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An older woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? SATA a. recommend installing grab bars b. have the home health nurse assess the home for fall risks c. encourage exercise to improve balance and mobility d. wear an emergency response pendant at home e. request that a family member move in with her

A B D

the nurse is assessing a client who was recently extubated. the client has oral medications prescribed. which clinical findings show the pt is safely able to take oral meds? a. manages oral secretions b. alert and oriented c. ability to pass flatus d. denotes are in place e. gag reflex present

A B E

An IV infusing in a client's left forearm becomes infiltrated. After removing the IV, which sites should the nurse select as possible sites to insert another IV catheter? (Select all that apply.) A. Right hand. B. Left hand. C. Right forearm. D. Right subclavian. E. Left subclavian.

A C

A PT with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement: A. Report serum albumin and globulin levels B. Provide diet low in phosphorus. C. Note signs of swelling and edema D. Monitor abdominal girth. E. Increase oral fluid intake to 1,500 mL daily.

A C D

The nurse plans to administer a bolus dose of IV heparin based on the clients weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of Heparin should the nurse administer?

9000

After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? a. use the bell to listen at the same site b. ask the pt to turn to his right side c. lift the stethoscope slightly off the skin d. listen for a high pitch extra sound

An elderly male client is admitted to the urology unit with acute renal failure due to a post-renal obstruction. Which question best assists the nurse in obtaining relevant historical data? A.Have you had any difficulty in starting your urinary stream?" B."Have you received any blood products in the last year?" C. "Have you taken any antibiotics recently?" D. "Have you had a heart attack in the last 6 months?*

which breakfast selection indicates that the pt understand the nurses instructions about the dietary management of osteoporosis? a. bagel w jelly and skim milk b. granola bar and grapefruit juice c. egg whites, toast, and coffee d. bran muffin, mixed fruit, OJ

Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4- year-old child who has streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2mL. How many mL should the nurse administer?

0.4

dosage cal

1.2 (1.16 round up)

PT with HIV beings active labor at 38 weeks gestation and receives a prescription for zidovudine 2 mg...

168

During an assessment by the home health of an older man who lives alone, the client reports that he is troubled by constipation. to formulate a plan of care, what additional info should the nurse obtain? SATA a. daily food and fluid intake b. current prescribed and OTC meds c. next scheduled visit w hcp d. level of physical activity and exercise e. methods currently used to treat constipation

ABDE

PT who is admitted to the ER following MVA is having difficult breathing While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left fields... a. elevate the HOB 45 degrees b. place client in trendelenburg position c. withhold narcotic pain med d. apply a high-flow o2 by face mask e. obtain a chest tube insertion kit

ADE

A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next? A. Record "no known drug allergies* on preoperative checklist. B. Assess client's knowledge of an allergic response. C. Assess diet's allergies to non-drug substances. D. Flag "no known drug allergies" on the front of the chart.

a client who is admitted to the emergency room following a motorcycle accident is having dyspnea While assessing client's chest and lungs, the nurse notes that there are no breath sounds over the left fields. Which actions should the nurse implement (SATA.) A. place diet in Trendelenburg position B. Apply a high-flow oxygen by face mask, C. Elevate the head of the bed as degrees D. Withhold narcotic pain medication E. Obtain a chest tube insertion kit

B C E

The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? Elevate the presenting part off the cord.

Elevate the presenting part off the cord.

75. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2

the nurse finds a female pt crying quietly in her room. what action should the nurse take first? a. pull up a chair and sit beside the client b. review the pt's record before attempting to intervene c. provide the pt privacy and quietly close the door d. ask the pt why she is crying

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?A.)Abnormal responses for cranial nerves I and II B.)Persistent coughing while drinking C.)Unilateral facial drooping D.)Inappropriate or exaggerated mood swing

A client is hospitalized for treatment of a myasthenic crisis and is concerned about what may have caused this illness. The client states, "I just had a little case of the sniffles and a bit of a sore throat... a. muscle weakness is an early sign of crisis and means that you need more rest b. the crisis may have been triggered by your cold. I bet it can feel pretty scary c. you probably just did too much at one time. you need to pace your activities d. it was probably an overdose of your medication. did you take a double dose

Monitor for signs of hydromorphone hours for four days. Which assessment is most important for the nurse to complete? a. observe for edema around the ankles b. auscultate the client's bowel sounds c. count the apical and radial pulses simultaneously d. measure the pt's cap glucose levels

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the clients history ... a. inadequate diversional activity b. alcohol use c. witness to an accident d. family hx of dementia

The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take? a. complete an adverse occurence report b. monitor for signs of bleeding c. obtain blood for coagulation studies d. notify hcp

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Case management and screening for clients with HIV B. Vitamin supplements for high-risk pregnant women C. Regional relocation center for earthquake D. Lead screening for children in low-income housing

What equipment should the nurse use to most accurately measure a 2ml dose of viscous liquid solution to be administered orally? a. 3ml syringe and a sterile needle b. 3ml syringe c. tuberculin syringe d. one ounce medicine cup

When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour

the healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose a. saturation of more than one pad an hour b. htn c. excessive lochia d. diff. finding the uterine fundus

the nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses

which diet should the nurse recommend for a client who is in acute renal failure? a. high pro, low carb, low sodium, low k+ b. low pro, high carb, low sodium, low k+ c. low pro, high carb, low sodium, high k+ d. high pro, low carb, low sodium, high k+

which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? a. Leukocytes, neutrophils, and thyroxine. b. Serum potassium, calcium, and phosphorus. c. Blood pressure, heart rate, and temperature. d. Erythrocytes, hemoglobin, and hematocrit

when caring for a pt with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention? a. Sloughing tissue around wound edges b. complaint of increased pain and pressure c. Change in the quality of the peripheral pulses d. Loss of sensation to the left lower extremity e. Weeping serosanguineous fluid from wounds

bcd

50: While caring for a client who is being mechanically ventilated the nurse respond to a high pressure alarm on the ventilator. Which assessment finding warrants immediate intervention? A: Endotracheal cuff pressure greater than 25 cm H2O B: Decreased lung compliance during ventilation C: restless client who is biting the endotracheal tube D: Bilateral crackles with increased secretion

77. A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect? A. Herpes simplex virus B. Toxic shock syndrome C. Syphilis D. Mononucleosis

A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history form the child's mother, the recent occurrence of what illness is most significant? a. chickenpox b. mumps c. sore throat d. influenza

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A. Mean arterial pressure (MAP) B. White blood cell count C. Blood culture D. Oxygen saturation

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? a. Increased time of ambulation between periods of rest. b. Decrease in intracranial pressure and cerebral edema. c. Absence of seizure activity for the duration of treatment. d. Normal electroencephalogram after drug administration.

A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure

A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg intravenously 60 minutes ago. Which action is most important for the nurse to implement? a. auscultate the lungs b. review serum k+ c. measure u.o d. administer albuterol via nebulizer

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse take? a. evidence of spread of the disease to the kidneys b. representative of a decline in the pt's condition c. confirmation of the autoimmune disease process d. indication of the onset of joint degeneation

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? a. the fire is burning my skin away right now b. the voices are telling me to kill the next person I see c. the nurse at night is trying to poison me with pills. d. the snakes on the wall are going to eat me

a pt with hematuria secondary to a uti has a prescription for cephalosporin cefoperazone. which action should the nurse implement? a. hold the schedule dose and consult with HCP b. monitor the pt's pt/inr before administering the dose c. administer the prescribed dose of medication as scheduled d. assess the pt's bp before and after the dose

In conducting a pain assessment of a client with osteoarthritis, which action should the nurse include? a. collect dietary hx of calcium-rich food intake b. measure VS changes after physical activity c. ask if pain lessens with elevation of extremity d. observe the pt during moment of affected joints

Medical asepsis requires that the nurse include what handwashing technique? a. hold hands higher than the elbows and scrub vigorously b. use hot water to ensure that pathogens are killed c. use a circular motion, washing from clean to dirty areas d. rinse soap off, keeping hands and forearms lower than elbows

The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take? A. Plan to observe the secured IV site after the insertion procedure B. Confirm that the nurse has gathered the necessary supplies C. Remind the nurse to tape the gauze dressing securely in place D. Instruct the nurse to use a transparent dressing over the site

The client is pleading for the nurse to release her arms, restrained in the wheelchair a. determine if the pt has a PRN prescription for an anti anxiety agent b. contact the HCP to ensure that a prescription for restraints was written c. close the door to avoid disturbing other pts in nearby rooms d. advise the staff nurse to remove the restraints from the pt's wrist

The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation? A. Determine the presence of hematemesis as the UAP irrigates the NGT B. Instruct the UAP to bring an antiemetic to the nurse at the bedside C. Assess the appearance of the emesis while the UAP checks bowel sounds D. Direct the UAP to measure the emesis while the nurse irrigates the NGT

The nurse is assigned to care for a client diagnosed with psoriasis. What is client's psychosocial need for acceptance? a. Encouraging the client to join a support group. b. Wearing gloves when interviewing the client. c. Allowing the client to ventilate feelings d. Shaking the client's hand during an introduction.

the nurse uses the glasgow coma scale to assess a client who has had a stroke. When the nurse calls out the client's name, the client does not open eyes, does not respond to painful stimulus...

gcs3

The nurse is developing the plan of care for a hospitalized child with von Willebrand disease. Waht priority nursing intervention should be included in this childs plan of care?

guard against bleeding injuries

One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

observe for unilateral swelling

Insulin admistration

obtain bg level verify the insulin prescrption draw insulin cleanse site

A client presents to the labor and delivery unit, screaming "THE BABY IS COMING" which action should the nurse implement first. Observe the perineum

Observe the perineum

after administering the ace inhibitors lisinopril, it is most important for the nurse to monitor which assessment finding a. blood pressure and risk for falls b. serum K+ and skin tugor c. HR and complaints of nausea d. eosinophil count and constipation

PT with hx of HF and type 1 DM is admitted with unstable angina. Which problem requires the most immediate intervention by the nurse? a. fve b. acute anginal pain c. activity intolerance d. fatigue

Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemoptasis

The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client a. with pneumonia whose k+ is 6.5 b. a.fib whose saline lock is infilrated c. heparin infusion + hematuria d. HTN BP 230/118

The mother brings her four month old so into the clinic with a quarter taped over his umbilicus. And tells the nurse the color is supposed to fix her child's hernia which explanation should the nurse provide? A. The quarter should be secured with an elastic bandage rap B. the hernia is normal variation that resolves without treatment C. restrictive clothing will be adequate to help the hernia go away D. and abdominal binder can be worn daily to reduce the protrusion

The mother of a 14-month-old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition... a. advise the mother that these foods will only be needed until b. reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients c. affirm that these prepared foods are the best way to ensure that the toddler gets all the needed nutrients d. teach the mother how to develop a budget to allow her to continue to provide the needed prepared toddler foods.

