness to delegate tasks unless others follow strict rules. 5. Imposes perfectionism in own completion of tasks.

4. Demonstrates unwillingness to delegate tasks unless others follow strict rules. 5. Imposes perfectionism in own completion of tasks. not: 1 or 3: describes a client with dependent personality disorder

The nurse provides care for a client that has difficulty getting comfortable at night. The client remains awake until the client requests acetaminophen. The client is able to fall asleep about an hour after taking the acetaminophen. Which nursing intervention should the nurse add to the client's plan of care? 2. Talk with the health care provider about prescribing a stronger pain medication for the client. 3. Instruct the client to avoid using acetaminophen routinely because of the adverse effects. 4. Administer the acetaminophen about an hour before the client goes to sleep.

4. Administer the acetaminophen about an hour before the client goes to sleep. rationale: The nurse should try to treat the discomfort so the client can become comfortable enough to sleep rather than losing sleep from discomfort. not 3: Instruct the client to avoid using acetaminophen routinely because of the adverse effects. Acetaminophen is safe and effective if taken as prescribed. The scenario does not give details that would indicate the client should avoid acetaminophen.

The nurse delegates several client care tasks to nursing assistive personnel (NAP). Which action will the nurse need to follow up? 3. NAP notifies maintenance of a broken electrical plug in a client's room. 4. NAP discontinues an indwelling urinary catheter.

4. NAP discontinues an indwelling urinary catheter. rationale: The nurse should complete the task of removing an indwelling catheter. The nurse needs to assess the client's response to the removal of the catheter and document the discontinuation of the catheter and any findings

Recommended amount of acetaminophen taken in a 24 hour period is

4g

Location of arterial phlebostatic axis

4th intercostal space near heart at the mid axillary line

reccomended extra calories for breastfeeding moms to consume

500

Breastfed infant should have

6-8 wet diapers a day

If the pt is incompetent to give consent

A court appointed guardian may do so

expected finding for client at 10 weeks gestation

fetal heart rate with a doppler

during an outbreak of legionnaire disease, most at risk client is

65 year old diagnosed with end-stage kidney disease rationale: he has 2 risk factors

Older adults erikson age

65-85 y.o ego integrity vs despair Successfully retiring, keeping or losing long term relationship

Mean Arterial Pressure (MAP) range

70-105, under 60 priority pt as organs are not getting enough perfusion can lead to ischemic organ damage and death

The nurse notes the presence of purulent drainage at the insertion site of a client's intravenous catheter. Which action will the nurse take after discontinuing the catheter? 1. Apply heat to the affected site. 2. Save the catheter to send to the laboratory.

A culture of the catheter tip will identify the organism causing the infection at the insertion site. will be done before treatment

The nurse provides care for a client who has mild pre-eclampsia. Which evaluation data indicate that the nursing interventions to help control mild pre-eclampsia have been effective?

A 2+ patellar reflex indicates the pre-eclampsia is controlled

he nurse assess a pregnant client at 10 weeks gestation. Which finding is consistent with the gestational age of the fetus?

A fetal heartbeat can be heard with a Doppler. not: Quickening, a fetal movement felt by mother, is first perceived at 16 to 20 weeks as a faint fluttering in the lower abdomen.

The nurse notes that four clients have returned from surgery within the last 24 hours. Which client is at the highest risk for developing a post-operative infection?

A middle-age client with a coronary artery by-pass graft. raitonale:The older adult client has three risk factors. These risk factors are recent surgery, age, and compromised nutritional status. This client is at the greatest risk for a post-operative infection. not: A middle-age client with a coronary artery by-pass graft.: rationale: The middle-age client has one risk factor, which is the recent surgery.

The nurse provides care for a client who sustained a burn injury. The nurse notes that the client has absent bowel sounds, abdominal distention, belching, mild nausea, and a reduced appetite. Which complication should the nurse suspect the client has developed?

A paralytic ileus rationale; is usually is symptomatic with decreased appetite and nausea, which will continue to worsen. The abnormal bowel sounds will, depending on the characteristics of the ileus, be hyper, hypo, or absent, with absent being the most common. not: Curling ulcer rationale: it results in pain and occult stool and vomitus.

How to turn a pt after lumbar laminectomy

A pillow is placed between the clients legs; the body is turned as a unit Rationale: the removal of a vertebral laminae. You want to promote a straight back the client shouldn't bend or twist at the torso.

The nurse provides care to a client receiving intravenous heparin. Which laboratory test result causes the nurse to be most concerned? Platelet count 50 mm3/L (50×109/L). Potassium level 3.2 mEq/L (3.2 mmol/L

A platelet count less than 100 mm3/L signals heparin-induced thrombocytopenia, a potentially life-threatening complication of heparin therapy. not: potassium 3.2 is abnormally low, but that is not an adverse effect related to heparin therapy.

Brudzinkis sign

A positive sign of meningitis, in which there is an involuntary flexion of the arm, hip, and knee when the patient's neck is passively flexed.

which code of ethics supports keeping client and family care consisten with the nurse professional code of ethics

fidelity rationale: refers to keeping faithful to ethical principles and the American nurse association code of ethics for nurses.

Patients are going to dinner at salon 15 units of isophane at 8 o'clock every day. at 16:00 the nurse sees which signs as complications from insulin

Irritability, tachycardia,diaphoresis

Patient on hospice care with anorexia and cachexia refusing food when not hungry

Is allowed to promote comfort

Priority ontime medication between myasthenia gravis pt,bipolar pt

Myasthenia gravis

barium swallow test requires

NPO 3 hours before

early signs of lithium toxicity

fine motor tremors, nausea and vomiting, diarrhea

Ventricular vigeminy in the presence of Myocardial infractions 1. expected 2. emergency

Name for Pvc, priority

Treatment for a patient admitted for cirrhosis of the liver and rising ammonia levels would be treated with

Neomycin will remove the Ammonia producing substances from the G.I. Tract and suppress ammonia production

The rectal route of drug in administration is contraindicated when which manifestation is present

Neutropenia, thrombocytopenia, muscositis, anal lesions

11 month old would need a rapid response tram if

New onset right sided paralysis of extremities, and inability to be aroused

Immunization

Newborns get hep b, flu shot at 6 months Seniors over 60 need vaccines to prevent shingles and pneumonia

Eardrop medication should be warmed to

No higher than Body temp 95-98.8 (104 degrees would be too hot

The nurse teaches a group of nursing students about managed care. Which information will the nurse include in the teaching session?

Encourages providers to focus on prevention. rationale: The focus of health care shifts from illness to health and wellness.

Client with abdominal aortic aneurysm can reduce risk of complication by

Encouraging fluid intake and fiber to precent constipation and rupture

When caring for a mechanically ventilated pt which should NOT be done

Endotracheal suctions after oral care rationale: suctioning is only done when adventitious sounds are heard it should not be done regularly

Warm saline soaks on wound appropriate for dehiscence Or eviscerated

Eviscerated if only dehiscence then stay with client and have colleague notify the health provider

Pt on antipsychotics medication develops tardive dyskinesia the nurse documents these findings where

Abnormal involuntary Movement scale (AIMS)

The nurse uses a tape measure to ensure that a client receives the correct size of knee-high antiembolism stockings. Which measurement does the nurse use for these stockings?

Achilles tendon to the popliteal fold.

Client diagnosed with bipolar disorder is in Manic phase with combative behavior. Initial priority nursing action

Administer and monitor Sedative and mood stabilizing medication

Alcoholic who had their last drink yesterday shows up with diaphoreses, tremors, and tachycardia what is the nurse priority

Administer lorazepam for alcohol withdrawal

task Lpn cannot do

Administering a blood pressure medication intravenously.

A patient on warfarin should avoid

Alcohol consumption and increasing intake of vitamin K, can be taken without food

Client at risk for latex allergy

Allergy to avocado, Has undergone multiple surgeries, employed as a health care worker.

bipolar Patient is extremely angry because the nurse he just found out his dad filed for divorce and he needs to talk tomorrow what should the nurse do

Allow him to use the phone

In case of bomb threat who is evacuated first

Ambulatory pts

A client relieves severe abdominal pain that radiates to the back by sitting forward with the knees bent. Which laboratory test will the nurse expect to be prescribed for this client? 1. Creatinine. 2. Serum amylase.

Amylase is a digestive enzyme secreted by the pancreas. Since the client is demonstrating signs of acute pancreatitis, the nurse should expect a serum amylase level to be prescribed.

Red blood cells (Rbc's) used for

Anemia your blood loss

a client suspected latex allergy. Which clinical manifestations noted on the nurse's assessment support this diagnosis. select all 1. Angioedema 2. bronchospasm 3. shock 4. pruritus of the hands 5. runny nose

Angioedema* bronchospasm shock* runny nose* not: pruritus of the hands (occurs with an irritant contact dermatitis. it is not indicatice of an immediate hypersensitivity reaction, but should be investigated further.

A pt with addisons disease will have

Anorexia

HEPATITIS A teaching

Anorexia is one of the most common symptoms af hepatitis A among children not black tarry stools: clay color stools is correct

Under maslow what is more important food and rest or safety and security

Food and rest

First lobe of the cerebral hemisphere is involved and control involuntary muscle movement such as speech and swallowing

Frontal

Droplet precautions

Fukn, men, robbed, my, purse= Flu, meningitis, rubella, mumps, pertusis

The nurse provides care for a client who reports severe right shoulder pain. Which abdominal organ should the nurse suspect is causing this client's discomfort?

