Hennessy
A pt. who weighs 110lbs receives a prescription for dalteparin 150 units/kg subcutaneously daily for 4 moths. The medication is available in 7,500 units/0.3mL prefilled syringe. How many mL should the nurse administer?
0.3mL
A infant who weighs 22lbs receives a prescription for amoxicillin 20mg/kg/day by mouth in divided doses every 8 hrs. The bottle is labeled, amoxicillin for oral suspension, USP 250 mg per 5mL. How many mL should the nurse administer?
1.3mL
A pt. who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg intravenously to be administered 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many mL should the nurse administer?
1.4 mL
A healthcare provider prescribes 500mL IV bolus of 0.9% normal saline to be infused over 30 min. How many mL/hr should the nurse set the infusion pump?
1000mL
A pt. is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump?
200 mL
A pt. with a chlamydia infection receives a prescription for a single dose azithromycin 1gram by mouth. The bottle is labeled Azithromycin for oral suspension, USP 200mg per 5mL. How many mL should the RN administer?
25mL
A pt. receives a prescription for a fluid bolus of 0.9% sodium chloride, USP 200mL to be infused in 30 min. How many mL/hr should the nurse program the infusion pump to deliver?
400mL
The RN is preparing to administer a suspension ampicillin labeled, 250mg/5mL, to a child with impetigo. The prescription is for 500mg four times a day. How many mL should the child receive per day?
40mL
The provider prescribes dopamine 2 mcg/kg/min intravenously for pt. who weighs 60kg. The IV bag contains dopamine 200 mg in dextrose 5% in water 250mL. The nurse should program the infusion pump to deliver how many mL/hr?
9mL/hr
A pt. with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in the pt.'s plan of care? Reference range (platelet count 150,000 to 400,000mm3). A. Assess urine and stool for occult blood B. Obtain pt.'s temp every 4 hr C. Monitor for signs of activity intolerance D. Require visitors to wear respiratory masks
A. Assess urine and stool for occult blood
The home care RN provided self care instructions for a pt. with chronic venous insufficiency caused by deep vein thrombosis. Which instructions should the RN include in the pts. discharge teaching plan? (SATA) A. Avoid prolonged standing or sitting B. Continue wearing compression socks C. Cross legs at knee but not at ankle D. Use recliner for long periods of sitting E. Maintain the bed flat while sleeping
A. Avoid prolonged standing or sitting B. Continue wearing compression socks D. Use recliner for long periods of sitting
The RN is performing trach care for a pt. when a code blue is called for another pt. on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take? A. Call for an assistant B. Respond to the code C. Finish the procedure D. Close the room door
A. Call for an assistant
NGN: (same scenario with 2yr old boy in pool) Placed a cervical collar with the assistance of the physician. The child's pulse is 121, the airway is patent, and there are no signs of bleeding. What complications should the nurse monitor for in the next 6-8 hrs after reviewing lab results, orders, and studies (not provided) (SATA) A. Cerebral edema B. Acute asphyxia C. HTN D. Respiratory distress E. Hyperthermia F. Subdural hemorrhage
A. Cerebral edema B. Acute asphyxia D. Respiratory distress F. Subdural hemorrhage
The RN discovers that a male pt. has attempted suicide by slashing his wrists. Which action should the nurse do first? A. Check the pts. level of consciousness B. Determine the depth of the slashes C. Estimate the amount of blood loss D. Find the object used to cause the injuries
A. Check the pts. level of consciousness
A pt. with a history of lung cancer reluctantly comes to the clinic bc of persistent hoarseness and a chronic cough. The pt.'s respirations are labored when speaking and the cap refill is 3 seconds. Which additional finding warrants intervention by the nurse? A. Coarse breath sounds B. Rust colored sputum C. Unexplained fatigue D. Clubbed fingernails
A. Coarse breath sounds
A pt. who is receiving zidovudine reports the appearance of pinpoint, red round spots on the skin. Which result should the nurse report to the healthcare provider? A. Complete blood count B. Allergy test C. Skin biopsy D. Electromyography