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What actions should the nurse take? A. Demonstrate how to help the client move more efficiently B. Affirm that the client should arise slowly from the chair C. Tell the UAP to assist the client in moving more quickly D. Offer a PRN analgesic to reduce painful movement

The nurse is caring for a child newly diagnosed with attention deficit hyperactive disorder (ADHD). The child's mother asks about information of the treatment options. Which information is most helpful for the nurse to provide? a. emphasize the addictive nature of popular medications b. offer effective time management strategies c. explore the combination of medication and behavioral therapies d. discuss dietary changes such as increasing protein intake

The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky abdominal pain, nauseas, vomiting, and abdominal distention. Which pathophysiological mechanism supports the client's clinical presentation? a. incompetent lower esophageal sphincter b. weakened diaphragm with high abdominal pressure c. intestinal scar tissue buildup from a chronic condition d. a hx of having h.pylori infection

The nurse is caring for four clients who are on the rehabilitation unit, which client should the nurse assess first? A. A client with an above-the-knee amputation who is complaining of phantorn pain. B. A client who is receiving a continuous tube feeding and is now vomiting. C. A client with left hemiplegia who is scheduled for hemodialysis today. D. A client with pneumonia who is scheduled for pulmonary function studies.

The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout? a. I need to take the prescribed amount of the drug to get rid of my gout b. I need to take this drug daily to keep from having any flare-ups c. pain and swelling can be controlled by taking this drug daily d. I should take this drug when I have gout attacks to reduce symptoms

The nurse is planning to teach infant care and preventive measures for SIDS to a group of new parents. Which information is most important for the nurse to provide a.Swaddle the infant in a blanket for sleeping. b.Ensure that the infant's crib mattress is firm. c.Place the infant in a prone position whenever possible. d.Prop the infant with a pillow when in a side-lying position.

The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for prophylactic hepatitis B immunizations? A. A child daycare worker who has a history of Type 2 diabetes mellitus B. An office worker who requires hemodialysis for chronic kidney disease C. A restaurant chef who was diagnosed one year ago with hepatitis D. A sales person who travels internationally and eats food in foreigr

The nurse is providing care for a child who is brought to the emergency department.. to the leg from a barbed wire fence. The child has not received any tetanus... early signs of muscular rigidity with spasms and jaw clenching or trismus. What is the nurse's highest priority for this child? a. Suction oropharyngeal secretions. b. Prepare for intubation with mechanical ventilation c. Minimize stimulation from sound, light, and touch. d. Monitor IV infusions.

The nurse is teaching a client newly diagnosed with systemic lupus erythematosus accurate for the nurse to provide? A. The client can expect to progressively lose function in a fairly predict B. The disease is characterized by alternating periods of flare-ups and.. C. Once an acute attack subsides, the client can expect to feel fine ag.. D. Systemic lupus erythematosus (SLE) is a chronic, incurable, termin

The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side... a. slip-on rubber shower shoes b. tennis shoes with velcro c. rubber soled slippers d. leather soled loafers

The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these under-served immunization groups? A. report describing influenza rates during times of greatest prevalence b. designation of clinics conveniently located in target neighborhoods c. legislative proposals that mandate influenza vaccinations for all d. radio announcements about the availability of the influenza vaccine

dosage cal ml/hr

200

Which type of leukocyte is involved with allergic responses and the destruction of cells? A.Eosinophils. B.Neutrophils. C.Lymphocytes. D.Monocytes.

a young pt who is being taught to use an inhaler for symptoms of asthma tells the nurse the intention to use the inhaler but, plans to continue smoking cigarettes. what is the best initial action? a. review factors surrounding pt's beliefs about smoking cessation b. revise the plan of care based on the pt's plans to continue smoking c. inform the hcp of this statement made by the pt d. explain that denial of illness can interfere with the treatment regimen

after taking lactulose for several days, which therapeutic response should the nurse expect for a client with hepatic encephalopathy a. improved mental status b. reduction in number of liquid stools c. ability to ambulate independently d. increase in UO

Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately A. Upper airway stridor. B. Oxygen saturations 90%. C. Expiratory wheezing. D. Blood tinged sputum.

An adult female with eroded tooth enamel presents to the clinic with complaints of abdominal discomfort and esophagus client tells the nurse that her diet consists mostly of high- sugar, high-fat foods that she usually consumes while drinking. She also describes taking laxatives and eating prunes whenever she overeats. What actions should the nurse take developing a plan of care for this client? (Select all that apply.) a. Ask the client how she prefers to eat. b. Encourage the client to record everything she eats. c. Ask the client what she would like to do about her eating habits d. Monitor lab values, particularly for electrolytes. e. Have the client self-report vomiting incidents

A C D

A client with a history of schizophrenia is admitted with diabetic ketoacidosis. what should the nurse implement during the admission process for this client? SATA A. Obtain psychiatric and medical admission records. B. Hold psychotropic medications until glucose is regulated. C. Interview client about reason for admission to hospital. D. Prepare the client for involuntary commitment admission E. Review the list of home medications and dosages

A C E

an older woman who lives alone in a two-story home is admitted after falling while shopping. which interventions to implement a. palpate and mark pedal pulses b. alert social worker c. assess ability to bear weight when standing d. evaluate pain using a standard pain scale e. support left leg with two pillows

AB D

A client who in an avid hiker expresses concern about losing too much potassium while hiking... SATA a. dried apricots b. seedless raisins c. lightly salted peanuts d. dried bananas e. dried apples

ABD

An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibeilation. Which nursing problems should the nurse expect to include in this client's plan of care? a. fatigue b. fve c. fvd d. decreased CO e. altered peripheral tissue perfusio

ABDE

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation... SATA a. Inspect skin for redness. b. Avoid range of motion exercises c. Apply alcohol to the stump after bathing. d. Use a residual limb shrinker e. Wash the stump with soap and water.

ADE

An INFANT is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats / minute. What action should the nurse take? Slow the feeding and monitor the infant's response.

Slow the feeding and monitor the infant's response.

A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemical on the hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? Determine type of chemical exposure

Determine type of chemical exposure

An adult male report that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his decease parents had hearth and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. Which risk factors should the nurse explore further with the client (SATA)

Family health history and history of hypertension

An older client is admitted to the psychiatric unit for assessment of a recent.. that in the evening this client often becomes restless, confused, and agitate important for the nurse to implement? A. Ask family members to remain with the client in the evening B. Ensure that the client is assigned to a room close to the nurse's station C. Postpone administration of nighttime medications until after... D. Administer a prescribed PRN benzodiazepine at the onset

While interviewing an elderly client, the nurse observes that the clients hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding? a. muscle flaccidity b. intention tremor c. transient ischemia d. sensory dysfunction

during the admission assessment, the nurse identifies multiple bruises at various stages of healing on a pt recently dx with aplastic anemia. the nurse reviews the pt's stat serum lab values which reveal PLTs 50k, WBC 3k, RBC 2.5, which action should the nurse implement a. implement contact precautions b. monitor for signs of bleeding c. provide a soft bristle tooth brush d. initiate sepsis protcol e. infuse blood products as prescribed

BCE

A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours a. Nausea and elevated blood pressure. B. Decreased appetite. C. Agitation and threats to harm staff. D.Difficulty walking.

Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider? A. Low urine output puts the client at risk for fluid overload. B. An increased urine output is expected after splenectomy. C. Oliguria signals tubular necrosis related to hypoperfusion. D. This output is not sufficient to clear nitrogenous waste.

The charge nurse is making client assignments in the intensive care department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12- week internship... a. pt with ARDS who is on a ventilator b. pt in end stage liver failure who is experiencing esophageal bleeding c. pt with chest tubes secondary to stab wound to the chest d. pt with multi system failure secondary to MVC

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum sodium of 145 mEq/L (145 mmol/L SI) C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) D. White blood cell count of of 12,000 mm3 (12 x 109/L SI)

A nurse working on an Endocrine Unit should see which client first? a. An older client with Addison's disease whose current blood sugar level is 62 mg/dL b. An adult with a blood sugar of 384 mg/dL (21.31 mmol/L) and a urine output of 350 c. An adolescent male with type 1 diabetes who is arguing about his insulin dose d. A client taking corticosteriods who has become disoriented in the last two hours.

An older adult client with chronic emphysema is admitted to the emergency room with weakness, palpitations, and vomiting. Which information is most important initial interview? A.History of smoking over the past 6 months. B.Sleep patterns during the previous few weeks C.Activity level prior to onset of symptoms. D.Recent compliance with prescribed medications

An older client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. The client is lethargic, moderately confused... a. administer the PT's usual dose of insulin b. obtain a serum K+ level c. assess pupillary response to light d. start IV infusion of NS

The nurse is caring for a client who has chronic obstructive pulmonary disease (COPD).. a recent fall. What nursing intervention requires the greatest caution when caring for a client A. Monitoring telemetry and cardiac rhythm. B. Assisting client to cough and deep breath. C. Increasing the client's fluid intake. D. Administering narcotics for pain relief.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? Distal pulse intensity

Distal pulse intensity

While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? Inquire about an electric bed for the client's home use Submit a referral for an evaluation by a physical therapist. Explain the usual progression of osteoarthritis and HF Request social services to review the client's resources

Submit a referral for an evaluation by a physical therapist.

*The home health nurse makes a bome visit to a male client with Amyotrophic Lateral Sclerosis (ALS). The client is sitting upright while feeding himself and coughs frequently during the meal. What action should the nurse implement? A. Demonstrate use of a tucked-chin position while eating B. Recommend the use of supplement liquid feedings C. Assist the client to lie down and turn to the side D. Encourage the use o assistive feeding devices

60 yo PT asks the nurse about hormone replacement therapy as a means of preventing osteoporosis. Which factor a. her mother and sister have a hx of breast cancer b. her 60 y.o sister has Alzheimer's dx c. she is taking medication for high bp d. she had problems with hot flashes several years ago

75. A client with a history of alcohol addiction says, my body feels fine when I abstain from alcohol consumption. But I miss my late.night glasses of wine, which concept should the nurse discuss with the client. A. Craving B. Tolerance C. Denial D. Withdrawal

76. A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10cm H20 mark with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Give blood from the collection chamber as autotransfusion. B. Manipulate blood in tubing to drain into the chamber. C. Add sterile water to the suction control chamber D. Increase wall suction to eliminate fluctuation in water seal.

96) The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bed pan. Which action should the nurse take? a. Evaluate the effectiveness of this measure to stimulate client voiding b. Recommend a complete bath to cleanse perineal area more fully c. Instruct the PN that this technique promotes infection in elderly females. d. Suggest contacting the health care provider for a prescription for catheter insertion

A 41 week gestation primigravida woman is admitted to labor and delivery for induction ofLabor. Which findings should the nurse report to the healthcare provider before initiating theinfusion of Oxytocin. A. fetal heart tones located in upper right quadrant B. Sterile vaginal exam refill in 3 cm dilatation C. Well physical profile results showing oligohydramnios D. Regular contractions or current every 10 minutes

A client arrives at the clinic experiencing shortness of breath with a possible right spontaneous pneumothorax. Which lung sounds should the nurse expect to auscultate? a. Diminished to absent breath sounds from the apex to the base of the right lung fields b. Adventitious popping sounds or crackles that occur on inspiration or expiration c. High- pitched harsh crowing sound or stridor heard during inspiration d. High pitched wheezing with a musical quality on inspiration and expiration

A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right with the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees

A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? a. place pt in trendelenburg b. administer O2 via facemask c. notify OR team d. admin a fluid bolus of 500ml

A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement A. Elevate the head of the bed 60 to 90 degrees B. Measure from corner of mouth to angle of jaw C. Administer a PRN analgesic D. Assess for a gag reflex

A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement? A Elevate the head of the bed 60 to 90 degrees. B Measure from corner of mouth to angle of jaw. c Administer a PRN analgesic. D Assess for a gag reflex.