Gall bladder. Not: spleen

Cpr indication

Gasping respirations and pulselessness=cardiacarrest

Patient with cluster headache

Give o2 100% via face mask

Pt who received insulin at 0800 and at 1600 appears diaphoretic and confused. Nurse first action is

Give skim milk

Whole blood is used for

Hemorrhage, Not usually used otherwise

Sign of post partum complications

Hemorrhage:Heavy clots Infection: high temp over 100.4, sudden increase inperineal pain, foul smell, hot, tender, or red breast, dysuria, pain or swelling in legs, chest pain or cough.

developmental concern in infant

Not rolling from tummy to side at 10 months Not transferring toys from hand to hand at 9 months Not begining to respond selectively to words Vocalizing sounds(coos) Note): not walkin is of concern at 18 months

client is recovering from lumbar puncture should be placed

flat supine rationale: prevent spinal headache post procedure not: semi fowler can cuase leaking of cerebrospinal fluid at the site, resulting in headache

client in early stage of lyme disease will have

flu like symptoms not: enlarged and inflamed joints rationale: thats in later stages

naproxen adverse

fluid retention and dizziness

Stable vtach

Anti arrhythmic med-Procainamide, amiotarone

Allopurinol

Anti gout med: S.e: rash, hepa and nephrotoxicity, GI upset -drink with 8 glasses of water/day

1 minute after birth dr does

Apgar score: appearance, Pulse, grimace, activity, respiration 0-2 score on each for a total of 10 best score

After taking a pt AbG when diagnosed with pneumonia, the nurse should

Apply pressure to the site Not: get ice for sample not more important than applying direct pressure

After a client had a paracentesis what is the priority for the nurse to ask

Are you feeling dizY

The nurse provides care to a client of Native American descent who has traditional beliefs about health and illness. Which action is most appropriate for the nurse to take? 1. Ask if cultural healers should be contacted. 2. . Explain the usual hospital routines for mealtimes, care, and family visits.

Ask if cultural healers should be contacted.

Mexican american mother becomes the distressed when the nurse complement the child outfit what should the nurse do next

Ask the mom if she can touch the child's hand

The nurse notes that a client who follows Judaism has roast beef and whole milk on the dinner tray. Which action will the nurse take first?

Ask the nutrition department for a new tray. Not: Replace the whole milk with skim milk.

Normal during pregnancy

Slight rectal bleeding (due to hemorrrhoids) vaginal bleeding is concerning

The nurse delivers a kosher lunch to a client who is Jewish. Which nursing action is most appropriate when assisting the client? 1.Replacing the plastic utensils with metal utensils. 2. Asking the client to unwrap the eating utensils and to prepare the meal for eating. View Explanation

Asking the client to unwrap the eating utensils and to prepare the meal for eating. rationale: The client should unwrap the eating utensils. The nurse can prepare the meal for eating. This complies with religious rules.

The nurse prioritizes the needs of several assigned clients. Which client need will the nurse address first? 1.Assessing a client with a reported blood glucose level of 60 mg/dL (3.33 mmol/L). 2. Implementing precautions for a client identified at risk for aspiration. View Explanation

Assessing a client with a reported blood glucose level of 60 mg/dL (3.33 mmol/L). rationale: maslow physiological over safety

A pt wuth alcohol abuse is being treated for alcohol intoxication. When given chlordiazepoxide for agitation what precaution should the nurse take

Assign lpn to remain with the client

Nurse caring for a child with adenoidectomy and tonsillectomy 10 hrs ago is getting ready for sleep. What would be helpful promoting sleep and comfort

Assist child in finding a position of comfort that will maintain an open airway, offer I collar and a cool oral rinse.

A nurse taking care of a patient with peripheral IV with doxorubicin suspected of extravasation should stop the infusion ,disconnect the IV tubing, and then

Attempt to aspirate the residual drug Cold compress would follow

ventilator alarm activated nurse should first

Auscultate breath sounds before dealing with alarm

he nurse provides care for a client diagnosed with chronic insomnia. The client reports, "About 1 to 2 hours before bed, I start thinking about whether I will sleep that night and I feel restless." Which intervention should the nurse recommend to this client? (Select all that apply.). Avoid negative associations with inability to sleep. 3. If unable to sleep, remain in bed.

Avoid negative associations with inability to sleep. not: 3. If unable to sleep, the client should get out of bed and try a relaxing activity to try and induce relaxation.

The nurse develops a teaching plan to promote optimal cardiac output during pregnancy. Which information is most important for the nurse include? 1. Take frequent rest periods between activities. 2. Avoid resting or sleeping in the supine position.

Avoid resting or sleeping in the supine position. rationale: Particularly in second half of pregnancy, the weight of the pregnant uterus compresses the vena cava (which can lead to maternal hypotension syndrome) and aorta (which can lead to fetal hypoxia). It is a priority to prevent compression of these major vessels.

What intervention mustbe done before taking the ABGs of a pt on mechanical ventilator

Avoid suctioning as it can affect ABGS result

Which clinical manifestation does the nurse explain to the client as indicative of sleep apnea? (Select all that apply.)

Awakening at night. *snoring Irritability snoring rationale: When the client goes to sleep, the muscles relax and the upper airway can obstruct, causing snoring. This can be a sign of sleep apnea

client with presbycusis. which client characterisitc will the nurse include in the teaching

responds to low pitched tones rationale:this client had difficulty hearing high pitched sounds as part of aging not:develops excessive earwax rationale: not true

should fluids be given or restriceted before bed in hiatal hernia

restricted

Client bit by tick is tested for lyme disease and receives which instructions

return in 4 weeks for testing

Student nurse auscultates the right middle lobe of the client is she place stethescope

right anterior chest between the 4ht and 6th intercostal spaces. not: posterior

A 9 month old patient should have which reflex

Babinski : toes hyperextend and fanned when sole of foot is stroked

Complication of PEEP

Barotrauma Rationale: (occurs at high levels of peep can cause overdistension and rupture the aveoli) -air from ruptured alveoli can escape into the lungs and cause a pneumothorax or subq emphysema

Position before and after lumbar puncture

Before: side lying After: supine for 4- 12 hrs

Pt with supra ventricular tachycardia and pulse of 238 is treated by

Being told to do bearing down vagal maneuvers

The nurse provides care for a client who takes a cyclobenzaprine hydrochloride extended release capsule once a day. Which finding indicates to the nurse that this medication is effective? 1. Experiences patchy hair loss. 2. Bends over to tie shoes. 3. Demonstrates hyperactive bowel sounds. 4. Experiences a 2 kg weight loss in 3 weeks.

Bends over to tie shoes. rationale: Cyclobenzaprine hydrochloride is a centrally-acting skeletal muscle relaxant. Evidence that the medication is effective would be the client's ability to bend over to tie shoes. Not: Demonstrates hyperactive bowel sounds. diarrhea is an adverse effect of medication

The nurse provides care for a client newly diagnosed with a benign brain tumor. The nurse teaches the client about the diagnosis. Which property of benign tumors should the nurse include in the teaching? 1. They are poorly differentiated. 2. They can cause tissue destruction.

Benign tumors can cause tissue destruction by the size and location in the body. not: They are poorly differentiated. Benign tumors are more differentiated, meaning they more closely resemble the cells of the tissue from which they arose.

Tunnel catheter

Best place in the central vein tunneled under the skin and brought out that it is done example Hickman and broviac

Testicular self exam

Best time to check after bath

A client with diabetes mellitus has an abdominal incision and is at risk for poor wound healing. What interventions can help prevent dehiscence select all 1.Binder, 2. docusate, 3. onsansetron, 4. monitor blood glucose 5. restrict diet

Binder, docusate, onsansetron, monitor blood glucose to promote (lower infection risk n promote wound healing) NOT: restrict diet as proper nutrition is needed to promote wound healing

Cryoprecipitate use for

Blood loss on mediately prior to an invasive procedure and clients with significant hypofibrinogenemia

The nurse performs an assessment on a full-term newborn. Which finding does the nurse report to the health care provider?

Bowel sounds cannot be auscultated in the abdomen. raitonale: Tinkling bowel sounds in 4 quadrants are present within 1 hour after birth

How to measure frequency of uterine contractions

By the number of contractions that occur within a given period of time

Med for pregnant pt with gonorrhea

Ceftriaxone Rationale: 3rd generation cephalosporin reccomended for pregnant pt with gonorrhea

African-American women have a higher rate and which diseases

Cervical cancer , hypertension, ischemic stroke

what is used to clean tracheostomy

Hydrogen peroxide-soaked gauze pads or cotton-tipped applicators are used to clean the stoma area, followed by use of sterile water soaked gauze pads, and cotton tipped applicators to remove hydrogen peroxide. the stoma would then be dried using sterile gauze pads to reduce the risk of infection

who is priority: Cient admitted with CHF reporting shortness of breath and had an extra dose of furosemide prescribed vs. acute asthma exacerbation who need a dose of iv methylprednisolone who is priority

CHF pt. as methyprednisolone takes time to take effect. But the SOB in the CHF pt works immediately and should be given urgently as this pt has sign of change in fluid status

other name for extended release tablets also called

CR: controlled release CRT: Controlled release tablet LA: long acting SA: sustained action SR: sustained release TR: timed release XL: extended length XR: extended release

Pt receives aminophylline iv. The client has clear lung skunds and unlabkred breathing. If the IV infiltrates the nurse should

Call the healthcare provider and recommend IV medication to change to PO. Rationale: continue iv use is nit needed as breathing has improved

Phlebitis priority or not

Can cause infection if client reports pain swelling or redness at side. Stop immediately

Neck swelling and increased pain 2 days after thyroidectomy expected or emergency

Can mean hematoma and can affect airway

Client with hypo parathyroidism should have

Cardiac monitor that's what it is at risk for laryngospasm

When diabetes type 1 client has had 2 high glucose readings for the last 2 mornings what should the nurse advise

Check glucose at night (Could be caused by somogyi effect, where am hyperglycemia is caused by pm hypoglycemia due to evening diet and insulin dosage)

Patient with dislocated shoulder is given local anesthetic. During the procedure he becomes agitated and shouts " help me"what should the nurse do next

Check his pulse oximetry Rationale; if the pt become suddenly agitated during the procedure can be a sign of excess medication the nurse should not provide more narcotics before checking the oximetry

A client with type 1 diabetes reports nausea and abdominal pain. The nurse should advise the client to

Check your blood glucose level every 3 to 4 hours

In a laryngectomy the laryngeal nerve is assessed by

Checking clients ability to swallow

The nurse of a pt with Guillain Barre should give priority to

Checking respiration, rate n depth Rationale; it is polyneuropathy with paralysis of muscles. Neuromuscular respiratory failure is the most life threatening condition

Drug that can cause renal toxicity

Cisplatin

Fluid overload during iv infusio intervention

Clamp the iv fluids to prevent pulmonary edema

The nurse delegates care of a client diagnosed with osteoporosis to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include? Clean up clutter in the room." "Perform passive range-of-motion exercises."