A. Complete blood count
The RN is providing lifestyle change education for a pt. to slow the progression of coronary artery disease. Which statement made by the pt. should the nurse recognize as needing additional education? (SATA) A. Consume foods with saturated fats B. Walk 30 min per day C. Use a salt substitute D. Keep a food diary E. Eat more canned veggies F. Include oatmeal or breakfast
A. Consume foods with saturated fats E. Eat more canned veggies
NGN: (same scenario with 2yr old in pool) The child is showing only minor signs of impact from the submersion injury and will likely be discharged in the morning. The nurse would like to give some education to the parents before discharge. What should the nurse include in pre-discharge education for this child's parents? (SATA) A. Contact information for community resources B. information about pool safety C. A warning about potential charges for child neglect D. When to follow up with the child's pediatrician E. Assessment of the parent's coping skills
A. Contact information for community resources B. information about pool safety D. When to follow up with the child's pediatrician E. Assessment of the parent's coping skills
The home health nurse is assessing an older pt. who lives alone. The pt. reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (SATA) A. Current prescribed and over the counter meds B. Next scheduled visit with healthcare provider C. Methods currently used to treat constipation D. Daily food and fluid intake E. Level of physical activity and exercise
A. Current prescribed and over the counter meds C. Methods currently used to treat constipation D. Daily food and fluid intake E. Level of physical activity and exercise
An S3 heart sound is auscultated in a pt in her 3rd trimester of pregnancy. What intervention should the nurse take? A. Document in the pts. record B. Prepare the pt for an echocardiogram C. Notify the healthcare provider D. Limit the pts. fluids
A. Document in the pts. record
The RN is providing discharge teaching to a pt. who underwent a pneumonectomy. The pt. wants to resume social activities with family. How should the nurse respond? A. Encourage family gatherings to reduce feelings of isolation B. Explain the need to avoid persons with respiratory infections C. Reinforce the need to avoid social contact for several weeks D. Recommend the use of a face mask during family events
A. Encourage family gatherings to reduce feelings of isolation
A pt. with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this pt.? A. Give the pt a schedule of planned daily activities B. Engage the pt in a game of cards C. Encourage the pt to have lunch off the unit D. Complete an assessment of social support.
A. Give the pt a schedule of planned daily activities
When assessing a pt. at 34 wks gestation, the RN notes that she has slightly elevated total T4 with a slightly enlarged thyroid, a HMT of 28% (37%-47%), HR of 92, and a systolic murmur. What findings require follow up? A. HMT of 28% B. HR of 92 C. Systolic murmur D. Elevated thyroid hormone level
A. HMT of 28%
NGN: Pt. w/ history of type 1 DM and asthma is readmitted to the unit for the 3rd time in 2 months with a fasting blood sugar of 325. Pt. describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which intervention should the nurse implement? (SATA) A. Have pt. demonstrate technique used to monitor blood glucose level B. Evaluate the pt.'s asthma medications that can elevate the blood glucose. C. Ask the pt. if they want a different manufacturer's glucose monitoring device. D. Have the pt. describe a typical day at work, home, and social activities E. Determine if the pt. is using a new insulin needle each administration.
A. Have pt. demonstrate technique used to monitor blood glucose level B. Evaluate the pt.'s asthma medications that can elevate the blood glucose. D. Have the pt. describe a typical day at work, home, and social activities E. Determine if the pt. is using a new insulin needle each administration.
An elderly pt. who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important to ensure the pt.'s compliance with self care? A. Have the pt. vocalize the instructions provided B. Provide written instructions for eye drop administration C. Speak clearly and face the pt. for lip reading D. Ensure that someone will stay with the pt. for 24 hrs.