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse? a. takes metformin HCL for type 2 DM b. report of PT's sobriety for the last 5 years c. CT scan that was performed six months earlier d. metal hip prosthesis was placed 20 years ago

A client is taken to the urgent care clinic after fainting while exercising at the gym. The client is weak, pale, and diaphoretic.. a. check blood glucose level b. auscultate heart sounds c. offer an oral hydration drink d. performa 12-lead ecgn

A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains blood glucose of 50 mg/dL, heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement? a. position pt with head flat and feet elevated b. suggests obtaining a medical alert bracelet to be always worn c. encourage the pt to eat low-carb and high protein meals d. reinforce the need to continue the outpatient clinic therapy

A client with Cellulitis of the right great dose has been taking an antibiotic for seven days which assessment should the nurse complete to determine effectiveness of the medication? A: observe for signs of inflammation on and surrounding the toe B: Determine the length of the capillary refill time of the toe C: Compare the pedal pulse volume of the right and left feet D: Note any thickening scarring or ridgeline present on the toe

A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor? a. an acutely distended bladder b. profuse forehead diaphoresis c. skeletal traction misalignment d. severe pounding headache

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously schedules. What action should the nurse take a. Advise the UAP to resume positioning the client on schedule B. Encourage the UAP to provide comfort care measures onlyC. Assume total care of the client to monitor neurologic function D. Assign a practical nurse to assist the UAP in turning the client

A client with cancer complains of fever, chills, malaise, and headache following administration of a colony-stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu-like symptoms? a. monitor lab values for an increase in WBCs b. administer antiemetics before, during, and after therapy c. administer acetaminophen q4h d. monitor v/s q4h for 24h

A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness

A dient with a new diagnosis of Raynand's disease lives alone. Which instruction should the nurse include in this cients discharge teaching plan? A. Keep room temperature 80F B. Develop a walking exercise routine C. Hire a care-giver for 8 hours daily. D. Wear TED stockings at night.

A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain and a possible ectopic pregnancy... a. NS at 20ml/h b. LR at 150ml/h c. D5W at 125ml/h d. D10W at 83ml/h

A female client who has a borderline personality disorder is being discharged today . When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, " My favorite nurse is on duty now". Which response is best for the nurse to provide to this client's dichotomous tendency? a. I am happy that you are getting better and will be able to go home. b. I am glad you like me. Which nurse was acting aloof to you? c. What did the night nurse do that makes you think she is aloof? d. Tomorrow I will talk to that nurse about how you were treated last night

A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in ..... used for peritoneal dialysis. While bathing, the her abdominal dressing becomes wet. What action should the nurse take? a. Change the dressing. b. Reinforce the dressing. c. Flush the peritoneal dialysis catheter. d. Scrub the catheter with povidone-iodine.

A male client being treated for testicular cancer with chemotherapy has decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? a. advise the pt that the txmt is having a beneficial effect b. instruct the client to obtain PSA testing c. inform PT that his chemo dose will be increased d. discuss options for hospice care w the pt and family members

A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins

A post- menopausal female client with osteopenia tells the nurse that she has increased her physical activity and hopes to participate in a charity walkathon. How should the nurse respond? a. Affirm the benefits of increasing her weight bearing activity b. Review the need for her to avoid large crowds of people c. Teach her how to take her pulse during prolonged activity. d. Explain the need to limit physical activity to reduce fracture fide.

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem? a. infection b. ineffective airway clearance c. altered comfort d. impaired gas exchange

A postoperative client has a large amount of serosanguineous drainage on the surgical dressing and the nurse notes that the operative report indicates that the client has a Penrose drain near the incision. What intervention should the nurse implement when changing the client's dressing? a. place sterile gauze dressing under the penrose drain b. apply sterile gloves before removing the souled dressing c. cover the penrose drain with saline moistened gauze d. wear a face mask or shield during the dressing change

A school age child is brought to the Emergency Center with fever and joint pain and is diagnosed with rheumatic fever explanation should the nurse provide the parents regarding the cause of this condition? a. A previous bacterial infection causes a chronic condition that effects the heart valves. b. The valves in the heart develop lesions that cause inflammation and scarring. c. Scar tissue causes the leaflets in the heart valves to become rigid and closed. d. An infection in the mitral valve results in a systemic infection that affects all heart valves

A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee ground materials is observed in the drainage from the nasogastric tube (NGT), which intervention should the nurse implement? a. verify correct placement of NGT b. perform gastrooccult test on the nasogastric drainage c. listen for evidence of diminished bowel sounds d. irrigate the NGT with water until water

A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take? a. initiate an ethics committee review of the case b. place a DNR bracelet on the PT's arm c. ensure resuscitation equipment is available d. ask the family to review options with the client

ABGs results indicate that a PT with respiratory failure who is being mechanically ventilated has respiratory acidosis. The ventilator rate is set at 6 breaths/minute. which action should the nurse implement to help correct the acidosis? a. increase in the ventilator rate b. provide manual resuscitation c. decrease the pressure support d. increase O2 concentration

After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? a.File a detailed incident report with the specific hiring facility. b.Warn the colleague that their actions are unprofessional. c. Comment anonymously about the action of a staff discussion board. d.Communicate the colleague's actions to the unit charge nurse.

After receiving report, the nurse can most safely plan to access which clients last? a. an adult client with no post op drainage in the JP drain w the bulb compressed B. an older client with dark red drainage on postoperative dressing, but no drainage in the Hemovac. C. And older clients with distended abdomen and no drainage from the nasogastric tube D. an adult client with rectal tube draining clear, PALE red liquid drainage

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement? a. encourage the pt to weigh herself daily at bedtime b. allow the pt to select an arts and crafts activity c. recommend exercise and recreation in the morning d. put the pt in change of choosing snacks for the unit

An alert older client with diabetes mellitus Type 1 is admitted with a serum glucose of 420 mg/dI (23.31 mmol/L (SI)). As the nurse administers 10 units of regular insulin intravenously (IV), the client immediately begins to vomit. What action should the nurse implement first? A. Turn the client to a lateral position. B. Check the client's serum glucose level. C. Provide an emesis basin. D. Hang a bag of IV normal saline.

An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip

An older client with cirrhosis of the liver and hepatic failure is places on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? a. decreased abdominal girth b. prothrombin time wnl c. improved loc d. clear, dark amber-colored urine

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? a.Determine the client's level of mobility and need for assistance. b.Instruct the UAP that all clients deserve equal care. c.Advice the client to maintain bedrest so that safety can be ensured. d.Assign another UAP to care for the client.

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is...nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the... a. Determine the clients level of mobility and need for assistance b. Instruct the UP that all clients deserve equal care. c. Advise the client to maintain bedrest so that safety can be ensured. d. Assign another UAP to care for the client.

During a 24-hour chart review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed by the pervious shift. which is the best immediate action? a. order the lab work as prescribed and follow procedures for completing an incident report b. telephone the nurse responsible for the error at home to report the omission of the transcription c. call the HCP and ask if the prescription is still needed d. notify the nursing supervisor of the previous shift's omission in not transcribing the prescription.

The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions? a. oranges b. kidney beans c. liver d. left green vegetables

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first? a. elevate the client's right hand on one or two pillows b. notify HCP of the finding immediately c. measure the client's BP and apical pulse rate d. complete a neurovascular assessment of the right hand

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? a. watery diarrhea b. yellow tinged sputum c. increased fatigue d. n/h

In monitoring tissue perfusion in a client following an above the knee amputation which action should the nurse include in the plan of care? A: Evaluate closest proximal pulse B: Note amount and color of wound drainage C: Assess skin elasticity of the stump D: Observe for swelling around the stump

PT dx with Hodgkin's dx undergoes biopsy of cervical lymph nodes under local anesthesia. Which intervention is most important to include in this client's plan of care? a. monitor for tracheal deviation and swelling at biopsy site b. assess for drainage on dressing covering cervical incision c. auscultate BP q15m for 1h d. perform neurological assessment prior to discharge

The laboratory findings for a client with chronic kidney disease (CKD) include elevated... and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate assessments. Based on these findings, which action should the nurse implement? a. Provide high protein snacks b. Administer PRN oxygen. c. Schedule frequent rest periods. d. Monitor glucose levels q4 hours

The mother of a one-moth-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? a. position the infant on the stomach occasionally when awake and active b. turn the infant not he left side braced against the crib when sleeping c. prop the infant in a sitting position with a cushion when not sleeping d. place a small pillow under the infant's head while lying on the back

The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? a. hypoalbuminemia that results in a decrease colloidal oncotic pressure b. hyperaldosteronism causing an increased sodium reabsorption in renal tubules c. decreased renin-angiotensin response related to increase in renal blood flow d. decreased portacaval pressure with greater collateral circulation

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? a. Positive Epstein-Barr, and malaise. b. Ear pain and fever. c. Elevated WBC and sedimentation rate. d. Increased BUN and serum creatinine.

The nurse identifies an electrolyte imbalance, crackles on auscultation with progressive heart disease. Which intervention should the nurse A. Measure ankle circumference. B. Record usual eating patterns. C. Evaluate for muscle cramping. D. Document abdominal girth.

The nurse includes assessment for fat embolism syndrome (FES) in the femur. Which findings should the nurse include that are often the earlier signs: a.Confusion, restlessness. b.Petechial rash. c.Tachycardia, fever. d.Pulmonary crackles.

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? a.Keep the nails trimmed short. b.Apply baby lotion to the skin twice daily. c. Bathe the child daily with bath oil. d. Allow the child to wear only 100% cotton clothing.

The nurse is assessing a client who retums to the unit after a thoracentesis in the procedure room. Which finding... a. Diminished breath sounds over the trocar insertion site b. Equal bilateral chest expansion. c. Scattered crackles unchanged from baseline d. Respiratory rate of 22 breaths/minute.

The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for... only private room available? a.Bacterial meningitis b.Viral encephalitis. c.Septic shock. d.Brain abscess.

The nurse is caring for a client admitted for evaluation of a descending aorti.. documenting, the nurse hears the client screaming. The client tells the nurse something inside is ripping and tearing." The client also reports dizziness.. cause? a. Impending rupture of the aneurysm. b. The client is having a panic attack. c. Clotting of the aneurysm. d. The client is hallucinating from the opioids.