Clean up clutter in the room." rationale:Safety is a priority in clients with osteoporosis. Falls can lead to fractures. Not:Passive range-of-motion exercises rationale: they are not the priority. Weight-bearing exercises prevent osteoporosis.

The nurse documents care on a client who is 3 hours postoperative after a right leg amputation. Which charting entry indicates a problem with the documentation?

Client post above the knee amputation, voids without difficulty, 2+ dorsalis pedis pulses bilaterally. Rationale: Since the client had right above knee amputation (AKA), the client no longer has a right doralis pedis pulse. This is incorrect documentation and should only reflect the doralis pedis pulse in the left leg.

which clients should be assigned to an LPN select all 1)Client takin ferrous sulfate reports black stools 2)client with bronchitis who requires a sputum sample collection. 3) client receiving oral nitrofurantoin cystitis

Client takin ferrous sulfate reports black stools client with bronchitis who requires a sputum sample collection. client receiving oral nitrofurantoin cystitis

A patient with an stage renal failure refused dialysis and is long term care facility. The next day the patient is agitated and tells the nurse "I have to go home to tend to my things I have so much to do. "What is the most likely interpretation of this pt behavior?

Client wants to go home before imminent death. Not: The client is becoming delirious and should be assessed for infection Rationale: The client knows he only has a few weeks left to live and wants to make sure I have possession of the ticket care of before he passes

Fresh frozen plasma used for

Coagulation defficiency

A confused pt does not have on id band and you have a med pass for him. How do you verify their identity

Compare their photo on file to pt

Pediactric client with burns on 20% of her body. Appears disoriented, a fever of 101, crying in pain needs what interventions

Complete assessment: may have sepsis infection

subluxation

Congenital hip dislocation.diagnosed in infants under 4 weeks. Sigs: unenven gluteal foldimited abduction Treatment: abduction splint bryants traction, open reduction

Pt's Bill of Rights

Consent to treatment, Providing info about medications, past illness Respect and consideration

The new graduate nurse notices that one of the other nurses has been sleeping on the unit during the night shift. The other staff members seem to have seen this nurse asleep, but they have said nothing. Which action does the new graduate nurse take?

Contact the nursing supervisor. not: This action is threatening and inappropriate. Tell the nurse if you see the sleeping again, you will report it.

Handling contacts or applying lip balm after blood draw specimen is

Contraindicated due to exposure to bloorborne pathogens

which client with Rh negative blood will receive RHo immune globulin

a client who is at 10 weeks gerstation and has an ectopic pregnancy, rationale: ectopic pregnancies could cause tube to rupture, med should be given before it ruptures. not a 28 weeks gestation and had a non-reactive non stress test.

The nurse is assessing a neonate born at 44 weeks' gestation. Which finding does the nurse document as consistent with the newborn's gestational age? 3. Cracked, peeling skin. 4. Abundant vernix.

Cracked, peeling skin.

a 9 months old infant weighing 9 pounds was taken from parents home due to neglect, he cannot roll over or sit up independently. which nursing diagnosis has the highest priority

Imbalanced nutrition: less than body requirements not: impaired growth and development rationale: lack of nutrients does not allow infant to perform milestones, nutrition is more important than neglect(psychosocial

Preschool children in game in the playground of age 5 will play by

Imitative play: talking on toy phone

Sign of complication at incision site 48 hours after surgery for a hernia repair

Incision line is red Expected: pink, swelling, slight crusting,

The nurse provides care for an adolescent client experiencing a migraine headache. Which finding causes the nurse to be most concerned 1. blurred vision 2.Urinary incontinence.

Incontinence of bowel or bladder could signal seizure activity or a stroke, which is an uncommon, but serious, migraine complication. not: ) Blurred vision is a typical migraine symptom.

treatment for malignant hypothermia

Dantrolene

Breathe self exams should be done

Day 5 and 7 of period

Client given NAcl at 125 ml/ hr in left arm has distended neck veins, shortness of breath, crackles in both lung based. What does nurse do first

Decreases the iv rate to 20ml:hr and notifies the health care provider Rationale: may need iv line for diuretics

The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions. 1. Demonstrating the procedure and having the client return the demonstration. 2. Asking an interpreter to replay the instructions to the client.

Demonstrating the procedure and having the client return the demonstration. not: interpreter An interpreter or family member may communicate verbal or written instructions inaccurately.

Mirtazapine

Depression med

Adderall adverse effects

Depression, tachycardia

A 3 y.old reports dysuria. The healthcare provider orders of catheterize urine specimen the nurse takes which action

Describes the procedure to the child in short, concrete terms while talking calmly

The nurse provides care for a client who requests testing for human immunodeficiency virus infection (HIV). Which intervention is most important for the nurse to perform before administering testing?

Determine when the client thinks the exposure to HIV occurred. rationale: Because there is a delay of several weeks after infection before antibodies can be detected, testing in the interim may result in false-positive results.

What interventions promote normal rest and sleep pattern for critically ill patient

Dimming lights Scheduling most interventions during the day Opening curtains in the morning (promote normal circadian rhythm)

Bipolar client flirts with other clients and disrupts unit activities

Distract the client and escort them back to the roon Rationale: they are no threatening NOt: set limits(confrontational response)

pt with dementia requires nursing intervention for which prescription

Divalproex sodium 350 mg PO twice a day. Risperidone 1 mg PO at 0800 and 0.5 mg at 1600 daily. Lorazepam 0.5 mh PO three times a day PRN anxiety rationale: all increase the risk of mortality in dementia clients

Ilness that require low fiber

Diverticulitis, ulcerative colitis

A client if found on the floor by an ap what is the most appropriate action by the nurse

Document event in the MAR and have the AP file an incident report

Developmental concern in preschool children

Does not walk at 18 months, Does not speak atleast 15 words, Does not imitate action or words or simple instructions Talks in excess about violence Not interested in pretend play or other children

A pt precribed doxorubicin 60 mg as part of the cancer therapy. The client is 5'6" tall weighs 145 pounds and has a body surface area of 1.75. what is the correct dose to administer

Dosage: (60) x Body surface area: 1.75= 105 mg

The difference between gastric ulcer and duldenal ulcer

Duodenal ulcer occurs 2 to 4 hours after meals

Diet for pt with pancreatic cancer

Eat cool foods, and small but frequent(ward off nausea) high-protein high carbohydrate meals

pt comes in for evaluation of acute onset of seizure. which diagnostic test will be performed

Electroencephalogram (EEG)

Pediatric client with an open reduction of the radius and owner of a right on is immobilized in a plastic hospital at three and four today scrap what non-Pharma logical nursing intervention and promote comfort for this client

Elevate the cast on the pillow and apply an ice pack the approximate area of the surgical incision Rationale: The cast should not be flat on matress instead elevated for the first 24 to 48 hours. Heat would not be appropriate because it can cause swelling

After a calf is done to the left arm on a preschool child the nurse takes which action first

Elevates the childs left arm on 2 pillows

Low urine output for the AFTER 24 hrs post op is expected or emergency

Emergency (potential for pre renal failure and a cute injury

Blood glucose under70 in type1 is expected or emergency

Emergency : life threatening

amyotrophic lateral sclerosis (ALS) experiencing increased dysarthria 1. expected 2. emergency

Emergency! Condition means loss of motor neurons, dysarthria means losig the ability to speak which is also accompanied by trouble breathig and swallowing

throbbing headache and nausea in a pt with spinal cord injury above t6 1. expected 2. emergency

Emergency(priority)

Mononucleosis pt reports abdominal pain expected or emergency

Emergency: spleen rupture is a complication of mono. Monitor hemoglobin and need surgery

3 year old with kawasaki disease diagnosed 10 days ago with skin peeling expected or non expected

Expected

Adenotonsillectomy with ear pain 1. expected 2. emergency

Expected

Auscultatingfine crackles in a pt who is1 day post op and has an order to ambulate in the am is expected or an emergency

Expected

Bladder spasm for client with a urinary catheter following a protastectomy 1. expected 2. non expected

Expected

Client with left pleural effusion and absent breathe sound in base is expected or priority

Expected

Flank pain with kidney stones expected or emergency

Expected

Itching and nausea with opiods is exepected or emergency

Expected

Pt on Cyclophosphamide reports blood in urine

Expected

Pt with copd and diminished breathe sounds expected or priority

Expected

Third cranial nerve pathology with double vision 1.Expected 2. unexpected

Expected

Patient in hospice care drinks liquids but is refusing food his family becomes and patience and asked that he be force-fed what is the next priority action

Explore the family's feelings about the patient not eating Not: explain hell choke. The family may feel rejected as if the patient is giving up

The nurse applies the prescribed medication to an adult client diagnosed with scabies. Which body area should the nurse avoid when applying the scabicide? 1. Fingers and hands. 2. Groin and axillae. 3. Face and scalp.

Face and scalp. rationlae: when treating an adult client diagnosed with scabies, the scabicide is applied from the neck down. The drug should not be applied to the face or the scalp of an adult client.

The nurse teaches the client diagnosed with anal-rectal cancer about the side effects of external radiation therapy. Which side effect is most important for the nurse to include in this teaching plan?

Fatigue is managed by incorporating frequent rest periods during activity. rationale: Fatigue is the primary side effect for the person receiving radiation to the anal-rectal area; it is best relieved by periods of activity alternating with rest. not: Alopecia is a concern with chemotherapy and with brain irradiation. A cooling cap may be used during some types of chemotherapy.

The nurse provides care for a newborn who is recovering from necrotizing enterocolitis (NEC). Which intervention does the nurse include in the newborn's plan of care? 1. Feed the newborn fresh breast milk. 2. Use droplet transmission precautions.

Feed the newborn fresh breast milk. The use of fresh breast milk is the preference for the newborn who is recovering from NEC. It is the preferred enteral nutrient because it confers some passive immunity (IgA), macrophages, and lysozymes. Also, breast milk is more easily digested than formula.