A. Have the pt. vocalize the instructions provided
NGN: The pt. is a 22 yr old female with history of asthma. She was diagnosed at the age of 4 and has 2 previous hospitalizations for asthma related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1-2 times a week. She reports taking edible marijuana to relieve severe premenstrual symptoms. She came to the ER with difficulty breathing while hiking, she took albuterol, but it did not work, friend called 911, paramedics gave 2 more doses of albuterol in route. Pt. reports having a cold earlier in the week but was feeling better before walk. For each statement click if pt. has a understanding of asthma triggers. A. I should have taken some allergy meds before hiking B. I should eat a snack halfway thru hike C. My friend smoked cigs on hike D. I have been stressed and need to work on it E. I should have taken extra fluticasone-salmeterol
A. I should have taken some allergy meds before hiking C. My friend smoked cigs on hike D. I have been stressed and need to work on it
A mother brings her 3 weeks old son to the clinic because he is vomiting "all the time". In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first? A. Initiate a prescribed IV for parenteral fluid B. Feed the infant 3 ounces of isomil C. Give the infant 5% dextrose in water orally D. Insert a NG tube for feeding
A. Initiate a prescribed IV for parenteral fluid
After an older pt. receives treatment for drug toxicity, the healthcare provider prescribes 24 hr creatinine clearance test. Prior to starting the urine collection, the RN notes that the pts. serum creatinine is 0.3 mg/dl( 0.5 to 1.1mg/dL). Which action should the nurse implement? A. Initiate the urine collection as prescribed B. Evaluate the pts. serum BUN level C. Notify the healthcare provider of the results D. Assess the pt for signs of hypokalemia
A. Initiate the urine collection as prescribed
The RN is preparing a pt. who had a below the knee amputation for discharge to home. Which recommendation should the RN provide to the pt.? (SATA) A. Inspect skin for redness B. Use residual limb shrinker C. Avoid range of motion exercises D. Apply alcohol to the residual limb after bathing
A. Inspect skin for redness B. Use residual limb shrinker
The mother of a 7month old brings the infant to the clinic bc the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? A. Instruct the mother to change the child's diaper more often B. Ask the mother to decrease the infants intake of fruits for 24 hrs C. Encourage the mother to apply lotion with each diaper change D. Tell the mother to cleanse with soap and water at each diaper change
A. Instruct the mother to change the child's diaper more often
NGN: A healthy male infant whose mother is diabetic, he was born vaginally at 39 weeks, his parents report no health issues. He has 2 older siblings, 4 yr old sister, and 6 yr old brother, neither with health issues. At the 9 month check up, the RN reviews the child's height, weight, and feeding progression. What should the nurse advice the parents concerning the child's nutrition? (SATA) A. Juice should be avoided in infancy and early childhood B. The majority of the child's calories should be coming from formula C. The parents can add raw fruit, cheese, or firmly cooked veggies to the diet D. The child should eat more times per day E. The parents should consider using a fluoride supplement.
A. Juice should be avoided in infancy and early childhood C. The parents can add raw fruit, cheese, or firmly cooked veggies to the diet D. The child should eat more times per day
When should the nurse conduct an Allen's test? A. Just before arterial blood gasses are drawn peripherally B. Prior to attempting a cardiac output calculation C. To assess for presence of a deep vein thrombus in the leg D. When pulmonary artery pressures are obtained
A. Just before arterial blood gasses are drawn peripherally
A pt. is admitted to the surgical ICU following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The pt. begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care? A. Maintain strict intake and output B. Assess warmth of extremities C. Keep head of bed raised 45 degrees D. Monitor blood glucose level
A. Maintain strict intake and output
Which assessment should the home health nurse include during a routine home visit for a pt. who was discharged home with a suprapubic catheter? A. Observe insertion site B. Palpate flank area C. Measure abdominal girth D. Assess perineal area
A. Observe insertion site
Following a cardiac cath and placement of a stent in the right coronary artery, the RN administers prasugrel, a platelet inhibitor, to the pt. To monitor for adverse effects from the meds, which assessment is most important for the RN to include in the pts. plan of care? A. Observe the color of urine B. Assess skin turgor C. Measure body temp D. Check for pedal edema
A. Observe the color of urine
A elderly pt. is taken to the clinic by their spouse who appears very worried. The spouse reports to the nurse that the pt. started not making any sense and asked to visit a brother whose been dead for many years. Which action should the nurse take? (SATA) A. Obtain the pt.'s tympanic temp B. Review the pt.'s current food and med allergies C. Ask if the pt. is experiencing any pain with urination D. Encourage increasing the intake of high protein foods E. Determine if the pt. has recently experienced a fall.