The nurse is having difficulty palpating a client's posterior tibial pulse while the client is lying in supine position. What action should the nurse take? a. Help the client to a prone position with the knee slightly flexed and palpate again. b. Apply less pressure when palpating over the middle of the dorsum of the foot. c. Use an ultrasound stethoscope placed behind and below the medial ankle bone. d. Extend the client's arm fully while supporting the elbow and attempt to repalpate

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the health care provider? a. Ortolani maneuver causing a click at the hip joint b. moro test precipitating a startle response c. babinski test that reveals fanning out of toes d. plumb line test indicates fetal position curvature

The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA)> the nurse includes activities to strengthen and mobilize the joints surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. exercise in a swimming pool b. splint affected joints during activity c. perform passive ROM exercises t.I.d d. being a training program lifting weights and running

The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports of the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the clients clinical recovery? a. lipase b. creatinine c. bilirubin d. glucose

The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling... a. ABI b. joint range of motion c. calf diameter d. skin elasticity

The nursing staff on a med unit includes a RN, PN, and UAP. Which task should the charge nurse assign to the RN? a. supervise a newly hired grad nurse during an admission assessment b. transport a pt who is recieving ivf to the radiology department c. administer PRN oral analgesics to a pt w hx of chronic pain d. complete ongoing focused assessment of a pt with wrist restraints

The unlicensed assistive personnel ( UAP) reportes that a gclient's blood pressure cannot be measured because the client has cast on both arms and his unstable to be turned to the prone position for blood pressure measurements in the legs. Which action should the nurse implement? A. demonstrate how to palpate the popliteal with the PT supine and the knee flexed B. add device that you a P to document the last blood pressure obtained on the client's graphic sheet C. document wide the blood pressure cannot be accurately measured at the present time D. estimate the blood pressure by assessing the pause volume of the clients radial pulses

What is the priority nursing action when initiating morphine therapy analgesia (PCA) pump? a. Initiate the dosage lockout mechanism on the PCA B. Assess the client's ability to use a numeric pain scale c. Assess the abdomen for bowel sounds D. Instruct the client to use the medication before the

What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse a. When I get out of bed quickly, I feel a little dizzy." b. The dressing over my incision feels like it is too tight." c. "I'm most comfortable when the head of the bed is raised." d. This IV infusion makes me urinate more often than usual'

When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages

When is the best time for the nurse to assess a client for residual urine? a. immediately after the client voids b. just prior to the pt void c. after draining the urinary cath bag d. when the pt's bladder is distended

When perfomring postural drainage on a client with Chronic Obstructive Pulmonary disease (COPD), which approach should the nurse use? a. explain that the client may be placed in five positions b. instruct the client to breathe shallow and fast c. obtain ABGs prior to procedure d. perform the drainage immediately after meals

When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include? a. increase the amount of dopamine available for muscles to function correctly b. sows the scarring in the myelin sheath improving muscle tone and strength c. reduces the inflammatory process improving nerve transmission and function d. acts as an anti seizure medication reducing the tremors caused by the disease

Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client? A. Orthopnea B. Pallor C. 2+ pitting edema of the feet D. Right-sided paralysis

Which snack selection indicates to the nurse that a school-age boy with gas... dietary restrictions? a. Sugar cookies b. Pizza. c. Chocolate milkshake d. Tacos.

While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take first? a. determine the client's vitals b. monitor u.o c. notify surgeon immediately d. assess the pt's level of pain

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement a. reduce the stimuli in the area before continuing the teaching b. provide the client with step-by-step written instructions c. reassure the client that the skill is not difficult to learn d. demonstrate the skill, speaking slowly and using simple terms

While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than did previously. Which action should the nurse implement first? A Submit a referral for an evaluation by a physical therapist. B Explain the usual progression of osteoarthritis and HF. C Inquire about an electric bed for the client's home use. D Request social services to review the client's resources.

a client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior? a. silence allows the pt to reflect b. the nurse is respecting the pt's loss c. the nurse is taking disapproval of the statemnt d. silence is reflecting the pt's sadness

a journalist asks the nurse working in the ED about condition of a local politician recently admitted to the medical center following a publicly reported building fire. which action should the nurse take? a. direct the journalist to the agency's communication.marking department b. document the official ID of the journalist before providing any information c. obtain verbal consent from a family member before discussing the pt's condition d. provide only general info regarding the pt's over all condition

a neonate has congenital adrenal hyperplasia presents with ambiguous genitalia. what is the primary nursing consideration when supporting the parents of a child with this anomaly? a. offer information about ultrasonography and genotyping to determine sex assignment b. explain that corrective surgical procedures consistent with sex assignment can be delayed c. discuss the need for cortisol and aldosterone replacement therapy after discharge d. support the parents in their decision to assign sex of their child according to their preference

a young adult was admitted 36h ago for a head injury that occurred as the result of a MCA. in the last 4h, his urine output has increased to over 200ml/h. before reporting the finding to the HCP, which intervention should the nurse implement? a. evaluate the urine osmolality and the serum osmolality values. b. obtain BP and assess for dependent edema c. measure oral secretions suctioned during last 4h d. obtain capillary blood samples q2h for glucose monitoring

an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? a. Add sterile water to the suction control chamber. b. Give blood from the collection chamber as autotransfusion c. Manipulate blood in tubing to drain into chamber. d. Increase wall suction to eliminate fluctuation in water seal.

the nurse assess an adult pt with partial rebreather mask and notes that the O2 reservoir bag does not deflate completely during inspiration and the pt's RR is 14 breaths/min. which action should the nurse implement? a. encourage the pt to take deep breaths b. increase the liter flow of oxygen c. remove the mask to deflate the bag d. dx the assessment data

the nurse assumes care of postop adult pt w type 2 DM and learns that the pt has a current BG of 750. a. assess for signs of fvd b. observe wound drainage characteristics c. measure the level of acute pain d. determine when the pt last ate

the nurse is communicating with a 12yo who is hearing impaired. Which action is best for the nurse to use when attempting to communicate with this client? a. use a picture board to communicate needs b. attract the child's attention before speaking c. convey ideas by writing short sentences d. emphasize emotions with facial expressions

the nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A) It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B) In the second phase of the disease, findings include peeling of the skin on the handsand feet with joint and abdominal pain C) Kawasaki dx occurs most often in boys, children younger than age 5 and children of Hispanic descent D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks

the nurse learns that a pt does not know the purpose of the antipsychotic medication ziprasidone. how should the nurse best explain the purpose of this medication? a. this medication helps people with schizophrenia b. this medication will help you think more clearly c. this is an antipsychotic med to calm you down d. anti antipsychotic med promotes socialization

to evaluate the effectiveness of a male pt new prescription for ezetimibe which action should the clinic nurse implement? a. remind the pt to keep his appointments to have cholesterol level checked b. teach the pt to weight himself weekly and keep a long of the measurements c. assess the elasticity of the pt's sin at the next appt d. encourage the pt to keep a dairy of food intake

when conducting diet teaching for a client who was dx with Crohn's dx, which foods should the nurse encourage the pt to eat? SATA a. clams b. raisins c. buttermilk d. orange juice e. processed cheese

a b

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) A) Take an additional dose for signs of hyperglycemia b) recognize s.s of hypoglycemia C) report persist polyuria to the hcp D) Use sliding scale insulin for finger stick glucose elevation E) Take Glucophage with the morning and evening meal.

a b c

A middle aged woman, diagnosed with Graves disease asks the nurse about this condition. Which etiological pathological should be nurse include in the teaching plan about hyperthyroidism SATA a. graves dx, an autoimmune condition, affects thyroid stimulating b. large protruding eyeballs are sign of hyperthyroid function c.early txmt includes levothyroxine d. t3 and t4 hormone levels are increased e. weight gain is a common complaint in hypterthyroidism

a b d

A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply.) A. Red blood cell count (RBC). B. Platelet count. c. Sodium and potassium. D. Albumin and protein. E. White blood cell count (WBC).

a b e

the nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply) a. Brings a heavy can close to body before lifting. b. Locks knees while preparing food on the counter. c. Widens stance while working near the sink. d. Bends from the waist to pick trash off the floor. e.Leans forward to pull a pan from a high shelf.

a c

the nurse is interacting with a female client who is diagnostic with postpartum depression. Which findings should the nurse document as an objective signs of depression? (Select all that apply) A) Expresses suicidal thoughts B) Avoid eyes contact C) Reports feeling sad D) has a disheveled appearance E) Interacts with felt effect

a d e

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request to this client? (Select all that apply) a. apple juice b. black coffee c. orange juice d. hot chocolate e. chicken broth

a e

A male client with HIV, who is receiving saquinavir PO in combination with other antiretroviral therapy, tells the home health nurse that he is always hungry and thirsty but seems to be losing weight. What action should the nurse implement? A. Use a glucometer to determine the client's capillary glucose level. B. Explain to the client that he may require an increased dose of his medication C. Teach the client strategies to ensure that he measures his weight accurately D. Reassure the client that he will gain weight as the viral hold decreases

43. Which conditions are most likely to respond to treatment with antihistamines? ( select all that apply) A. allergic rhinitis B. contact dermatitis C. otitis D. myocarditis E. bronchitis

A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply) A. Platelet count B. Red blood cell count (RBC) C. White blood cell count (WBC). D. Albumin and protein E. Sodium and potassium

abc

when conducting diet teaching for a client who is on a postop full liquid diet, which foods should the nurse.. a. lentils b. potato soup c. tea d. cheese e. whole grain breads

abc

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? (Select all that apply). A) Provide supplemental oxygen B) Auscultate bilateral lung fields C) Administer a nebulizer treatment D) Reinforce occlusive CT dressing E) Give PRN dose of pain medication

abd

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) a.Headache and tremors b.Irregular heart rate c.Skin hyperpigmentation d.Postural hypotension e.Pallor and diaphoresis

abe

When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) a. Fruits without sauce b. Canned soup. c. Fresh or frozen vegetables without sauce. d. Cottage cheese. e. Pickled olives.

acd

An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) A) Administer a daily dose of lisinopril as scheduled. B) Assess the client for postural hypotension. C) Notify the healthcare provider immediately D) Provide a PRN dose of acetaminophen for headache E) Withhold the next scheduled daily dose of warfarin

102) A family member accompanies a client with schizophrenia to the mental health unit. The family member describes to the nurse the client experienced a prolonged psychotic episode that lasted for 3 days. Which action should the nurse implement first? a. Review the list of medications taken at home b. assess if warning signs were observed c. explore possible triggers to the episode d. verify nutrition and hydration status

23. While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Apply ice first, then a warm compress to the IV site B. Discontinue the painful IV after a new IV is inserted C. Review the medical record for the date of insertion D. Document that the medication was not administered

26 yo is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. which symptoms indicate to the nurse that the prescribed dosage is too huh for this pt? a. muscle cramping, dry, flushed skin b. palpitations and SOB c. bradycardia and constipation d. lethargy and lack of appetite

A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushedand his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs

74. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. Theclient makes all of these statements during their conversation. Which statement wouldalert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on."

A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 mL/hour.... a. Assess bowel sounds in all quadrants b. Encourage popsicles and fluids of choice c. Evaluate postural blood pressure measurements d. Obtain a specimen for urinalysis

A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior... a. draws picture of self with facial features b. talks to an imaginary friend c. sits quietly in her mother's lap d. ignores other children in the play area

A cent with a prescription for do not resuscitate* (dNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The impending signs of death should be documented. B. The cent's need for pan medication should be determined C. The nurse manage should be updated on the client's status D. The client's status should be conveyed to the chaplain

A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? a. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) b. It is critical to report promptly to your health care provider any findings of peptic ulcers c. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors d.With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

A client is admitted to the hospital with symptoms consistent with a right hemispheric stroke. Which neurovascular assessment requires immediate intervention by the nurse? a. orientation to person and place only b. unequal bilateral hand grip strengths c. pupillary changes to ipsilateral dilation d. left-sided facial drooping and dysphagia

A client is receiving IV heparin and oral warfarin after a pulmonary embolism the client's activated partial prothromboplastin time (aPTT) value is two times the (PT) level is the same as the control, and the international normalized ratio prescription should the nurse implement? A. Withhold the heparin and continue the same dose of warfarin B. Increase the warfarin dose C. Decrease the heparin dose D. Increase the heparin dose and decrease the warfarin dose

A client is receiving a continuous infusion of normal saline at 125 mL/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 mL ... a. review last administration of IV pain medication b. decrease IVF to KVO rate c. administer PRN dose of acetaminophen d. calculate total intake and output for last 24h

A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab tests indicate an elevated TSH and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement? A) Assess for presence of non-pitting edema. B) Administer the prescribed dose of levothyroxine. C) Offer additional blankets and a warm drink. D) Note client's most recent hemoglobin levels.