Client receiving impramine would have which symptoms

Fever, dry mouth, increased fatigue, sore throat (tricyclic antidepressant)

Priority for pt in vtach

Find if they have a pulse

Cerebella damage can affect

Find the difference between sweet-and-sour taste

Position after cardiac cathe via femur

Flat or in a little position Not! Fowler

Client was in on heparin induced thrombocytopenia (HIT) is undergoing chemo and having central venous access device place which of these types of venous access device minimize the risk of (HIT) related complications

Groshong; Is the valve catheter that does not require heparin flushes

Care for client with short leg cast

Handle with palms of hands, Elevate affected limb to the level of the heart Comapre toes with opposite leg Place fan in clients room

after a cholecystectomy ptreports abdominal pain and bloating, the nurse should

Have pt walk down the hallway, Rationale: increases absorption of co2

Possible cause of guillain barre syndrom

Having recent viral infection as a cold or immunization.

Client with hypovolemic shock should not have

Head of bed in high fowlers, can cause bo to drop more

MRI contraindications

Hearing aids, pace makers, transdermal objects, tattoos

Only iv complication you treat with cool compresses

Hematoma

Expected sign of glomerunephritis

Hematuria (blood in urine)

Priority lab to monitor in acute kidney injury

Hemoglobin when low can lead to thromboembolic events such as stroke, MI, and heart failure

Priority during clients recovery from surgery

Hemorrhage

ContAct

Herpes simple, zoster, MRSA, scabies, pediculosis

Patient with chronic liver disease and psoriasis of the liver diet will be there

High 3000/day carbohydrates to help prevent protein catabolism. restrict protein 40g/ day and increase to 100g/day as symptoms improve

Signs of malignant hyperthermia

High everyhing except bp high temp, cardiac dysrhythmia, muscle rigidity of the jaw or other muscles, hypotension, tahypnea, and dark cola-colored urine.

Best position for emphysema

High fowlers Not: semi fowlers

Unexpected characteristic of newborn

High pitched cry (could be due to neurological problem) Sunken fontanelles Note; swollen genitals normal

Priority diagnosis in care for pt after a lower gastrointestinal xray who reports weakness

High riskfor fluid volume deficit Rationale:preparation for test, low residue or clear liquid diet 2 days prior,NPO for 6-8 hrs prior, enemas, laxatives

As a client receives a pyelogram they will feel

Hot feeling and skin becomes flushed

A client with heart failure says he hasnt been feeling like himself. The nurse should ask about

How do you position yourself for sleep

a client being treated for hypotension by dopamine should have the infusion reduced if they have

Hr of 120/min

Risk for Coronary Artery Disease

Hypertension, obesity, diabetes mellitus

u wave on EDG rhythm strip

Hypokalemia

Client with sepsis who was intubated 3 days ago is at risk-for

Hypotension

Sign of neurogenic shock

Hypotension and bradycardia (apical hr of 48/min)

Gastric ulcer teaching

I can eat most food as long as it doesnt upset my stomac

24 hr urine specimen

I will discard my first morning specimen collected all of urine for 24 hours of place the urine in one container

A client with enoxaparin is correct when he states

I will not pull back the plunger after inserting the needle Rationale : aspirating or pulling back the plunger after needle insertion can cause damage to small capillaries and blood vessel's and can lead to hematoma formation and bleeding

infant with fever, high pitched cry, vomiting, and irritable shows signs of

ICP: priority when 3 month old due to potential bacterial meningitis, droplet precaution should be initiated

Primary goals of case management is

Improve coordination of care and the transition of care. And to reduce the fragmentation of care

Anticipated goals or rehabilitation program for pt with ARDS

Improved exercise capacity Decreased anxiety, depression, hospitalization

Expected Behavior of right sided stroke patients

Impulsive behavior

A client with addisons disease taking cortisone needs an adjustment to meds

In increased levels of stress

feet and led elevated is a position that promotes

Increases blood return to heart

The nurse provides care for a client experiencing a sickle cell crisis. Which nursing diagnosis is the priority for the nurse to include in the plan of care?

Ineffective peripheral tissue perfusion. rationale: Due to infarction, ineffective peripheral tissue perfusion is the highest priority for a client with a sickle cell crisis. not risk for infection, not as important

Cause and effect relationship exist with stress and

Infectious diseases, motor vehicle accidents, some chronic ilnesses

a pt with rheumatoid arthritis recovering from endocarditis should

Inform dentist should i ever need any dental work

The nurse learns that a client with a seizure disorder has a serum phenytoin level of 35 mcg/ml. Which action does the nurse take first? 3. Inform the health care provider and expect a change in the phenytoin order. 4. Ensure suction is at the bedside.

Inform the health care provider and expect a change in the phenytoin order. rationale: A serum phenytoin level above 25 mcg/ml is toxic. The priority is to inform the health care provider. not:ensuring suction does not address pehenytoin

The nurse provides care to a client with a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Which action will the nurse take first? 1. Educate about calcium-rich foods. 2. Instruct to avoid drinking alcohol. 3. Initiate seizure precautions.

Initiate seizure precautions. rationale:hypocalcemia increases irritability of the central nervous system and peripheral nerves

Infant receiving prescibed im injections in dorsogluteal site is at risk for

Injury due to, sciatic nerve injury piercing major blood vessel

An older client with Medicare insurance asks the nurse to explain the "donut hole" in prescription drug coverage. Which response by the nurse is best?

It is a temporary limit on what the drug plan will pay for covered drugs. rationale:This coverage gap begins after the client and the drug plan have spent a certain amount for covered drugs in a year.

Common side effects of flu

Itching, redness, headache, low grade fever,

Pt recovering from abdominal surgery with low bp and high resp needs

Iv salune bolus to increase bp

appropriate care for a pt who was just extubated

Keep NPO due to aspiration risk. Mouth care with oral sponges, Incentive spirometer Warmed humidified oxygen via face mask

Cause of high pressure alarm in mechanical ventilator

Kinks, biting endotrach tube, excessive airway secretions,

A pt on bed rest should restrict with beverage

Large amounts of milk or milk products Rationale; too much milk can increase the demand on the kidneys to excrete couch and they can lead to kidney stones

How to go upstairs with cane

Leads with the cane followed by the bad leg and then the good leg

To take a bp via arterial catheter, the nurse should place the airfilled interfave of the stopcock at the phlebostatix axis located at

Level of atria at 4th ics 1/2 anterior posterior diameter 45%

What does the nurse monitor for post op fluid volume

Level of consciousness Urine output Respiratory rate Lung sounds

Quadriplegic patient has

Limited to no mobility of hands and arms

What factor would lower spo2 reading on pulse oximeter

Low blood volume: pt with low bp

Struggles when quitting smoking

Low level of income, Stress and depression, psychosocial problem, continued exposure to smoke stimuli

hormone replacement therapy benefit n risk

Lowers the risk of osteoporosis but increase coronary artery disease, breast cancer, dvt and stroke

Other name for chicken pox rash

Maculopapular: vecome vesicular: fluid -filled vesicles form crusts

1 day old test for PKU teaching

Make sure protein has been ingested, beforr they leave the hospital Done by gurthrie test

When a low tidal alarm is going off for a pt being mechanically vented, and the nurse checked the tubing but is not able to stop alarm. What should she do?

Manuelly ventilate with a resuscitation bag attached to trach. ET pt

The nurse provides care for a client with an enteral feeding tube. The nurse discovers that the client's continuous enteral tube feeding is 100 mL behind the prescribed infusion schedule. Which action should the nurse take first?

Measure residual volume. rationale: the reason the prescribed amount of tube feeding may not have infused could be due to a high gastric residual volume. Assessing the current residual volume is the first thing that the nurse should do.

Nurse caring for Child with wilmurs tumos should

Measure the childs abdominal girth- measures size of tumor. It is a rare kidney cancer treatment is surgery to remove tumor then chemo

Expectedand adverse thiazide (chlorthalidone) adverse

Mild to moderate fasting glucose

Best nursing action for Elderly client diagnosed with dementia.

Monitor wandering behaviors during a 7 day period

A young adult military veteran who served time in the Gulf War reports headache, sore throat, shortness of breath, a rash, and nausea when exposed to paint and certain air fresheners. Which condition does the nurse suspect is most likely causing the client's symptoms?

Multiple chemical sensitivities: rationale: this is commonly seen with scented products and paint fumes. These occur in Gulf War veterans.

Praey importance of care in pancreatic cancer

Nutrition consisting of low fat, high calorie diet, avoid alcohol. Rationale: pancreatic cancer risk of profound weight-loss and anorexia. Not: urinary retenion, urine will be darker but kidney function not affected

Best nursing action for Infant with depressed anterior fontanelles, high temperature and vomiting and diarrhea

Observe the infants ability to take in fluids

After pediatric patient has a tonsillectomy what interventions promote adequate nutrition an oral hydration in a pediatric patient

Offer chips: advance to clear liquids and suction gently to remove oral secretions as needed Dont: NPO not required, no soft food first few hours after surgery. Milk products are controversial

Client who just delivered infant had boggy uterus to the right of the midline. what action should the nurse take

Offer the client a bed pan (sign on full bladder) Not massage:

Intervention for pt who had cardiac arrest and is unresponsive and comatose

Ontaining equipment and fluids for induction of therapeutic hypothermia therapy. Rationale: Hypothermia therapy is indicated in all comatose pts who do not follow commands. neurologic injury is the most common causeof mortality in pts who has cardiac arrest especially v-fib.

The nurse notes visible, but not excessive, drainage on the dressing of a postoperative client. Which action is most appropriate? Outline the border of the drainage with a pen or Place pressure on the wound.

Outline the border of the drainage with a pen rationale: it continues it can be monitored. If the drainage becomes excessive if can be reported. not: 2nd option Pressure creates a risk for injury to the incision or underlying tissues.

peripherally inserted central catheter (PICC)

PICCs are inserted into a basilar or cephalic vein just below or above or below the antecubital space of the clients right arm by a doctor specially trained ID therapy nurse. The catheter terminates in the superior Vena cava. PICCS often remain in place for long periods of time

Client taking benzodiazepine is expected to have

Physical dependence

Intervention for pt with critically low hemoglobin

Place o2 on client. Prevents ischemia when low hemoglobin leas to low delivery of oxygen to cells

A client receiving a blood transfusion experiences a febrile reaction. Once the transfusion is discontinued, which action will the nurse take next? 1)Flush the blood tubing with normal saline. 2) . Place the bag and tubing in a biohazard container to send back to the blood bank.