A. Obtain the pt.'s tympanic temp C. Ask if the pt. is experiencing any pain with urination E. Determine if the pt. has recently experienced a fall.
The RN is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the RN report to the healthcare provider? A. Ortolani maneuver causing a click at the hip joint B. Plumb line test indicates fetal position curvature C. Babinski test that reveals fanning out of toes D. Moro test precipitating a startle response
A. Ortolani maneuver causing a click at the hip joint
An older pt. is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident. Which intervention should the nurse in the plan of care? (SATA) A. Place a bedside commode next to bed B. Measure neurological vital signs every 4 hrs C. Suction oral cavity every 4hrs D. Encourage family to participate in the pt.'s care E. Play classical music in room
A. Place a bedside commode next to bed B. Measure neurological vital signs every 4 hrs D. Encourage family to participate in the pt.'s care
The RN is evaluating a tertiary prevention program for pts. with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective? A. Pt.s who incurred disease complications promptly received rehab B. Pt. relapse rate of 30% in a 5yr community wide anti-smoking campaign. C. At-risk pts. received an increased number of routine health screenings D. Pt.s reported having confidence in making healthy food choices.
A. Pt.s who incurred disease complications promptly received rehab
The RN is caring for a pt. who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the pt. first? A. Reason for taking aspirin B. Dosage of ibuprofen C. Presence of gastric pain D. Amount of pain control
A. Reason for taking aspirin
The RN is caring for a pt. with an STI, genital herpes. The pt. reports having sex with multiple partners. Which response should the nurse provide? A. Remain non-judgmental and assure the pt. of confidentiality. B. Provide counseling that most contraceptives protect against infection C. Clarify that all STIs are transmitted through sexual intercourse D. Inform the pt. that complications will not result from reinfection.
A. Remain non-judgmental and assure the pt. of confidentiality.
Six weeks after the birth of a child with Trisomy 21, the parents return to the prenatal clinic for a follow up visit. They have spoken with a genetic counselor, but are still unsure about the risk of having another child with Trisomy 21. The couple brings literature from the counselor with them, and asks the RN to explain it. Which action should the RN take? A. Review the literature and answer any questions B. Determine their reasoning for seeking genetic counseling C. Tell the couple that it is best to call the counselor with questions D. Recommend a community support group
A. Review the literature and answer any questions
NGN: The RN reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? (SATA) A. Screen for orthostatic hypotension B. Provide oral care at least twice a day C. Monitor calcium levels D. Assess mental status regularly E. Assist the client to the bathroom F. Have an opioid agonist at the bedside
A. Screen for orthostatic hypotension B. Provide oral care at least twice a day D. Assess mental status regularly E. Assist the client to the bathroom
NGN: (same scenario with 2yr old from the pool) The parents are at the beside and state that each parent thought the other parent was watching the child. They are unsure how long he was in the pool or how he might of fallen in. The temp of the pool was cool as the temp outside which was 64degrees. What are the first four actions the nurse should take? A. Take the childs pulse B. Place a cervical collar on the pt. C. Look for any open wounds D. Call CPS E. Determine if the child's airway is clear F. Start a peripheral intravenous line
A. Take the childs pulse B. Place a cervical collar on the pt. C. Look for any open wounds E. Determine if the child's airway is clear
NGN: Pt. is an 11 month male with a 2 day history of fussiness, increased nasal secretions, and cough. The baby is 24.3lbs. He was born at 34 wks and spent several weeks in the neonatal ICU for poor feeding. He is currently up to date on vaccinations and is meeting appropriate developmental milestones. The parents deny he takes any meds at home. Select which assessment findings indicate that the baby has an increased fluid requirement. (SATA) A. Temp 103 B. BP 89/51 C. Respiratory rate 55 D. Copious, clear secretions from both nostrils E. O2 sat 95% F. Wet diaper with 12mL of urine G. HR 159bpm