A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 to 125... a. withhold next scheduled dose of txmt b. maintain the prescribed fluid restriction c. increase neurologic checks to Q2h d. assess for increasing FVO

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol... a. you may have an increased chance of having preeclampsia b. you mat be at higher risk for having a spontaneous miscarriage c. this medication will have no effect on your unborn child d. you may experience PP hemorrhaging after delivery

A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? a.Do not take any over-the-counter medications. B Avoid exposure to large crowds. c Eat a high carbohydrate, low fat, low protein diet. D Call the crisis hot line if feeling lonely.

A middle-aged client is returned from the intensive care unit to the surgical unit following a right pneumonectomy for cancer of the lung... a. pain at level of 6 on a scale of 1-10 with use of PCA b. absence of lung sounds on the operative side c. high-pitched course sound over the trachea d. requests to see his family at his bedside immediately

A middle-aged male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition... a. provide a routine schedule of activities to facilitate trust b. encourage the client to reflect on personal goals and priorites c. discuss the cause of the accident with the client and his family d. allow long periods of uninterrupted rest in order to reduce fatigue

A multiparous client who delivered her infant three hours ago asks the.. because it helped reduced perineal pain after her last delivery. a. Apply an ice pack to the perineum for the first 24 hours b. Review the use of sitz bath equipment with the client. C. Teach the client how to practice Kegal exercises. D. Use an analgesic spray to the perineal area to reduce

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 30 feet awav. What action should the nurse take first? A. Return to the car to call emergency response 911 for help. B. Stabilize the victim's neck and roil over to evaluate his status. C. Open the airway and initiate resuscitative measures. D. Examine the victim's body surfaces for arterial bleeding.

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A. offer assurance that there are a variety of effective treatment for breast cancer B. explain that counseling will be provided to give her info about her cancer risk C. provide information about survival rates for women who have the genetic mutation. D. gather additional information about the client's daily history for all types of cancer.

After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dl. What action should the nurse implement? A. Initiate the urine collection as prescribed. B. Notify the HCP of the results. C. Evaluate the client's serum BUN level. D. Assess the client for signs of hypokalemia

After placing a 36- week- gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next? a. administer vit k injection b. remove the wet blankets and linens from the isolette c. place erythromycin ophthalmic ointment in both eyes d. open the isolate door to assess the infant's v.s

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are... a. irregular pulse rate b. ST elevation in three leads c. complaint of radiating jaw pain d. bile colored emesis

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? A. 0800, 1200, 1600, 2000 B. 1000, 1600, 2200, 0400 C. Administer with meals and a bedtime snack D. Give in equally divided doses during waking hours

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain? a. JVD b. fatigue c. hepatomegaly d. lower extremity edema

An adult is admitted to the Emergency Department following ingestion of a bottle of antidepressants secondary to chronic pain. A NG tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, taint soundi on the left side and chest movement that occurs only on the right side of the thorax. Which procedure should the nurse prepare for first? A. Insertion of a left-sided chest tube. B. Retraction of the nasogastric tube. c. Setup of patient-controlled analgesia. D. Placement of an endotracheal tube.

An older client has been diagnosed with chronic venous insufficiency. To promote venous return, which action should the nurse encourage the client to take? a. sit at these of the bed for 15m before standing b. wear cotton socks and enclosed toe shoes whenever outside c. lie down in bed 2xd d. drink 8 to 10 ox of water a day

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first? A. Call respiratory therapy. B. Begin manual ventilation immediately. C. Monitor oxygen saturation levels q5 minutes. D. Silence the alarm and call the technician.

Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended

During a clinic visit, a client with a kidney transplant asks, "What will happ Which response is best for the nurse to provide? a. A different combination of immunosuppressant medication b. Dialysis would need to be resumed if chronic rejection be .. c. Dialysis may be necessary until the chronic rejection can .. d. The immunosuppressant medication will be increased un ..

During the administration of an IM pain med, the nurse aspirates blood into the med syringe barrel. what action should the nurse take? a. inject the IM med at a rate of 1ml/10s b. remove the syringe needle from the tissue and prepare a new sterile dose for administration c. select a new IM site and inject the med d. discard the medication in the syringe and request instructions from HCP

Following a house fire, an adult male is admitted to the emergency department with partial and full thickness burns burned on the dorsal surfaces of both arms and hands and his anterior legs. Using the Rule of Nines to assess the surface area should the nurse document? a. 50% b. 27% c. 9%. d. 36%.

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the nurse? a. remind the client that is also important to switch to decaffeinated coffee and tea b. review the need to avoid foods that are rich in milk and cream c. reinforce this teaching by asking the client to list dairy foods that he might select d. suggest that the client also plan to eat frequent smalls to reduce discomfort

In observing a clients face, which assessment finding requires the most immediate intervention by the nurse? a. cornea are jaundiced b. oral mucosa is cyanotic c. face is flushed and diaphoretic d. eyelids are matted and crusted

PT is ambulating with a two-wheeled walker by rolling the walker forward and then moving each foot forward... a. offer to adjust the height of the walker b. encourage the pt to continue using the walker as observed c. demonstrate more coordinated movement of the legs and walker d. explain the need to remove the wheels from the walker

The nurse who is working on a post surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first? a. an adult who has a collapsed lung rx to a fall from ladder 8h ago and now has 100ml chest tube drainage b. young adult who had an abdominoperineal resection 3 days ago and is currently complaining of chills. c. an older adult who had a mastectomy 2 days ago and has 50ml serosanguinous fluid in the JP drain d. teenager who had a gunshot wound repair yesterday and has quarter-size dark drainage on the dressing

The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been ... a. antibiotics take two weeks to become effective against infections such as athlete's foot b. stop using the ointment and encourage complete drying of feet and wearing clean socks c. applying too much ointment can deter its effectiveness. apply a thin layer to prevent maceration d. continue using the ointment for a full week, even after the symptoms disappear.

The practical nurse (PN) reports that a client who has a fingerstick glucose.... and diaphoretic. What action should the charge nurse take? a. Assess client for polyuria and polyphagia. b. Give the client a glass of orange juice. c. Notify the healthcare provider. d. Collect a blood sample for hemoglobin A1c

When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding: a. crying b. Sitting upright c. Vomiting d. Straining on stool

When using a Yankauer oral-tip catheter to suction a client's oropharynx, which action should the nurse take before inserting the catheter into the oropharynx? A. Ask the client to begin swallowing. B. Turn on the continuous suction device. C. Assess the nares for a deviated septum. D. Apply suction by occluding the port.

Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? a. ensure that the drainage bag is attached to the bed frame b. ensure continued sterility of the specimen container c. securely fasten the clamp on the drainage bag d. label the container with the client's identifiers

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy? a. Report any allergies to shellfish or iodine b. Report any painful urination, blood in urine, or fever c. Lay prone for 24 hours after the procedure. d. Avoid strenuous activity and sports for at least 2 weeks

Which intervention should the nurse include in a preoperative preparation for a client scheduled for gastric bypass surgery? A. Advise the client's family to seek dietary counseling and exercise planning. B. Encourage the family to participate in monitoring the client's dietary intake. C. Suggest avoiding shopping for food by designating someone to grocery shop. D. Teach the client how to prepare small meals that are low in fat and sugar

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? a. electrolytes b. liver enzymes c. blood glucose d. complete blood count

Which long-term outcome is most important for the nurse include in the plan of care for an older adult client with chronic pyelonephritis? a. maintains BP WNL b. manages ADLs independently c. restricts fluid intake to 1L/d d. measures oral temp daily

Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick."

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked a. Use a topical lidocaine analgesic for cracked lips b. Use a water soluble lubricant on affected oral and nasal mucosa c. Ask the mother what she usually uses on the child's lips and nose d. Apply a petroleum jelly to the child's nose and lips.

While making rounds, the charge nurse notices that a young adult client... yesterday is sitting on the side of the bed and leaning over the bed... oxygen at 2 liters/minute via nasal cannula. The client is wheezing a... intervention should the nurse implement? a. Assist the client to lie back in bed. b. Administer a nebulizer treatment. c. Call for an Ambu resuscitation bag. d. Increase oxygen to 6 liters/minute

While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Apply ice first, then a warm compress to the IV site B. Discontinue the painful IV after a new IV is inserted C. Review the medical record for the date of insertion D. Document that the medication was not administered

a male pt who is admitted to the mental health unit for txmt of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. which assessment finding is most important for the nurse to report HCP a. blood alcohol level of 0.09 b. serum lithium level of 1.6 c. 6h of sleep in the past 3 days d. weigh loss of 10lb in past month

a pt is being treated for hepatic failure. on exam, the pt has a weight gain of 4.4lbs in 24h and elevated pulse rate. which intervention should the nurse include in the plan of care? a. review ABGs b. assess for dependent pitting edema c. dx abdominal girth d. record usual eating patterns

a pt who is admitted to the ICU w SIADH has develop.. which should the nurse implement first? a. patch one eye b. evaluate swallow c. reorient often d. range of motion

after falling down the basement steps, a client is brought to the emergency room. x-rays confirm that the PT right leg is fractured. following application of a leg cast, which assessment warrants immediate intervention by the nurse? a. circumferential edema of right foot b. right foot pale with sluggish cap refill c. complaint of throbbing right leg pain d. increased temp to lover extremity