Place the bag and tubing in a biohazard container to send back to the blood bank. rationale: The tubing and blood bag should be sent to the blood bank for analysis. Not: Flushing the tubing will cause the blood that is in the tubing to be infused into the client, making the reaction worse

The nurse examines the medical record of a client with type 1 diabetes mellitus (DM). Which health problem causes the nurse the most concern? 3. Pneumonia. 4. Hypothyroidism.

Pneumonia. The most common precipitating factor in the development of diabetic ketoacidosis is infection.

Bruit heard over aorta when auscultating abdomen means

Possible aneurism notify HCP asap

A pt had severe bone marrow suppression due to chemotherapy. Which nursing diagnosis reflects a potential life-threatening complication the patient may have.

Potential for infection Rationale: bone marrow depression have a decreased and white blood cells count which means they cant fight infection

New s3 heart sound in older adult is 1. expected 2. emergency

Potentially life threatening, as fluid overload or heart failure can lead to shock

Student using a doppler ultrasound device should not

Press firmly while moving the probe proximal to distal

Petechiae after taking sulfa 1. expected 2. emergency

Priority : sign of thrombocytopenia

5 days post op Tonsillectomy pt wants to return to soccer practice same day

Priority informt

Pt. with heart failure, short of breathe coughing up pink frothy sputum expected or emergency

Priority pt even over wheezing asthmatic sob

Homeless man drowsy with a temp of 95 1. expected 2. emergency

Priority sign of hypothermia which can lead to cardiac and respiratory arrest and coma

pt with splecetomy reports headache and chills expected or priority

Priority: minor spleen infections can become life threatening s o any indicator of low grade fever, chills, or headache should be met with appropriate intervention

myasthenia gravis with trouble swallowing expected or priority

Priority: neurologic disorder afffects facial muscles involved in chewing, swallowing. weakness can progrss to respiratory muscles. treated with pyridostigme to increase muscle strength

Purpose of turning and having pt cough and deep breathe every 2hrs is for.

Promoting ventilation and respiratory acidosis

The nurse provides care for a client after an above the knee amputation (AKA) 2 days ago. The nurse places the client in which position?

Prone position. rationale: The client is placed in the prone position for a short time on the first postoperative day and then for 30 minutes three times a day to stretch the flexor muscles and prevent hip contracture.

nurse priority intervention is required with

Pt taking Haloperidol for 4 days and has temp of 102 rationale: may be neuroleptic malignant syndrome:

Common side effect of doxorubicin

Red colored urine

Russell's traction

Reduce fractures of the hip or femur

which of the following body systems is responsible for the production of erythropoietin?

Renal system

Sign of hiatal hernia

Report of awakening at night with heartburn

The nurse provides care for a pediatric client experiencing an acute episode of croup. It is most important for the nurse to assess the client for which acid-base imbalance?

Respiratory acidosis. rationale: Respiratory acidosis is caused by increased carbon dioxide in the blood. The pediatric client experiencing an acute episode of croup has narrowed airways, making it difficult to breathe; thereby, this makes it difficult to eliminate carbon dioxide.

The nurse delegates care of a stable client to nursing assistive personnel (NAP). Which right of delegation is the nurse following?

Right circumstance.

Best position for a client who just had liver biopsy

Right side side lying Rationale: to prevent hemorrhage you would apply pressure by laying pt on the side of liver

Patient prescribed lisinopril should be instructed to minimize potential adverse reaction

Rise slowly from a lying to sitting position

the nurse provides care for a client with an oral temperature of 90 °F (32 °C). Which nursing diagnosis will the nurse use first to guide this client's care? .

Risk for cardiac dysrhythmia. not: Acid-base imbalance will most likely occur; however, this is not a priority. rationale:Severe hypothermia can lead to cardiac arrest.

Patient concerned with the appearance of his nose after facial surgery to remove melanoma how should the nurse respond 1.Scar tissue is part of the healing process, they will tell you how to heal your wound to reduce risk of complications 2.you can cover it up with make up

Scar tissue is part of the healing process, they will tell you how to heal your wound to reduce risk of complications Not: you can cover it up with make up

Position for paracentesis

Semi Fowler

serotonin reuptake inhibitors drug names and adverse

Sertraline, fluoxetine, paroxetine Increase risk of suicide at start of medication. Look out for pt that reports having increased energy but deppressed

cervical traction

Stabilize of the spinal fracture or muscles spasm

Priority intervention for A pt stabbed with scissors in the abdomen

Stabilize scissors with sterile dressing

The nurse reviews prescriptions from a health care provider for a client's care. Which prescription will the nurse question before implementing?

Start heparin infusion by 0800 hours rationale: The heparin infusion is missing a dose or amount of heparin to be infused. This prescription should be questioned before implementing.

Negative pressure wound healing is a sterile or clean technique

Sterile

Quadriplegic client diagnosed with a C2 and C3 factor. what matters does the nurse implement to keep the client comfortable, meet elimination needs and prevent autonomic dysreflexia

Straight catheterize the client to prevent bladder distention and prevent ball infection

Adults over 85

Suicidal thoughts and behavior

Angiogram position after procedure

Supine with the right leg extended Rationale: Pt must keep their leg straight after procedure so you want to prevent constriction of the blood vessel and keep the right leg at or below the level of the heart

The nurse provides care for a client with face, ear, and neck burns. Which is the best position for the client?

Supine without pillows or padding. not: Supine with padding on the affected side. raitonale:A supine position minimizes pressure and irritation to the burned areas, but burned areas may stick to pillows or padding. Pillows may cause contractures in clients with neck burns.

The nurse is teaching the client about the warning signs and symptoms of lung cancer. Which statement is appropriate for the nurse to include in the teaching?

Symptoms of lung cancer are vague and often present late in the disease." not: ) Constant coughing and bloody sputum are late, not warning, symptoms of lung cancer.

Unstable vtack pt

Synchronized cardioversion

Low PaCO2 sign on can lead to

Systemic inflammatory response syndrome: SIRS leads to hypotension and impaired end-organ perfusion. can occur in trauma, tissue, ischemia, infection, and shock, other s/s: tachycardia, leukocytosis, or leukopenia, and tachypnea

The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication?

Take the medication with a full glass of water." rationale: prevents acid reflux and an be taken anytime of day, The client must remain upright 30 minutes after taking

Who needs vitamin b6

Tb positive pt given to prevent peripheral neuropathy when taking isoniazid

How should the nurse respond to a Client that is anxious about and ask nurse about refusing the surgery

Tell me how you feel about the surgery Not; you have the right to refuse

buck's traction

Temporarily immobilizes a fractured leg

The nurse mentors a nursing student. The student asks which organization requires all clients to be assessed for pain. Which response by the nurse is correct?

The Joint Commission not: The American Nursing Association (ANA

Pt with pallor, reporting fatigue, dyspnea on exertion concerns nurse when she sees

The angle between the nail plate and the possible nail fold is straightened to 180°

The nurse receives report for a group of adult clients. Which client will the nurse see first?

The client diagnosed with failure to thrive lying supine with a nasogastric tube feeding infusing.

As a witness you confirm that

The client gave his consent, signature is authentic, the client is competent

The nurse provides care for a client who had a transcutaneous electrical nerve stimulation (TENS) unit on the right shoulder for 2 hours. Which client action would lead the nurse to determine that the TENS unit was effective?

The client is working on the assigned physical therapy exercises rationale:The pain is controlled enough for the client to feel comfortable working on the assigned exercises. not: the client request acetaminophen

The nurse provides care to clients on a progressive care unit. Which client does the nurse see first? 1. The client with a blood pressure of 86/44 mm Hg receiving intravenous antibiotics for urosepsis. 2. The client with a blood glucose of 215 mg/dL receiving treatment for diabetic ketoacidosis.

The client with a blood pressure of 86/44 mm rationale:client with urosepsis has low blood pressure, which could indicate poor organ perfusion. This client should be seen first by the nurse. not the DKA: has a blood glucose level that is not causing distress. This client can be seen later.

The nurse provides care for a client taking warfarin for a mechanical prosthetic heart valve. The client has an international normalized ratio (INR) of 3.1. Which is the correct interpretation by the nurse of this finding? 1.The next dose of warfarin needs to be stopped 2.The client's treatment goal has been achieved

The client's treatment goal has been achieved rationale: The desired goal for warfarin therapy is an INR of 2.5 to 3.5 The next dose of warfarin needs to be stopped

A nurse caring for a pt with a single lumen venous acces device (CVAD) would be worried if

The clients dressing is changed daily using the sterile technique. Rationale: it should be transparent semi permeable dressing changed every 5-7 days, gauze dressing is changed every 2 days and both are immediately changed if soiled, or dislodged. Not: pt receives insulin through CVAD as its compatible with parenteral solutions.

The nurse prepares to make an initial home care visit to a client newly diagnosed with end-stage heart failure. Which action will the nurse take before visiting the client? (Select all that apply.) 1. Evaluate the safety of the client's neighborhood. 2. Determine nursing diagnoses for the client. 3. Establish desired outcomes for the client. 4. Collect information about the client's diagnosis and treatment. 5. Arrange the visit at a time when it is safe to be in the area.

The nurse prepares to make an initial home care visit to a client newly diagnosed with end-stage heart failure. Which action will the nurse take before visiting the client? (Select all that apply.) 1. Evaluate the safety of the client's neighborhood. 4. Collect information about the client's diagnosis and treatment. 5. Arrange the visit at a time when it is safe to be in the area. not: 2. Determine nursing diagnoses for the client.During the second, or entry phase, of the home visit, the nurse determines nursing diagnoses. 3. Establish desired outcomes for the client. 3) During the second, or entry phase, of the home visit, the nurse, in collaboration with the client and family, establishes desired outcomes.

The nurse notes that a client's heart rate decreases from 55 to 45 beats/min. Which action does the nurse take first? 1. Determine if the client is lightheaded. 2. Administer 0.5 mg of intravenous (IV) atropine.

The priority action is for the nurse to determine if the client is symptomatic. not: administer atropine If the client is symptomatic, atropine 0.5 mg through the intravenous route is administered every 3 to 5 minutes up to a maximum dose of 3 mg. However, this is not the first action the nurse takes.