A. Temp 103 C. Respiratory rate 55 D. Copious, clear secretions from both nostrils
NGN: A 2yr old child fell in a pool, when retrieved by a family member, he was not breathing, the family member started CPR and the ambulance brought him to the hospital. What factors are important in determining the level of hypoxemia that the child may have experienced during submersion? (SATA) A. The amount of time the child was submerged B. Temp of the water C. Whether or not anyone witnessed the fall into the pool D. Oxygen concentration of the ambient air E. The weight of the child
A. The amount of time the child was submerged C. Whether or not anyone witnessed the fall into the pool D. Oxygen concentration of the ambient air
An adult pt. is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the pt. is the earliest indication to the nurse that the pt is experiencing an adverse reaction to this procedure? A. Tingling on tongue or lips B. Episodes of shivering C. Salty taste in the mouth D. Difficulty breathing
A. Tingling on tongue or lips
The charge RN is making assignments for one practical nurse and three RN's who are caring for neurologically compromised clients. Which pt. with which change in status is best to assign to the practical nurse? A. Viral meningitis whose temp changed from 101 to 102 B. Myxedema coma whose BP changed from 80/50 to 70/40 C. Diabetic ketoacidosis whose glascow coma scale score changed from 10 to 7 D. Subdural hematoma whose BP changed from 150/80 to 170/60
A. Viral meningitis whose temp changed from 101 to 102
When performing suctioning for a pt. with a trach, which action should the nurse include? A. Wear protective goggles B. Apply water soluble lubricant to catheter C. Instill 3 mL of normal saline before suctioning D. Instruct the pt to cough as the suction tip is removed
A. Wear protective goggles
A RN is managing the care of a pt with Cushings Syndome. Which intervention should the nurse delegate to the UAP? (SATA) A. Weigh pt and report weight gain B. Report any pt complaints of pain C. Evaluate the pt for sleep disturbances D. Note and report the pts. food and liquid intake during meals E. Assess the pt for weakness/fatigue.
A. Weigh pt and report weight gain B. Report any pt complaints of pain D. Note and report the pts. food and liquid intake during meals
The pt. is a 7 yr old with spastic cerebral palsy admitted to pre-op for heel cord lengthening. Child has cognitive and speech delays. Experiences absent seizures numerous times daily according to parent. The nurse is developing the plan of care for the child. To provide atraumatic care for this child post-op, what will be a priority? A. pain assessments B. antibiotics C. occupational therapy D. wound care E. physical therapy
A. pain assessments
A pt. is being discharged home after being treated for HF. Which instruction should the nurse include in this pts. discharge teaching plan? A. weigh every morning B. perform range of motion C. limit fluid intake to 1500mL daily D. eat high protein
A. weigh every morning
A primiparous woman presents in labor with following labs: Hemoglobin 10.9 (12-16), Hematocrit 29% (37%-47%), hepatitis surface antigen positive, group B strep positive, and rubella non-immune. Which intervention should the nurse implement? A. Transfuse two units packed red blood cells B. Administer ampicillin 2grams intravenously C. inject hepatitis B immune globulin 0.5mL D. Give measles, mumps, rubella vaccine 0.5mL
B. Administer ampicillin 2grams intravenously
A RN enters a pt.'s room to administer oral meds and finds a UAP providing care to the pt. The pt.'s condition has obviously deteriorated. The pt. is lying a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action? A. Explain to the UAP that changes in a pt.'s condition should be reported immediately B. Advise the UAP to stop providing care so the nurse can assess the pt.'s condition C. Ask the UAP to position the pt. so the oral meds can be administered D. Determine why the UAP did not notify the nurse of the change in the pt.'s condition.
B. Advise the UAP to stop providing care so the nurse can assess the pt.'s condition
A RN is assigned to care for four surgical pts. After receiving report, which pt. should the nurse see first? A. An adult who is in bucks traction, and scheduled for hip arthroplasty within the next 12 hrs. B. An older pt. who is receiving packed red blood cells on the 3rd day post-op for colon resection C. An older pt. with continuous bladder irrigation who is 2 days post-op for bladder surgery D. An adult one day post-op laparoscopic cholecystectomy requesting pain meds.