When is it most important for the nurse to assess a pregnancy clients deep tendon reflexes (DTRs)? a. within the first trimester of pregnancy b. during admission to L&D c. when the pt has ankle edema d. if the pt has elevated BP

the father of a 4y.o has been battling lung cancer. after discussing the remaining options w his hcp, the pt requests that all txmt stop and that no heroic measures be taken to save his life. when the pt is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? a. reassure the pt that his child will be allowed to visit b. obtain a detailed report from the nurse transferring the pt c. mark the chart with pt's request for no heroic measures d. provide the pt written info about end-of-life care

the nurse determines that an older female client has kyphosis has lost two inches of height in the last three years, and has a recent history of spinal vertebral fractures... a. rate of bone resorption that exceeds rate of bone deposition b. progressive weakening of the muscle fibers of the lower back c. deterioration of the myelin sheath surrounding nerve fibers d. vertebral compression caused by increased bone density

the nurse has agreed to serve as a pt's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the pt. to successfully represent the client, which is essential for the nurse to take ? a. listen to the ethics committee discussions and then inform the client what actions should be taken b. develop self-awareness of the nurse's personal values to avoid imposing these values to the pt c. educate the pt about current nursing literatures findings rx to the pt ethical dilemma d. challenge members of the healthcare team whose options differ from the wishes of the pt

the nurse is preparing a client with an acoustic neuroma for a MRI: Which client complainis life threatening and should be reported to the healthcare provider immediately? A: intensifying headache B: right ear hearing loss C: difficulty with balance D: Facial numbness

the nurse observes an elderly male client walking aimlessly in the hallway and staring ahead blankly. how should the nurse enter computer documentation of this finding? a. demonstrates signs of early dementia b. appears confuse and depressed c. ambulatory and disoriented to place d. wandering behavior with flat affect

the nurse working in a disaster area assess an adult PT who has partial-thickness burns on the lower legs, or approximately 10% of the lower body... a. black b. yellow c. red d. green

what action should the nurse take first when a client is inadvertently given an incorrect dose of a medication? a. dx the events leading to the error in the nurse's notes b. notify the HCP c. assess the pt for any adverse effects d. complete an incident report dx the facts

when the nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome(SOS). Which information is most important to provide parents of newborns and infants. A. keep a bulb syringe accessible for use for an infant. B. Do not prop bottles for an infant during naps and bedtime C. position the infant in a supreme position while sleeping D. remove pillows and soft toys from the crib at bedtime

which action should the community health nurse take to assess a pediatric client with a family tree genogram that is positive for a genetically inherited syndrome a. note any repetitious patterns of behavior b. observe for defined group of malformations c. obtain blood samples for genetic testing d. refer to social services for review of risk factors

while assessing a PT BP using an aneroid sphygmomanometer, the nurse inflates to an initial reading of 160mm calibration. upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. which action should the nurse implement next? a. reposition the stethoscope in the antecubital fossae over the palpable brachial pulse point b. release the air and reinflate the cuff to 30mm hg above the pt's previous systolic reading c. inflate the cuff quickly to a higher than the previously auscultated systolic sound d. continue the BP assessment until the last Korotkoff sound is heard

A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply) a. Protect medication from exposure to light b. Monitor for changes in level of consciousness c. Observe for onset of generalized bruising or bleeding D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes

b d e

The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: a. peripheral pallor of the skin b. increased pulse rate c. clenched fists d. restlessness e. increased temp f. increased RR

bcdf

The nurse is caring for a client who is admitted to the emergency center after a motor vehicle collision. The client begins to experience decreased level of consciousness which signs indicate the client is manifesting Cushing Triad?

bp 180/80, BOUDING HEART RATE W APENIC EPISODES

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned about this regression in toileting. Which information should the nurse provide the parents? A. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers. C. Children usually resume their toileting behaviors when they leave the hospital. D. A potty chair will be brought from home so he can maintain his toileting skills.

A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. Which is the priority nursing problem for this client? a. altered sleep pattern b. imbalanced nutrition: less than c. risk for injury d. disturbed thought processes

Which client is the most likely candidate for total parenteral nutrition? a. pt diagnosed with type 1 diabetes w DKA b. obese pt who is on a medically supervised starvation diet c. older pt who is having laparoscopic cholecystectomy d. pt experiencing acute exacerbation of crohn's disease

A client has a new prescription for the maximum recommended dosage of pipercillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider before administering the prescribed dose? a. elevated WBCs b. presence of gram negative bacteria in sputum c. decreased creatinine clearance d. elevated cholesterol and lipoproteins

A client tells the nurse that he is "very nervous" about the surgery he is scheduled to have in the morning. Which actions should the nurse implement? a. provide the pt with distractions to decrease his anxiety b. explore the pt's preception of the impending surgery c. notify HCP about the PT expressed fears and anxiety d. present the PT with information about the surgical procedure

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take? a. assign a practical nurse to assist the UAP in turning the pt. b. encourage the UAP to provide comfort care measures only. c. advise the UAP to resume positioning the client on schedule d. assume total care of the pt to monitor neurologic function

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care... a. atelectasis b. exit site infection c. peritonitis d. outflow obstruction

A client with chronic renal insufficiency is preparing for discharge from the hospital. which information for the nurse to include in this client's discharge teaching? A. use a topical applications to manage pruritus B. strategies to promote independent selfcare C. instructions regarding a restricted protein diet D. need for maintaining good oral hygiene

A client with syndrome of inappropriate antidiuretic hormone secretion. Which intervention is most important for the nurse to include in the plan of care? a. initiate seizure precautions b. assess neurological status q8h c. limit oral water intake d. administer a hypertonic IVF as prescribed

A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. which questions is best for the nurse to ask this client a. are you aware that you do not have a fully functioning immune system b. have you considered that you are putting yourself at risk for developing infections c. is it possible that you will be in direct contact with the children at the school d. do you realized that you will be exposed to many different kinds of germs

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication? a. apical HR 72 b. HTN c. BP 90.76 d. muscle weakness

A mother brings her 3-year-old son to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102.. a. put a cold cloth on his head and administer acetaminophen b. assist the child to lie down and examine throat c. notify HCP + obtain a trach tray d. listen to lung sounds and place him in a mist tent

A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently

A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority? a. impaired parenting rx to inexperience b. acute pain rx to abdominal incision c. risk of injury rx to uterine atony d. ineffective breastfeeding rx to fatigue

A s3-year old female client with symptoms of osteoarthritis asks what form of exercise would be most beneficial tor her the vest response by the nurse? a. "Limt your exercise to just your daily activities. b. Jogging or running are excelent acrobic exteroses c. Swimming is an excellent exerose for you. d. Tennis or racguetball will increase your muscle strength

A successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? a. reinforce the reality of his financial situation b. direct him to drink a glass of red wine at bedtime c. teach him to limit sugar + caffeine intake d. encourage him to initiate daily rituals

A woman is brought to the labor and delivery unti after delivering a term infant and the placenta in the hospital parking a, inspect the perineum for lacerations b. collect specimen for hemoglobin + hemocrit c. massage the fundus and give an oxytocic agent d. place the infant to breast for bonding

A woman who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. she states that she is pain free. which intervention should the nurse include in the pt's plan of care? a. encourage positive self accolades for dietary adherence b. determine if the pt is over-hydrating to feel satisfed c. maintain the pt on an npo status d. administer daily vitamin supplements

After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasksshould the nurse assign to this worker who wants to help during the care of the woundedworkers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness

An adult client comes to the clinic and reports his concern over a lump that "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these finding suggest? A. Bacterial infection B. Lymphangitis C. Malignancy D. Viral infection

During the admission assessment of a terminally ill client, the client expresses being an agnostic... a. invite the pt to a healing service for people of all religions b. provide information about the hours and location of the chapel c. document the statement in the pt spiritual assessment d. offer to contact a spiritual advisor of the pt's choice

Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which is most important for the nurse to implement? a. page the pediatrician STAT b. inform the parents of the infant's condition c. continue resuscitative efforts d. repeat the Apgar assessment in 5 mins

In assessing a 70-year-old client with Alzheimer's disease, the nurse notes that the client has deep inflamed cracks at the corners of the mouth... a. scrub the lesions with warm soapy water b. notify HCP of need for oral antibiotics c. ensure that the client gets adequate B vitamins in foods or supplements d. encourage the PT to drink orange juice for added vit C

PT with uremia is experiencing uremic frost. Which action should the nurse implement? a. provide frequent skin care and apply lotion b. evaluate bony prominences for breakdown c. explain that hemodialysis is needed. d. monitor the pt's oral fluid intake

The charge nurse is making assignments on an in-patient psychiatric unit. The staff consists of two psychiatric technicians and one practical nurse (PN). Which team assignments is the best to assign to the PN? a. detoxification precaution check list b. routine morning VS and weights c. administration of routine medications d. one-on-one observation of a suicidal client

The client with which type of wound is most likely to need immediate intervention by the nurse? a. ulceration b. confusion c. laceration d. abrasion

The healthcare provider prescribes oral vancomycin for a female client who has Clostridium difficle in the stool. Which action should the nurse take before administering the first dose? a. assess body temperature b. auscultate bowel sounds c. check serum creatinine d. measure O2 sat

The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? a. hold the walker securely to prevent slipping when the client rises b. apply a gait belt to assist the client to rise our of the chair c. instruct the client to use the arms of the chair for support. d. encourage client to use the weaker leg with the walker when rising

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. he tell the nurse that she may be getting alzheimer's disease. what action should the nurse take a. explain that memory loss and confusion are common with vit B12 deficiency b. determine if the client is taking iron and folic acid supplement c. encourage the husband to bring the pt to the clinic for a CBC d. ask if the client is experiencing any change in bowel habits

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? a.Length and frequency of the client's tobacco use. B. Genetically inherited disorders of family members. C. Frequency of laxative use for chronic constipation. D. Ingestion of shellfish or fish oil capsules daily,

The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision

The nurse is assessing a client with closed head injury sustained in a motor vehicle collision. Which finding indicates the lowest level of neurologic functioning? a. Localization of a tactile stimulus b. withdrawal from painful stimuli c. decerebrate posturing during position changes d. decorticate posturing during tracheal suctioning

The nurse is assessing the mood of a depressed male client. When asked how he feels, the client looks down and states, "I don't know! I just can't think." Which activity should the nurse suggest that this client perform? a. complete a written self-esteem assessment b. review the pt handbook about unit therapies c. set daily goals in the community meeting d. read, "the depression recovery book"

The nurse is assisting the healthcare provider with a wound debridement confused. The client is draped and a sterile field is created. Which nurse implement for client safety? a. Assess for discomfort when procedure is completed. b. Verify that the client has given informed consent c. Instruct the client to keep hands under the sterile field d. Pour cleansing solution onto the sterile cloth field.

The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? a.Diminished bowel sounds b.Loss of appetite c.A cold, pale lower leg d.Tachypnea

The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take? a. monitor for s+s of bleeding or hemorrhage b. compare daily electrolytes level prior to each morning dose c. advise to sit up slowly from a reclining position d. administer the medication on an empty stomach

The nurse is educating a client with end-stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the clients daily diet? a. intake of protein should be increased to stimulate the kidney's nephrons function b. intake of protein should be increased due to its loss through the filter membrane c. the protein intake should be decreased to prevent nitrogenous waste buildup d. intake of protein should be decreased due to progressively failing function of the kidney

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats/minute. Which action should the nurse take? A Pause and monitor for a continued drop of the heart rate. B Continue the insertion since this is a typical response. C Postpone the feeding until the infant's vital signs are stable. D Insert the feeding tube into the infant's nasal passage.

The nurse plans to administer a low dose prescription for dopamine to a client who is in septic shock. Which physiological parameter should the nurse use to evaluate a therapeutic response to dopamine? a. pupil response b. heart sounds c. urinary output d. temperature

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignment is best for the charge nurse to the this nurse A. Transfer a client to another unit. B. Perform the admission of a new client. C. Assist cardiac nurses with their assignments. D. Monitor the central telemetry.

The psychiatric nurse is caring for clients on an adolescent unit Which client requires the nurse's immediate attention a. A 16-year-old client diagnosed with major depression who refuses to participate in group b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. c. An 18-year-old client with antisocial behavior who is being yelled at by other clients d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. What information about the most commonly prescribed medication, mebendazole, should be included? A. Insert the medication as a rectal suppository. B. A second dose of medication should be given in two weeks. C. Only children with perianal itching should take the medication. D. It is safe for children of all ages to take this medication.