A client with diabetes returns from the post-anesthesia care unit (PACU) after a transurethral resection of the prostate (TURP). Which intervention will the nurse perform first?

The priority is to check the patency of the indwelling urinary catheter during the immediate post-operative period. not: Checking a capillary blood rationale: glucose level is a part of comprehensive post-operative management of client with diabetes. However, this is not the first priority during the immediate post-operative care of a client recovering from a TURP.

The nurse performs a pelvic exam on a client admitted in labor to determine the station of the presenting part. The client asks the nurse, "What does the term station mean?" Which explanation does the nurse give to the client? 1. The relationship of the presenting fetal parts to the ischial spines. 2. The relationship of the fetal parts to the external cervical os.

The relationship of the presenting fetal parts to the ischial spines

The nurse auscultates heart sounds in a school-age client. Where does the nurse place the stethoscope to listen to the aortic area of the heart?

The second right intercostal space

Platelets are used for

Thrombocytopenia

Nasogastric tube goes

Through the nose and into the stomach

Nasal intestinal to goes

Through the nose pass the stomach and into the small intestine

Percutaneous tube goes

Through the skin directly into his stomach

pt with contractions sustained over 2 minutes required

discontinue IV oxytocin not discontinue

Fasting lipip profile should be

Total cholesterol: Under 200, Tyglycerides: under 150 LdL: under 100 HDL: male; more than 40 Female; more than 50

The nurse provides care for a client diagnosed with trigeminal neuralgia. The client reports severe burning and shooting pain. Which understanding does the nurse have about managing this type of pain?

Treatment will include the use of adjuvant analgesics. rationale: Neuropathic pain is not well controlled by opioid analgesics alone and often requires the addition of tricyclic antidepressants or anti-seizure drugs to help prevent pain transmission.

Client with holter monitor studying should be taught

Trigger the event market when pain or other symptoms occur Use regular toothbrush instead of electric Keep diary of acitivities focusing on symptom occurence Immediately report fast heart rate or difficulty breathing

If a pt with ng tube vomits and then during irrigation nurse feels resistant she should

Turn the patient to his side she should NOT! -Changing ng tube from intermittent to continuous. -continue irrigation wven after resistance is met

Leading cause of death in people of 1-44

Unintentional injuries

signs of phenytoin toxicity

Unsteady gait

The nurse provides care for a client with rhabdomyolysis. Which finding will the nurse determine is most appropriate for the client?

Urinary output >60 mL per hour. Not:Pupils equal and reactive to light. Rationale: muscle breakdown can lead to myoglobinuria, which can put the kidneys at risk for acute renal injury. Keep the client hydrated and a urine output of 200 to 300 ml per hour.

Client with high BUN and creatinine should also have reviewed his _____ to confirm possible renal toxicity

Urine output

Before administering meds the nurse should

Use 2 identifiers is more important than asking for their name

Mechanical ventilation DONT

Use bolus for feeding (Instead do continuous enteral feedings)

90 degree traction

Used on the femur if skin traction is not suitable

Position: feet elevated and head lowered (trendelenburg)

Used to insert central venous pressure line or for treatment of umbilical cord compression

The nurse observes a visitor in the room of a client diagnosed with Clostridium difficile. For which action by the visitor does the nurse intervene?

Uses alcohol hand rub after leaving the client's room. rationale: c.diff not killed by alcohol needs to wash with soap and water not: Removes all protective equipment before leaving room. as All personal protective equipment must be discarded before the visitor exits the client room.

The nurse prepares to administer a prescribed intramuscular (IM) immunization to an infant. Which site does the nurse use to administer the medication?

Vastus lateralis

Best muscle to administer im injections to adults is the

Ventrogluteal Rationale: no major nerves or blood vessels nearby, can accomodate greater than 2ml an more irritating meds Not deltoid: not developed in some adults especially older can only use some amount of medication

Pt with unstable copd oxygen of 86% room air and respirs of 32/min should use a

Venturi mask : delivers high flow regardless of pattern or rate

A patient needs a platelet transfusion which is required for platelet transfusion Verification of 2 patient identifiers cross matching ABO compatibility or RH compatibility Specialized platelet filter

Verification of 2 patient identifiers ABO compatibility or RH compatibility Specialized platelet filter Crossmatching:Not needed for platelet and Plasma because they do not contain red blood cells

Uti teaching

Void every few hours Vitamin c will make the urine more acidic

Best indicator of fluid loss in glomerunephritis

WEIGHT

Intervention for client receiving mechanical ventilation and sedated

Wash with chlorexidine Maintain head of bed 30-45 Pause sedation daily to assess wean ability Place manual resuscitation bag at bedside

carboxy hemoglbin is

What forms in red blood cells when carbon monoxide forms with hemoglobin. Normal value is under 5% in non smokers and under 10% in smokers.

6 y.old with history of epilepsy was admitted with uncontrolled seizures. The nurse should ask.

What was ur child doing before the seizure

Client with disseminated herpes simplex virus (HSV) admitted into the maternity unit shoudl be placed in

a single client rm until the lesions have crusted over she should be in contact precautions not: a rm with a client who just a vaginal birth

pt with lumbar laminectomy shoudl always exersice which muscles

abdominal

the nurse in a psychiatric unit of the hospital declines the clients request to organize a pary on the unit for the clients friends. he becomes angry and uses abusive language towards the nurse. which statement reflects that the nurse understands the clients behavior

abusice language is one of the behaviors symptomatic of the clients illness rationale: symptoms will respond to treatment not: modeling acceptable behavior as it will not change clients behavior

prenatal client comes to clinic accompanied by her spouse who states they were in a car accident and her abdomen hit the steering wheel. the nurse sees the wife wringing her hands and avoiding eye contact. her records show 2 missed prenatal appointments. whic actions does the nurse take

accompany the client into the restroom to obtain a urine sample rationale: gets client away from abuse to be further assesed without the client feeling fearful not ecort he couple to an exam room: she may not be safe with the spouse

client taking with haloperidol for 3 has fever of 103.5, bp of 200/199, pulse of 122 bpm. He is pale and sweating excessively, nurse should first

administer bromocriptine as prescribed rationale: this med counteracts NMS neuroleptic malignant syndrome not: asses LOC

Client with small-bore feeding tube inserted for intermittent feedings, the nurse should take which interventions when administering medications to the tube

administer each medication separate not: flush the tube with 15 ml, as the minimum amount for flushing is 30 ml

the nurse caring for a bipolar disorder pt who is pacing the halls, and making hostile comments to other clients. he resists the nurse attempts to move the client to another rm in the unit. most important action for nurse is to

administer haloperidol IM: will decrease hyperactive behavior so client can take fluids and food. not: inform about unit rules

the client who was admitted to rehab for a hip replacement surgery. during an episode of confusion the client became a danger to self and required vest restrainment application. the nurse knows that which of the following are also considered forms of restraints

administergin haloperidol raising all 4 of the side rails fastening a bed sheet tightly across the clients chest clipping a tray across the front for the clietns wheenchair.

The nurse is providing care to a client diagnosed with measles. Which transmission-based precaution does the nurse implement when caring for this client?

airborne

precaution for rebeola

airborne

abrupt tearing, moving, upper to lower) back pain and epigastric pain sign of

aortic dissection: when the arterial wall layer tears and allow blood between inner and middle layers, usually accompanied with hypertension.

intervention for client in motor vehicle accident

apply hard cervical collar inspect clients respirs place on flat surface use log rolling if moving, DONT:asses for neck range of motion

nurse caring for a client after discharge to follow up on newborn. the client reports that the newborns eyes look yellow. how should the nurse response

are you breastfeeding or bottle feeding? rationale: breastfed newborns have jaundice for a few days due to lack of mild production or inadequate feeding bottle-fed newborns taking the appropriate amount of formula ted to not be as jaundiced. assessign how the newborn id fed is important to determine dehydration not bilirubin level: finding feeding type is more important

nurse gets report from co-worker was possibly infected with TB. The nurse best reply is

are you concerned that you may be infected with TB. if so she will return to work and wear a mask until TB screening is done

a neonate is hypothermic which intervention should the nurse postpone

bathing the newborn should be postponed unitl the skin temp is stable and can adjust to heat loss from bath

pt with cholecystitis diet option

bbq chicken, green peas, lemonade rationale: low fat, low carb, high protein diet.

rh negative mom who gave birth to rh positive child asks why she was given RhoGAM,

because it will prevent the formation of antibodies.

type 2 diabetes mellitis pt prescribed pioglitazone and meformin should be questioned if which are present

being 6 weeks pregnant, *history of heart failure, *hisotry of lactic acidosis not: history of hypertension

pt receiving treatment for adrenal crisis responds favorably to treatment is which sign is observed

blood pressure has increased. rationale: without treatment sodium falls and causes hypotension.

who is priority between a client with chest pain unrelieved by nitro vs. a pt with 3rd degree burns to the face.

burn pt. rationale: any pt with a burn to face, chest, abdominal burns can cause severe edema that restricts the airway,

nurse working in rehab will most likely see which complication of IV drug abuse

cellulitis: rationale: most narcotic addicts do not inject sterile purified material with aseptic techniques; causing cellulitis

The nurse provides care for a client diagnosed with type 2 diabetes mellitus. The nurse anticipates that the client will be prescribed a second-generation sulfonylurea. Which medication in the hospital formulary belongs to this class of drugs? 1. Metformin. 2. Glipizide.

glipizide

The nurse provides care for a client diagnosed with cutaneous Kaposi sarcoma lesions. The nurse notes that the lesions are open and draining small amounts of serous fluid. Which personal protective equipment (PPE) does the nurse use when bathing and changing the linens for this client?

gown and gloves

parenteral nutrition bag of 1000mL has been infusing for 24 hours and still has 200 mL remaining. what will the nurse do when changing the solution

change the infusion as schedules rationale: the unused solution is discarded, not: infuse the remaining solution over the next 2 hours: the solution bag should NOT hang for more than 24 HOURS. Slowing rate can cause hypoglycemia

client in manic episode would have

grandiose delusion, difficulty concentrating, agitation,

the nurse is assessing a 6 hr old new born. the nurse notes swelling on the parietal areal of the newborn's head that does not cross the suture line. which term does the nurse use to describe this finding

cephalhematoma: rationale, it is a collection of blood between a skull bone and its periosteum. the cephalhematona does not cross a cranial suture line. it appears several hours of the day after birth.