B. An older pt. who is receiving packed red blood cells on the 3rd day post-op for colon resection
The RN is caring for a pt. with the STI infection Syphilis. The pt. reports having had prior sexually transmitted infections. Which response should the nurse provide? A. Discuss that partners without similar symptoms may not be infected B. Answer questions directly and correct any misinformation C. Provide counseling that most contraceptives protect against infection D. Notify that persons with STIs are reported to local health departments.
B. Answer questions directly and correct any misinformation
A pt. with cancer is admitted to the oncology unit and tells the RN that he is in the hospital for palliative care measures. The RN notes that the pts. admission prescriptions include radiation therapy. Which action should the RN implement? A. Notify the radiation department to withhold the treatments for now. B. Ask the pt. about his expected goals for this hospitalization C. Determine if the pt. wishes to cancel further radiation treatments D. Explain that palliative care measures can be provided at home
B. Ask the pt. about his expected goals for this hospitalization
One hour after arriving on postop unit, a woman who received spinal anesthesia 5 hrs ago is complaining of severe abdominal incisional pain. Her vitals are: temp 99, HR 110, RR 30, BP 160/90. The pts. skin is pale, and the surgical dressing is dry and intact. Which intervention is most important for the nurse to implement? A. Provide pillow for splinting B. Assess the IV site for patency C. Place in a high fowler position D. Administer an IV analgesic
B. Assess the IV site for patency
The RN is caring for a pt. with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the RN that the pt. may be experiencing a complication? A. BP 130/80 B. Cervical spine stiffness C. Dark yellow urine D. Excessive perspiration
B. Cervical spine stiffness
When caring for a pt. with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the RN? (SATA) A. Sloughing tissue around the wound edges B. Change in the quality of the peripheral pulses C. Weeping serosanguineous fluid from wounds D. Loss of sensation to the left lower extremity E. Complaint of increased pain and pressure
B. Change in the quality of the peripheral pulses D. Loss of sensation to the left lower extremity E. Complaint of increased pain and pressure
A pt. is admitted for treatment of infection after a spider bite on the lower extremity, the infection has began spreading up the leg. Which admission assessment findings should the nurse report to the provider? (SATA) (This doesn't give all info) A. RBC B. Core body temp C. Swollen lymph nodes in groin D. Location of the IV site E. WBC
B. Core body temp C. Swollen lymph nodes in groin E. WBC
NGN: Pt. is 70yr old female training for triathlon. She was hit by a car while jogging and has an abrasion that is 25 cm by 12 cm on her right leg and a liver laceration. She underwent an exploratory laparotomy to repair the live laceration and to search for other internal injuries. The pt. has no chronic medical conditions and is in good health. She takes a calcium and magnesium supplement daily. She denies smoking or drinking alcohol. What age related factors into this patients wound healing? (SATA) A. insulin resistance B. Decreased epidural turnover C. Pigmentation changes D. T-cell function decrease
B. Decreased epidural turnover D. T-cell function decrease
The RN is preparing to administer 1.6mL of medication intramuscularly to a 4month infant. Which action should the RN include? A. Select a 22 gauge 1 1/2 inch needle for the intramuscular injection B. Divide the medication into two injections with volumes under 1mL C. Administer into the deltoid muscle while the parent holds the infant securely D. Use a quick dart-like motion to inject into the dorsogluteal site.
B. Divide the medication into two injections with volumes under 1mL
A pt. is receiving continuous ambulatory peritoneal dialysis since the arteriovenous graft in the right arm is no longer available for use for hemodialysis. The pt. has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5g/dL (3.5-5.5). Which intervention is the priority for the nurse to implement? A. Recommend the use of support stockings to enhance venous return B. Ensure the pt. receives frequent small meals containing complete proteins C. Evaluate patency of the AV graft for resumption of hemodialysis D. Instruct the pt to continue to follow the prescribed rigid fluid restriction amounts
B. Ensure the pt. receives frequent small meals containing complete proteins
The RN discovers that an elderly pt. with no history of cardiac or renal disease has an elevated serum mag level. To further investigate the cause of this electrolyte imbalance, what info should the nurse to obtain from the pt.'s medical history? A. Genetically inherited disorders of family members. B. Frequency of laxative use for chronic constipation C. Length and frequency of the pts. tobacco use D. Ingestion of shellfish or fish oil capsules daily.