Two days after admission for a fractured wrist from a fall while intoxicated, a male client with a hx of mental illness and alcohol abuse becomes anxious, agitated, and diaphoretic. His VS are 99.6, HR 112, RR 26, and BP 190/108. He tells the nurse that bus are crawling in his bed. Which prescription should the nurse administer? a. Busprione b. Codeine c. Chlordiazepoxide d. Risperidone

Which assessment finding places a client at risk for problems associated with impaired skin integrity? a. smooth nail texture b. scattered macula on the face c. cap refill 5 seconds d. absence of skin tenting

Which dietary instruction should the nurse include when teaching a client how to reduce episodes of Raynaud's Syndrome? a. reduce saturated fat intake b. increase calcium intake c. eliminate caffeine intake d. avoid hot beverages

While admitting a client to the surgical unit who had a pneumonectomy 4 hours ago, the call system alarm is initiated by a client in another room. Which action should the nurse implement? a. investigate the reason for the call bell alarm then complete the admission assessment b. tell the unit clerk to ask the client via the intercom c. ask a coworker to respond to the client call light d. complete the postop admission assessment then investigate

a client with hypothyroidism reports difficulty falling asleep because of feelings of depression. which action should the nurse implement? a. withhold next scheduled dose of levothyroxine b. request a PRN sedative-hypnotic to help with insomnia c. review most recent thyroid function test results d. encourage increased exercise and activity during the day

a kid who is very drowsy and has a rash and fever comes to the school's office. after reviewing the child's past medical hx, the nurse is alerted to risk for viral meningitis. which finding is most important for the nurse to report to the HCP? a. past hx of exacerbated asthma b. febrile sexier before one year of age c. a recent exposure to mumps at school d. known to share silver with w classmates

a pediatric home care nurse schedules a visit to the home of a 4 week old newborn who had low T4 and high thyroid stimulating hormone at birth and was diagnosed with congenital hypothyroidism or cretinism. which instruction is most important for the nurse to provide the parents of this child? a. monitor the infant's daily intake and weekly weight b. offer a low sodium formula between breast feedings c. administer supplemental thyroid hormone daily d. stimulate the infant during feedings to ensure adequate intake

a pt tumor measures 2cm before and after receiving a course of radiotherapy, what physiological mechanism renders this response to radiation therapy for cancers? a. cellular anchorage that is necessary for cancer cell growth is removed b. cell growth is disrupted during the resting phase of the cell cycle c. production of ionizing energy damages DNA, hence stops replication d. reduction of contact inhibition results in cell health by phagocytosis

a pt who recieved hemodialysis yesterday is experiencing a BP of 200/100, HR 110, and RR 36 breaths/min manifesting SOB, bilateral 2+ pedal edema, and an O2 sat on room air of 89%. Which action should the nurse take first? a. Elevate the foot of the bed b. Restrict the client's fluids c. Begin supplemental oxygen d. Prepare client for hemodialysis

a pt who weighs 176lb receives a prescription for enoxparin sodium 80u SUBQ daily at 0900. what action should the nurse take before administering this medication? a. explain to the pt the painful effects of administering enoxparin b. clarify the correct dosage with the hcp c. determine if the pt is receiving heparin or warfarin d. use a filter needle to give the subq injection

a pt with gout experiences an acute attack. the pt reports he has been trying to lose weight. which pt intoxication is most important for the nurse to obtain? a. serum cholesterol level b. capillary glucose level c. daily caloric intake d. daily calcium intake

a pt with stage 4 bone cancer is admitted to the hospital for pain control. the client verbalizes continuous, severe pain of 8. which intervention should the nurse implement? a. give maximum dosage when score reaches 10 b.educate pt on signs and symptoms of narcotic dependency c. administer opioid and non-opioid medication simultaneously d. alternate IV an IM analgesics medications

the mother of an infant with hypospadias is concerned because she had been told her child cannot be circumcised according to her jewish faith tradition. which response is best for the nurse to provide? a. your faith is important but correcting this b. circling the penis now may contribute to frequent urinary infections c. during the surgery part of the foreskin is used to repair the meatus d. I understand your concern. would you like to talk to the pediatrician

the nurse is developing a plan of care for a PT who reports intermittent claudation and who is newly diagnosed with type 2 diabetes... a. the pt will express acceptance of their newly dx health status b. bp readings will be less than 160.90 c. skin on the lower legs will be intact at the next clinic visit d. nurse will show the pt how to perform stress management techniques

the nurse is performing intake interviews at a psychiatric clinic. a female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction a. marijuana b. benzodiazepines c. methamphetamine d. alcohol

the wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complementary medical therapies might cure the disease. which response should the nurse provide a. encourage the wife to ventilate her feelings about having a husband with Parkinson's disease b. Compile a list of alternative medication that are effective in curing Parkinson's disease c. explain that there are no known conventional, alternative or complementary therapies that cure Parkison's dx d. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism

while adding water to the chest tube drainage system, the nurse knocks over the container causing the blood to spill into the adjacent chamber. which action should the nurse take? a. increase suction to 30cm b. assess tubing for fluctuation with respirations c. replace chest tube drainage system d. mark drainage in both chambers

When preparing a client who is to undergo a resection of a leiomyosarcoma of the uterus, the nurse notices that apixaban is listed on the medication reconciliation list. Which assessment finding requires immediate nursing intervention? a. abdominal redness and itching b. nausea and dry mouth c. bleeding gums d. finger joint pain

c apixaban: blood thinning leiomyosarcoma cancer

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply). a. bedside commode is positioned near the bed b. saline lock is present in the RFA c. full pitcher of water is on the bedside table d. pt is lying in a supine position in bed e. low NA diet tray was brought to the room

c d

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) A) Take out dentures and place in a labeled cup B) Apply a body shroud C) Place a small pillow under the head D) Remove resuscitation equipment from the room E) Gently close the eyes

c d e

129. The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client's serum blood potassium is elevated, which finding A. Tall peak T waves on the cardiac monitor B. Peripheral pitting edema at 2 + indentation C. Serum creatinine above 0.5 mg/dl or 44.2 micro-mmol/dl D. Anuria for the last 12 hours.

A 17-year-old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. The promote parent-infant attachment behaviors... a. explore the basis of fears with the PT b. provide a video on newborn safety and care c. ask if she has help to care for the baby at home d. encourage rooming-in while in the hospital

A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse where she is. What information is most important tor the nurse in obtain? a. use of sleeping medications b. hx of this behavior c. use of anti anxiety meds d. hx of alcohol

A client arrives in the emergency department (ED) with deep, full-thickness burns over the anterior surface of both upper legs. Which priority intervention should the nurse implement? a. start iv antibiotics b. administer tetanus shot c. give iv analgesia d. give an IV bolus of NS

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, redfluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage

A client has an intravenous fluid infusing in the right forearm. To determine the client's distal poise rate most accurately, which action should the nurse implement? a. Elevate the cent's upper extremity before counting the pulse rate. b. Auscultate directly below the TV site with a Doppler stethoscope. c. Turn off the intravenous fluids that are infusing while counting the pulse. d. Palpate at the radial pulse site with the pads of two or three fingers

A client in the third trimester of pregnancy complains of frequent nasal stiffness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement? a. ask a nurse with more experience to validate the costal angle finding b. ask the hip to evaluate the client's respiratory status c. examine the client for signs of tissue anoxia, such as pallor. d. record the respiratory finding in the client's record as normal

A client is hospitalized with inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid... a. obtain VS measurements b. measure capillary glucose level c. encourage ambulation in the room d. monitor for bloody diarrheal stools

A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L (24mmol/L). Which assessment finding warrants immediate intervention by the nurse? a. muscle stiffness b. abdominal pain c. mental stupor d. fruity breath

A client who takes nonsteriodal anti-inflammatory drugs (NSAIDs) every day for rheumatoid arthritis is being treated for anemia... a. offer dietary selections rich in iron b. monitor liver function test results c. protect skin from bruising d. observe for GI bleeding

A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger? a. Loud hallway noise. B. Frequent cough. c. Fever. d. Full bladder.

A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out.

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness

A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting? a.Provide information on ways to increase activity for the family. b. Have several teachers talk about health risks associated with obesity. c. Distribute a shopping list of suggested healthy snack items. d.Determine the parents' degree of concern about their children's weight.

A nurse seeks to alter a provision of a state's Nurse Practice Act regarding nurse-client rations, which the nurse believes to be unsafe. What action is most likely to impact a ruling by the states board of nursing? a. notify the state's board about the matter anon b. file a grievance at the medical center where the nurse is employed c. send a letter of concern to the ANA d. consult with the appropriate state legislative representative

A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides

A pt uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The pt calls the nurse to report incrsd erythema with purulent exudate at the site. What action should the nurse implement? a. advice the pt to apply plastic wrap over the ointment to promote healing b. instruct the pt to continue the ointment until all erythema is relieved c. explain that the pt needs to complete all prescribed doses of the med d. schedule an appt for the pt to see the doc

A resident in a long-term care facility has moderate dementia, is having difficulty eating in the dining room. the client becomes frustrated when dropping utensils on the floor and refuses to eat. a. allow pt to choose foods from a menu b. assign a staff member to feed the client c. have meals brought to the pt's room d. encourage pt to eat finger foods

A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? a. ask family to remain nearby, but in another room b. encourage family to speak often with the client c. teach family how to assist the client to a wheelchair. d. instruct family to offer client only soft bland foods.

After placement of a left subclavian central venous catheter (CVC), the nurse... findings that indicate the CVC tip is in the client's superior vena cava. Which should the nurse implement? a. Notify the healthcare provider of the need to reposition the.. b. Remove the catheter and apply direct pressure for 5 minutes. c. Secure the catheter using aseptic technique. d. Initiate intravenous fluids as prescribed.

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Ask the client to write feeling in a journal and then review it together C. Explain the purpose of each medication the client is currently taking D. Play a board game with the client and begin taking about stressors

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during bright red tissue during a follow-up appointment, the nurse observes that the ulcer site contains. What action should the nurse take in response to this finding? a. Irrigate the wound with sterile saline. B. Immediately apply a pressure dressing, c. Obtain a capillary IN measurement D. Document the ongoing wound healing

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. what action should the nurse take first? a. report the finding to the police department b. discuss txmt options for abusive partners c. determine the frequency and type of pt's abuse d. explore pt's readiness to discuss the situation

An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? a. onset of mild confusion b. pale, diaphoretic skin c. pain score 8 out of 10 d. weak palpable distal pulses

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide to this client? a. wear prescription glassess b. eat a diet high in carotene c. avoid frequent eye pressure measurements d. maintain prescribed eye drop regimen

An adult woman who has a history of inferior myocardial infraction, esophageal reflux, and type 1 DM is admitted to the telemetry unit for sudden onset of dizziness with palpations and a burning sensation in her chest a. review pt's last meal b. administer an oral antacid c. assess blood glucose d. evaluate telemetry cardiac rhythm

An older adult client is receiving a second unit of blood when the nurse enters the room and finds the client sitting up in the bed. The client is dyspneic and seems confused. Lung auscultation reveals crackles in the base of both lungs. Vital sign measurement reveals a rapid, bounding pulse and elevated blood pressure. After discontinuing the transfusion, which intervention should the nurse implement? A. Monitor the hives and pruritus B. Obtain a urine specimen C. Keep the IV access line intact for diuretic administration D. Send the blood bag and blood tubing to the blood bank

An older male client who was successfully treated for Herpes zoster (shingles) with an antiviral medication reports that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take? a) Contact the healthcare provider about the need to resume the client's antiviral medication. b) Teach the client about the importance of completing the full course of antiviral medication. c) Reassure the client that the infection is resolved and the pain should soon disappear. d) Review the medication record to determine when the last analgesic was administered.