a client with a history of smoking and and drinking reports a nonproductive cough, chest discomfort and dyspnea. the nurse hears isolated wheezing in right lun. the nurse should

call radiology to arrange for chest x-ray. rationale: confirms pts symptoms, he may have a chest mass, that is only visible on xray not: pulmonary function test, dont to confirm COPD, not needed until other testing are done first

The visiting nurse notes that a client diagnosed with asthma is in the "red zone" of the peak flow meter system. Which action does the nurse take first?

call the healthcare provider not: repeat the test rationale: red zone is emergency situation do not waste time

client experiencing early symptoms of dystonic reaction related to antipsychotic medication would require the nurse to

call the provider about administrating im diphenhydramine rationale: dystonic reaction = muscle tightness in throat, neck, tongue, mouth, eyes, and back. difficulty talking and swallowing

biohazard bin should include

canister of gastric secretions: rationale: large risk the secretions can escape and lead to infections not: blood tinged adhesive bandage: if it were soaked in blood it would be disposed in biohazard bin but blood tinged is not enough blood that would escape. it would just go in trash.

the client with a flail chest from a motor vehicle crash. what finding is expected

chest on affected side is pulled inward during insparation and bulges outward during exparation. normal is expansion outward during insparation and pulling inward during exparation.

bryant's traction

children <3 y <35 lbs with femur fx

the nurse discovers the iv infusion tubing disconnected from a central venous device, and the client coughin, short of breath and cyanotic. the nurse will immediatley

clamp the tubing rational: clamping the device will prevent further air from entering the clients circulation not: reconnect the tubing to the central venous device: the pts signs of embolism, the device is contaminated which will cause a bloodstream infection if reconnected

NG tube clean or sterile procedure

clean: wear gloves, gown, mask, and goggles

what lab values are monitored durin heparin therapy

clottign time=ptt or partial thromboplastin time. therapeutic range 1.5-2.5 times baseline values

best multidisciplinary care for a client diagnosed with breast cancer is

collaboration: rationale: defines the multidisciplinary team approach to building a plan of care of the client. not case management: coordinates the care, improves outcomes, and reduces cost but not initially plan the care of the client.

the nurse cares for a client admitted with stroke and facial paralysis. she will plan to prevent which complication

corneal abrasion. rationale: the client will be unable to close eye voluntarily and the cranial nerve 7 will not be able to produce secrections that protect the eye not: inability to talk, because although it may occur, nurse cannot prevent it

sign a pt with closed head injury has developed diabetes insipidus

cracked lips, urinary output of 4l/24hrs, urine specific gravity of 1.004

The nurse prepares to administer fondaparinux med to a client. Which laboratory test result will the nurse monitor in the client receiving this medication?

creatinine level: rationale an anticoagulant that inhibits factor Xa is excreted by the kidneys; creatinine level should be monitored periodically, and the drug stopped in clients who develop unstable kidney function or severe renal impairment.

PT admitted with chest pain, nurse should be concerned with which lab values

creatinine phosphokinase of 4 ng/mL normal: 0-3, enzyme is specific to Mi, indicates tissue necrosis or injury to heart muscle

which client should the nurse stay with 1. a pt disoriented to person, place, and time or 2. a client who is hostile an irregular vital signs

disoriented client rationale: risk for self injury, such as falls, and disorientation can be sign of serioud head truama or shock not: irregula vitals, they require close monitoring but does need nurse to stay with them

The nurse provides care for a toddler who is a ward of the state. The toddler requires surgery. Who is authorized to give written, informed consent for the procedure? 3. Foster parent. 4. Social worker who placed the child in the foster home.

forster parent The social worker has no legal authority in this matter.

client with a history of multiple sclerosis has not been able to live alone due to impaired mobility. what statement shoudl the nurse make

do you have any pain or ulcer on your legs, ankles or hips? rationale: client with MS will have skin breakdown, look for areas of injury due to falls, look for signs thrombosis. not a motorized wheelchair:

when obtaining a health history form an older female client the nurse should ask

do you take calcium supplements rationale: calcium supplement intake can be modified to lower risk of osteoporosis not: is there a family history of osteoporosis its a non-modifiable risk.

client with radium implnt. durign the removal it is most important for the nurse to take which action

document the date and time of removal together with the total time of implant treatment not handle radium with forceps.

client with acute respiratory distress is anxious, edematours, and cyanotic. the client received morphine. the nurse recognizes which as desired response to the med

decreased in anxiety, not: enhanced ventilation and decreased cyanosis, as medication does not improve ventilation

client with pulselessness and asystole should NOT be treated with

defibrillation shock rationale: defibrillation is used to put ventrical dysrhytmias back into rhythm. it cannot create a rhythm if there is not any

pt with pituitary dwarfism would have

delicate features: (appear younger than chronological age) not: abnormal body proportions

cleint diagnosed with paranoid disorder believes family member are trying to steal from him. he demonstrates which symptom

delusion of persecution: rationale: question mentions family not delusion of reference: as that relates to public events or people are related to the pt.

allen test is done to

determine the patency of the ulnar artery

pt with parenteral nutrition has the pn abruptly discountinued. nurse expects which sings

diaphoresis, confusion, tachycardia. rationale: hypoglycemia

heparin injection administration

dont administer under 2 inches from umbilicus, dot aspirate or massage after injection.

a nurse provides care to infant and toddler clients who may have been expose to hepatitis A outbreak, to control disease transmission andn prevent future outbreak of hep A. the nurse shoudl

educate staff and clients about proper hand hygiene protocols, not :restricting contact with children who have symptoms of Hep A rationale: hep A is communicable 2 to 3 weeks before the onset of symptoms. restricting contact with clients who are symptomatic is not effective

The nurse provides home care to a client receiving intravenous therapy and enteral nutrition. Which care objective will the nurse identify as a priority for this client?

education rationale: Home care requires education not: Case management rationale: is observing and examining the client to determine what the health status is, what the care needs are, and what resources are available to meet those needs.

client with inguinal hernia should take which precautions to reduce postop swellign

elevate the scrotum not: low fiber diet which will increase risk of constipation and not reduce swelling

which labs concern nurse the most 1)elevated serum anti-streptolysin o (ASO) titer 2) urinalysic with leukocytes 3)e. coli

elevated serum anti-streptolysin o (ASO) titer rationale: means glomerunephritis, infection can be serious threat to healtl 2) just means urinary tract infection

cause of nausea during 1st trimester

elevation in the hormones not increase in basal metabolic rate

aortic dissection emergency or nonemergency

emergency:: requires surgery and lowering back pain

pt admitted after rape. the nurse knows the spouse of rape victim usually has which behavior

emotionally distressed and needing assistance

a nurse caring for a post op pt after intracranial surgery should encourage/ discourage pt from

encourage: using a turning sheet under the clients head to mid thigh to res position the client in bed. (helps maintain body alignment, and lowe ICP) discourage: coughing (it can incrase ICP)

how should a nurse reply to a client worried about his restaurant business and handling stress once he returns

give the client complementary therapies related to relaxation ans say pretend this is a menu. which of these would you like to order for yourself. not: who is supposed to take care of the restaurant while you are here in the hospital? does not show coping option

Sign that patient is not using crutches correctly

has them here torn and worn at the axillary pads. Rationale; they should be supported by arms and hands.

A client in a nursing home is found onthe floor nonresponsive with a blood pressure of 98/50. A heart rate of 120 beats per minute and respiration of 28 and oxygen saturation at 94% he has a signed DNR and do not intubate form that should the nurse do

have another staff member call 911 gather paperwork and contact the primary provider to notify of the transfer all the while the nurse stays with the client to continue to assess for any change in condition

pt in citizens center says he wants to avoid gettting pneumonia, the nurse should ask

have you had the flu shot this year rationale: pneumonia often follow viral infection or flu. the nurse should ask if client received the influenza vaccine. not: how often do you cough and deep breathe (used for prevention in hospital settings)

further teaching is needed when a client takinG risperidone says

he has to take the med even though he is no longer depressed. rationale: risperidone is an antipsychotic, not an anti-depressant he should know the correct indication not: i will report changes in my sleeping habitsas it can lead to abnormal derams, insomnia, oversedation

client with paroxetine, nurse should report to the health care provider that

he is being started on digoxin: lowers effectiveness

Purpose of compulsive handwashing and OCD client

help avoid undesirable thoughts and maintain some control over guilt and anxiety

cystic fibrosis client diet 1.high protein, high calorie 2. high protein, low sodium

high protein, high calorie low: high protein, low sodium

a nurse gets a call from a parent saying his 10 year old has not stopped bleeding from his nose even though he applied pressure, which response is most important

how long have you applied pressure? rationale: the parent shoudl apply direct pressure for 5-10 minutes continuously. if that has occured the child should be taken to the emergency dept. to be treated with silver nitrate applicator and compressed gelatin foam. not how much bleeding has occurred: difficult to ascertain

client with peptic ulcer disease (PUD) receives cimetidine, which statement indicates successful teaching

i should eat 3 meals a day not: i can drink coffee as long as its decaf. rationale: coffee stimulates acid secretion. client should avoid coffee, aspirin, meat extracts, alcohol and take the med until ulcer heals

teaching for client with herpes zoster

i should expect only 2 side of my face to hurt, this pain may linger for months i will try to not scract the lesions not: i will take antibiotics for the infection it requires antivirals,

client with myasthenia gravis is wrong if he states

i should use paper and pencil to communicate with my husband: rationale: they can speak written communication is not necessary

client with neutropenia understands teaching if she says

i will call my health care provider if i develop a fever. rationale: incease risk of infections not: using soft toothbrush, this is for thrombocytopenia not neutropenia

client with diabetes mellitus is having a hyperglycemic even if he has which symptms

polydisia (thirst), polyuria, polyphagia (increased eating) rationale: pts body will be trying to get rid of excess glucose through renal excretion. Which cause dehydration. Sweating and bradycardia not a sign,

what should be reported to hcp if seen in a pt that just underwent general anethesia

muscle stiffness confirmed by high temp. treated with dantrolene expected: difficult to arouse, pinpoint pupils

parent of client with asthma needs further teaching if she states

my child like sleeping on the bottom bunk rationale: dust mites can trigger astham. not: my child sleeps on a foam pillow and mattress as long as they are covered and zippered in allergen -impermeable covers