B. Frequency of laxative use for chronic constipation
Which instruction regarding skin care should the nurse provide to a pt. who is receiving radiation therapy for metastatic breast cancer? A. Protect the site from getting wet during bathing B. Gently pat the skin dry after rinsing with water C. Frequently apply moisturizers to prevent dry skin D. Use a sponge to debride the affected area
B. Gently pat the skin dry after rinsing with water
The PN reports that a pt. who has a fingerstick glucose of 35 mg/dL (74-106) is alert and diaphoretic. Which action should the charge nurse take? A. Collect a blood sample for hemoglobin A1c B. Give pt. a glass of orange juice C. Notify the healthcare provider D. Assess pt. for polyuria and polyphagia
B. Give pt. a glass of orange juice
A 6wk old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-op nursing action has the highest priority? A. Mark an outline of the olive shaped mass in the right epigastric area B. Maintain a continuous infusion of IV fluids per prescription C. Monitor amount of intake and infants response to feedings D. Instruct parents regarding care of the incisional area
B. Maintain a continuous infusion of IV fluids per prescription
A pt. with a foul-smelling drainage from an incision on the upper left arm is admitted with a suspected MRSA. Which nursing intervention should the RN include in the plan of care? (SATA) A. standard precautions & wear mask B. Monitor pt.'s WBC C. Institute contact precautions for staff and visitors D. Send wound drainage for culture and sensitivity E. Explain the purpose of a low-bacteria diet.
B. Monitor pt.'s WBC C. Institute contact precautions for staff and visitors D. Send wound drainage for culture and sensitivity
The RN is providing care to a pt. having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the post-op period? A. Obtain vital signs every 2 hr during hospitalization B. Provide an eye shield to be worn while sleeping C. Teach a family member to administer eye drops D. Encourage deep breathing and coughing exercises
B. Provide an eye shield to be worn while sleeping
An older pt. is being admitted to a short-term rehab facility after a long hospitalization. The RN is performing a functional assessment with the pt. Which action should the nurse implement? A. Encourage the pt to lie as still as possible during the assessment B. Question the pt. about the frequency of falls in recent months C. Assist the pt with values clarification about end of life care options D. Ask the pt. how often episodes of sundowning are experienced
B. Question the pt. about the frequency of falls in recent months
A pt. who is having GI difficulties is undergoing diagnostic procedures. The pt. asks the nurse about the difference between ulcerative colitis and crohn's disease. Which information should the nurse offer? A. Anal abscess and fistula rarely occur in Crohn's disease B. Rectal bleeding is a predominant symptom in ulcerative colitis C. Constipation is more common in Crohn's disease D. Colitis and Crohn's disease dont involve chronic inflammation of the GI tract.
B. Rectal bleeding is a predominant symptom in ulcerative colitis
A pt. who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The provider changes the script to Febuxostat. Which instruction should the nurse include in the discharge teaching? A. Eat high protein foods to achieve ideal body weight B. Report experiencing right upper quad discomfort C. Use electric heating pad when pain is at its worse D. Replace dietary table salt with salt substitutes
B. Report experiencing right upper quad discomfort
A pt. with a history of COPD is admitted with pneumonia. Vitals include HR 122, RR 28, BP 170/90. Which assessment finding warrants the most immediate intervention by the nurse? A. Bilateral diffuse wheezing B. Shortness of breath on exertion C. Temp 100.5 D. Yellow expectorated sputum
B. Shortness of breath on exertion
A pt. develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority first) A. Assess vitals B. Stop the infusion C. Initiate an adverse event report D. Contact healthcare provider E. Document reaction to the drug
B. Stop the infusion A. Assess vitals D. Contact healthcare provider C. Initiate an adverse event report E. Document reaction to the drug
The RN observes a pt. prepare a meal in the kitchen of a rehab facility prior to discharge. Which behavior indicate the pt. understands how to maintain balance safely? (SATA) A. Bends from the waist to pick trash off the floor B. Widens stance while working near the sink C. Locks knees while preparing food on the counter D. Brings a heavy can close to body before lifting E. Leans forward to pull a pan from a high shelf
B. Widens stance while working near the sink D. Brings a heavy can close to body before lifting
A pt. with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the RN use to provide education about pain relief options? A. Repeat info to the pt. B. Write info on a whiteboard C. Talk loudly into the affected ear D. Speak directly facing the pt.