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last yearhas become increasingly abusive since his release from prison six weeks ago. Which intervention for the nurse to implement? a. tell the pt to call adult protective services if his son's abuse continues b. refer the client to a program for victims of domestic violence c. verify the pt's report by determining if there is physical evidence of abuse d. assist the pt in developing an emergency safety plan

An unresponsive male victim of diving accident is brought emergency department where it it is determined that immediate surgery is required to save his life. The client is accompanied by a close. But no family members are available. What action should the nurse take first? A. Continue to provide life support until a third ward search for guardian is completed B. ask the man's friend to sign the informed consent since the client is unresponsive C. notify the unit manager that and an emergency court order is needed to allow surgery D. carry on with the surgical prep of the PT without assigned confirmed consent

As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids on which pathophysiological process? a. removing gastric secretions and to relive abdominal distention b. reducing hydrochloric acid secretion c. restoring and maintaining a positive fluid balance d. decreasing the formation and secretion of pancreatic enzymes

As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

During an evening shift on a medical unit, the only nurse on the unit is busy with unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personal (UAP), reports to the nurse that a healthcare provider is on the telephone... a. be sure to write down what is prescribed then repeat it back to the hcp b. remain the pt and monitor the v/s while the nurse takes the call c. ask the hip to remain on 'hold' until the nurse can confirm the prescription d. tell the hip the nurse will return the phone call asap.

Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure? a. I feel sick to my stomach and am going to throw up b. I'm having pain in my lower back when I move my legs c. my throat hurts badly when I swallow and when I talk d. I have a headache that gets worse when I sit up

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of fallot. what instruction should the nurse give the parents if their child becomes pale, cool, and lethargic? a. assist the child to a recumbent position b. provide a quiet time by holding or rocking the toddler c. encourage oral electrolyte solution intake d. contact their HCP

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement? A. No action is required since postoperative bleeding can be expected B. Lower the client's head while assessing for symptoms of shock C. Call the health care provider and prepare to take the client back to the operating room D. Outline the area with ink and check it every 15 minutes to see if the area has increased

Prior to obtaining an axillary temperature, the nurse should perform which action? a. check the last oral temp reading b. position the pt's arm at heart level c. ask when the PT last ate or drank d. place a protective sheath over the thermometer

The charge nurse in critical care unit is reviewing clients conditions to determine who is stable enough to be transferred. Which client status reports indicates readiness for transfer from the critical care unit to a medical unit? A.Myocardial infraction with signs bradycardia and multiple ectopic beats B. pulmonary embolus with the and intravenous heparin infusion and new onset he hematuria C. adult respiratory distress syndrome with pulse oximetry of 88 percent saturation D. chronic liver failure w HBG of 10.1 and a slight bilirubin elevation

The nurse administers the osmotic diuretic mannitol to a client who has a closed head injury. Which assessment finding indicates an immediate response to administration of the mannitol? a. A decrease in skin turgor b. An increase in serum osmolarity values c. an increase in serum sodium d. a decrease in intracranial pressure

The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings

The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse take in response to the finding? a. ask the client to describe recent alcohol use b. keep the client's feel elevated when in bed c. assess the client's muscle strength and tone d. complete a thorough neurologic assessment

The nurse is assessing an elderly bedridden client. Which finding indicates that the turning and positioning schedule is effective in protecting the client's skin? A. the pt feeling better after being turned and positioned. b. only small areas of redness remain longer than 30m after pt is turned c. reddened skin areas disappear within 15m of being turned and positioned d. no complaints of pressure or pain

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? a.Determine if the client is experiencing any anxiety. b.Auscultate the client's bilateral lung sounds and oxygen saturation. c.Notify the healthcare provider about the client's distress. d.Assess the delivery mechanism of the oxygen tank, tubing, and cannula.

The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system A. Tubing located on the top of the suction chamber. B. Stopper port located above the water-seal level. C. Rubberized port at the bottom of collection chamber. D. Plastic tubing located at the chest insertion site.

The nurse is conducing a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? a. Gradual onset of continuous eye pain and blurred vision. b. Recent change in the ability to read and drive after dark. c. Gray-white circle around the iris of both eyes. d. Cloudy opacity of the crystalline lens.

The nurse is feeding an older adult who was admitted with aspiration p coughing while attempting to drink through a straw. Which intervention. a. Assess the client's oral cavity for ulcerations b. Monitor the client when using a straw for liquids c. Teach coughing and deep breathing exercises d. Request thick nectar liquids for the client.

The nurse is preparing to gavage feed a PREMATURE INFANT through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats / minute. Which action should the nurse take? A. Continue the insertion since this is a typical response B. pause and monitor for a continues drop of the heart rate C. Insert the feeding tube into the infant's nasal passage D. Postpone the feeding until the infant's vital signs and stable

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients? a. ensure supplemental oxygen and respiratory medications are available at all times b. use nasal or cough tissues followed by handwashing at all times c. get annual flu and pneumococcal vaccine d. avoid large crowed areas during the colder months of the year

The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulifram. What information should the client acknowledge understanding? a. admit to others that he is a substance abuser b. completely abstain from heroin or cocaine use c. attend monthly meetings of alcoholics anon d. remain alcohol free for 12h prior to the first dose

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflo and requiring staff to observe airborne, as well as standard precautions? a. A female adolescent admitted with multiple genital Herpes simplex I lesions. b. An older client with scabies who is admitted from an extended care facility c. Twin siblings admitted with scarlet fever that is complicated with pneumonia d. A client with a positive Mantoux and sputum cultures results positive for AFB

The nurse notes that a postoperative adult client's respiratory rates 10 breaths/ minute. Which factor is the most likely explanation for this finding? A.The client has a 20-pack year history of smoking cigarettes. B. The client's hemoglobin is 10.1 or/dl and hematocrit is 30.4%. C. The client has a history of allergic bronchitis with recurrent bacterial pneumonia. D. The client's pca pump with morphine sulfate was dc 15m ago

The nurse should be most concerned about risk for injury (falls) after administering: a.Pantoprazole. b.Famotidine. c.Clarithromycin. d.Promethazine.

To prevent medication errors by an older client who is sometimes confused, which intervention by the home health nurse implement: a. Have an alert family member administer medications. b. Encourage taking medications at the same times daily c. Instruct the client to wear glasses when reading labels d. Provide education both verbally and in written format

Twenty-four hours alter admission for hemiparesis and unilateral blindness, a male client's condition resolves and he tells nurse that he "feels fine" and is ready to go home. What action should the nurse take a. arrange transfer to a rehab unit b. add "ineffective coping" to the plan of care c. maintain bedrest to prevent injury from falls d. document the resolution of the symptoms

When a blood transfusion is prescribed for a client with large uterine fibroids, she states that she is afraid of getting AIDs from the blood transfusion. What response is best for the nurse provide? a. ask the pt to talk about her fears regarding AIDS b. have the HCP explain the risks involved c. inquire about pt's exposure through sexual partners d. state the rigorous blood product screening negates risks

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? A) Use a sponge to de-breed the affected area B) Frequently apply moisturizer to prevent dry skin C) Protect the site from getting wet during bathing D) Gently path the skin after dry after rinsing with water

Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness

Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.

While auscultating a client's abdomen, the nurse hears a low pitched blowing sound in the upper midline area. What is the likely indication of this finding? a. normal borborygmus sounds b. a minor variation c. hyperactive bowel sounds d. possible renal artery stenosis

While inserting an indwelling urinary catheter into a client, the nurse observes urine flow in the tubing... a. inflate the balloon with 5ml of sterile water b. document the color and clarity of the urine c. ask the pt to breathe deeply and slowly exhale d. insert the cath and additional inch

a client recovering from pneumonia who has a hx of severe COPD and PVD is being discharged from a skilled nursing facility. What action is most important for the nurse to implement? a. demonstrate specific strengthening exercises b. explain exercise daily regimen c. provide typed instructions for healthy diet selections d. reinforce need for adequate hydration

a female client w otosclerosis is scheduled for a stapedectomy. what info is most important to provide the pt about the post op care? a. med to manage pain are available b. avoid turning head until dressings are removed c. can go to bathroom independently d. hearing may seem muffled initially

a newly hired UAP expresses fear to the charge nurse about collecting a sputum specimen from a pt who is HIV+ What action should the charge nurse take first? a. demonstrate the proper use of PPE b. offer to assist the uap with the collection of the specimen c. provide the uap with the infection control policy. d. determine the gap's knowledge about hiv transmission

a pt with hx of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension, which assessment finding need intervention a. decrease UO b. low BG levels c. profound weight gain d. ventricular arrhythmia

after assessing a pt, the nurse identifies three nursing problems. when developing the pt's plan of care, which action should the nurse take next? a. collaborate with the pt to est. goals b. cluster supportive pt data c. identify pt care interventions d. prioritize the identified nursing diagonsis

after expecting symptoms caused by abnormal heart rhythm, a client is placed on a temporary pacemaker. when he client expresses concerns and fear of the pacemaker, how should the nurse respond? a. use simple terms to describe how the pacemaker function b. offer reassurance that the staff will monitor the pacemaker c. reinforce that the pacemaker is a temporary measure d. encourage discussion about the concerns and fears

an ambulatory client with a saline lock wants to take a shower. Which action should the nurse take? a. protect the iv site with a gauze dressing b. advise the client to take a sponge bath c. remove the saline lock while the client showers d. tape a plastic bag over the iv site

client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube

he nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well."

the nurse assesses a pt who has just returned from a diagnostic study, as seen in the pic. the client has a perception for a NGT to low intermittent suction and now reports feelings of nausea. what action should the nurse implement first? a. auscultate bowel sounds b. administer an IV antiemetic c. remove tape from the cheek d. connect the tube to suction

the nurse who is working on a surgical unit receives a change of shift report for a group of clients for the upcoming shift. A client with which condition requires immediate attention by the nurse? a. Gunshot wound 3 hours ago with dark drainage of 2 cm noted on the dressing b. Mastectomy 2 days ago with 50 mL bloody drainage noted in the JP drain c. Collapsed lung after a fall 8 hrs ago with 100 mL blood in the chest tube collection container d. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills

An adult client is admitted to the psychiatric unit because of a daily, completion... hours or longer to complete. The client worries about staying clean and re...day area. This client's handwashing is an example of which clinical behavior: A.Phobia. B.Addiction. C.Obsession. D.Compulsion.

d obsession = thought compulsion = action

The nurse is reviewing a clients urinalysis results and identifies a specific gravity of 1.035. Which action should the nurse implement based on this finding? a. explain that the urine finding is normal b. recommend the use of salt with meals c. tell pt to report reduced u/o less than 1000ml/d d. instruct pt to increase oral fluids to a minimum of 2400 ml/d

d, normal 5-30

A client in the intensive care unit is being mechanically ventilated, has an indwellingurinary catheter in place, and is exhibiting signs of restlessness. Which action should the nursetake first? ● Review the heart rhythm on cardiac monitors ● Check urinary catheter for obstruction ● Auscultated bilateral breath sounds ● Give PRN dose of lorazepam (Ativan)

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