HIV infections related to iv drug use caused by

narcotics

common initial adverse effect of estrogen

nausea

can ap perform pain assessments

no

is a pt with beclomethasone treatment required to get blood sugar checked

no

The nurse instructs a client receiving intramuscular cyanocobalamin injections. Which client statement indicates that teaching is effective?

no alcohol drinking

can an AP time the seizure of a client

no only a nurse can

if a nurse wirtes an incident report for making a med error should she keep a copy of the incident report in her personal records

no, It is not a good idea to print and keep an incident report, but it also does not offer the nurse any protection to have a copy

can Minors with cognitive impairment give consent with a parent.

no, Cognitively impaired persons of any age cannot sign their own consent forms.

does Flushed skin appearance require immediate action by nurse

no, it could be cause by non-emergency reason

does Empty bedpans as soon as possible prevent the transmission of healthcare-associated infections when providing care for clients.

no, it is a good practice but has no effect

is Pregnancy-induced hypertension a risk for fetal macrosomia?

no, only obesity and diabetes

a preschool child is brought in for dehydration. is it appropriate for parents to hold the client in a bear hug during the procedures

no, they should not be asked to restrain their child. they should give comfort and support but staff should perform any restraint.

can an ap deligate ambulation to another AP

no. the AP's do not delegate

normal ageing pattern

nocturia, not: incontinence

2 hr old newborn has hands and feet that are bluish colo the nurse attributes this to

poor perfusion of blood to the periphery of the body not:low hemoglobin level (their hemoglobin is usually elevated)

the nurse wants to privde info for a family with a history of hypertension. the nurse prepares to teach the client about primary prevention measure. which should she include select all 1. Regularly measure blood pressure 2. maintain a healthy weight 3. stress reduction techniques 4. reduce salt intake.

not: Regularly measure blood pressure (that is a secondary prevention includes screening for risk factors for a certain cindition and then providing meausre to promptly recognize its occurence, such as regularly measuring blood pressure to screen for hypertension 2. maintain a healthy weight 3. stress reduction techniques 4. reduce salt intake.

following the removal of a brain tumor from a child, the nurse observes a colorless drainage on the dressing. which action does the nurse take first? 1. Outline the drainage on the bandage 2. notify the health care provider

notify the health care provider rationale: it may be cerebral spinal fluid, the nurse should monitor for sings of increased icp, hemorrahge, and meningitis not: Outline the drainage on the bandage (althought appropriate, the priority is to contact the HCP.

after thyroidectomy most important assessment is

numbness in the fingers rationale: decrease in calcium not: confusion; as it is an indication of hyperthyroidism

sumatriptan med, look out for

numbness or weakness especially on one side of the body

diet for pt prescribed furosemide needed potassium

one medium bakes potato, 1 cup of cantaloupe not: apple

fecal impaction is associated with

oozing of liquid feces

gait belts shoud be used

over the clients clothes with clip in front, removed from client immediately after use

a 2yr old does not have a pulse.cpr is started and the AED arrives with adult pads what should the nurse do

place an AED pad on the chest and the other on the back note: 2 are required regardless of age, on an adult it would be one on the upper right chest and another on the lower left side

post-op cataract client is cautioned about not makein sudden movement or bending over. the nurse understants that the rationale for this is to prevent which complication

pressure on the ocular suture line

pt with lung contusion oxygen at 90% and severe inspiratory chest pain expected or priority

priorit: life threatening can lead to lung collapse and acute respiratory distress. o2 of 90% indicates hypoxemia

kidney transplant pt reporting low grade fever and generalized body pain should be 1. expected 2. emergency

prioritized for diagnotic rationale: he is immuno suppresed and these are signs of systemic infection that can lead to sepsis.

A client receiving a liter of iv fluid at 120 ml/hr has 460 ml remaining after 2 hours

priority due to risk of fluid overload leading to heart failure

client 2 hours post foot amputation surgery had a surgical dressing saturated with bright red blood priority or expected?

priority: 2hrs post op serosanguineous is expected. bright red. can mean hemorrhage.

client with lymphocytic leukemia is admitted to the hospital for treatment of hemolytic anemia. which intervention should the nurse take

promote quiet environment to promote adequate rest rationale: primary problem is activity intolerance not: isolate client from visitors since its only necessary when WBC fall under 500/mm. the question did not mention WBC,

initial stage sign of glomeru-nephritis

proteinuria, hematuria

lab value used to monitor warfarin therapy

prothrombin time

sign of prolapsed colostomy

protruding stomal

who has the highest risk of developing TB

pt that is HIV positive not a ot with mantoux test with 4mm area of induration.

the nurse provides care for an older client diagnosed with type 1 diabetes mellitus and hypertension. the client receives a ct scan with contract. what should the nurse do?

question whether the scan must be done with dye rationale: the older client with decreased glomerula filtration, hypertension, and diabetes can cause renal compromise that will worsen with a CT scan with contrast.

client with history of diabetes mellitus type 1 is recently experiencing permanent vision loss and is having trouble adjusting. which action by the nurse is most appropriate

recommend the client join a support group not warn the client that failure to adapt can increase the risk for injuries rationale: seems to be a threat, disrespectful and unethical

pt with descending colon tumor will have which signs

rectal bleeding, flat ribbonlike stools, alternating diarrhea constipation notL colicky abdominal pain: thats a symptom for ascending tumor

if a pt scheduled for a colon resection in the am had a polyethylene glycol-electrolyte solution and soapsuds enema the previous evening. This morning he passes a medium about of soft brown stool. the nurse should conclude that

the bowel preparation is incomplete: he should not have remaining soft stool.

client who was abused by a family member shows Initial s positive outcome from treatment if

she verbalized not being responsible for the sexual abuse rationale: abuse survivors need assistance challenging the belief that they are bad and deserved the abuse. not: the client reestablishes a trusting relationship with other family members: this is a positive long term goal but the initial step is to acknowledge not being responsible for the abuse

infant with absence of tears when crying and refusing liquids

sign of moderate dehydration

pt with hepatitis a shoudl have which type of precatution

standard

lumbar puncture teaching

stay still during procedure, food and water restriction not required local anesthesia

a cane should be held on weak or strong side

strong side

toys for toddlers

stuffed animals, push pull, low rocking horse, dolls, cloth picture books, pounding toys, not: playground materials, dress up clothes, educational computer programs, tricycle, skates thats for preschool.

the nurse using a hydraulic lift should take which actions

suspend the client in the sling above the bed prior to moving the lift. not: remove the sling from the client once the client is seated in the chair(it should be kept under the client to facilitate transfer back to bed and promote comfort.

the inner cannula of tracheostomy can be changed by parents (t) or (f)

t: should be removed or cleaned every 8 hrs

nurse will determine which as a sign of increase respiratory rate distress for 4 yr old admitted with droolign and inflamed epiglottis,

tachypnea

pt with garlic capsules daily should have follow up by nurse if

the client take regular insulin for type 1 diabetes rationale: garlic can have direct hypoglycemic effect and potentiate the actions of diabetic drugs. not: the client had hypertension: garlic is tkane to lower cholesterole and blood pressure

client with left total hip replacement. which finding concerns the nurse

the client's heels are on the bed with toes pointed upward. rationale: heels should be kept off the bed to prevent skin breakdown not: pillow between the legs as this prevents dislocation of the prosthesis.

myasthenia gravis pt need more assitance with muscle faitgue during

the end of the day

which observation confirms possble fractured right hip

the lg appears to be shortened and is adducted and externally rotated

the nurse goes to neighbors house during a snow storm she is in her 40th week of gestation adn has been having contractions for several hours, which concerns the nurse the most

the woman ask for help to go to the bathroom. rationale: sign she is going into the transition. due to increased pelvic pressure the desire to urinate arrives the nurse shoudl asses the clients cervis and prepare for emergent delivery.

MRI teaching

this prcedure tkaes 90 minutes to complete. there will be no discomfort

priority goal for pt with pneumonia secondary to pulmonary disease

to improve the quality of ventilation (CO2 and oxygen) not just oxygen

which meal would have less protein chicken and cranberries or tofu and spinach

tofu (7g/oz) and spinach (2g/oz) rationale:chicken (7g/oz) and cranberries=0

what symptoms would alert to the nurse pt may have alcohol problems while hospitalized for physical illness

tremors, high temp, nocturnal leg cramps, not night sweats seen in pts with TB leukemia and other infections

a tracheostomy should be suctioned before trach care true or false

true: suctioning keeps the area clean longer

4th stage of labor palpate fundus at

umbilicus

client needed sputum culture ans sensitivity should be told

upon awekening, cough deeply and expectorate into a container

client with broken jaw urgent or non urgent

urgent: airway problem

can a pt taking is a pt with beclomethasone have the treatment stangind or lying

yes

can flu and pneumococcal vaccine be administered at the same time

yes

varicose vein prevention teaching: pt can cross legs at ankles, thighs, wear tight sock?

yes at ankles, no at thighs, or wear tight socks rationale: they can wear elastic hose or stockings

client with DVT can get up to use the bathroom?

yes, bed rest is not required unless the client is having severe leg pain and edema. Ambulation can reduce leg pain

should a nurse question order for metoclopramide med to a pt with frequent involuntary finger movement

yes, the med increase GI motility. The nurse should report the clients condition with the dr, because it can cause tardive diskinesia,

child with honey colored crust, vesicles, and redding macules arounf the mouth. dr will parents

your child has an infection that can be treated with antibiotics

"The door should be kept closed to the room of a client with a clostridium difficile (C. diff) infection." 1. A gown should be worn when measuring the blood pressure of a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection." 2. "The door should be kept closed to the room of a client with a clostridium difficile (C. diff) infection."

— Contact precautions are used to minimize the spread of pathogens that are acquired from direct or indirect contact, especially multidrug-resistant organisms such as MRSA. Not:The door does not need to be kept closed to the room of a client with a C. diff infection. Contact precautions are being used.