B. Write info on a whiteboard
A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The pt. tells the nurse that the voices are saying "kill, kill". Which question should the nurse ask the pt. next? A. "When did these voices begin?" B. "Do you believe the voices are real?" C. "Are you planning to obey the voices?" D. "Have you taken any hallucinogens?"
C. "Are you planning to obey the voices?"
A 3 yr old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide? A. "Does your child seem mentally slower than his peers also?" B. "Haven't you been feeding him according to recommended daily allowances for children?" C. "His smaller size is probably due to the heart disease." D. "You should not worry about the growth tables. they are only averages for children."
C. "His smaller size is probably due to the heart disease."
The parent of a child born with myelomeningocele asks the nurse, "What did i do to deserve this?" Which response is most helpful? A. "You didn't do anything wrong." B. "Is there any particular reason why you think this is your fault?" C. "This must be a very difficult time for you." D. "With surgery, your baby should have a full recovery."
C. "This must be a very difficult time for you."
A pt. with a history of unstable angina presents to the ER with constant chest pressure that is unrelieved with rest. The pt. appears anxious, pale, and diaphoretic. After obtained the pts. vitals, which action should the nurse take? A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema B. Secure pt. consent for coronary angiography and percutaneous coronary intervention C. Administer four 81mg aspirin tabs providing instructions to chew before swallowing D. Place an indwelling urinary catheter and institute strict intake and output measurements
C. Administer four 81mg aspirin tabs providing instructions to chew before swallowing
A pt. presents at the ER reporting a raspy voice, cold intolerance, and fatigue. Lab results show an elevated TSH and low T3 and T4 levels. After the pt. is admitted to the telemetry unit, which intervention is most important for the nurse to implement? A. Offer additional blankets and a warm drink B. Note the pt.'s most recent hemoglobin level C. Administer prescribed dose of levothyroxine D. Assess for presence of non-pitting edema
C. Administer prescribed dose of levothyroxine
A pt diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A. Furosemide B. Aspirin, low dose C. Allopurinol D. Enalapril
C. Allopurinol
In planning care for a pt. with early stage Alzheimer's disease, the RN establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this pts. plan of care? A. Engage the pt. in regularly scheduled activities during the day B. Offer the pt. frequent reassurance that he/she will be safe C. Arrange the pts. environment so the pt. can move about freely D. Assign a UAP to provide the pt. with total person care
C. Arrange the pts. environment so the pt. can move about freely
The RN implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome indicates that the program was effective? A. New screening protocols were developed, validated, and implemented B. Pts. who incurred disease complications promptly received rehab. C. Average pt. scores improved on specific risk factor knowledge test. D. More than half of at risk pts. were diagnosed early in their disease process
C. Average pt. scores improved on specific risk factor knowledge test.
A pt. has received a prescription for orlistat for weight and nutrition management. In addition to the meds, the pt. plans to take a multivitamin. Which teaching should the RN provide? A. Multivitamins are contraindicated during treatment with weight control meds such as orlistat B. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals. C. Be sure to take the multivitamin and the meds at least two hrs apart for best absorption and effectiveness. D. Following a well-balanced diet is a much healthier approach to good nutrition than depending on a multivitamin.
C. Be sure to take the multivitamin and the meds at least two hrs apart for best absorption and effectiveness.
Which instruction should the RN delegate to a UAP? A. Call pharmacy to obtain pts. next antibiotic B. Observe pts. gait to determine the need for assistance C. Bring a sterile chest drainage unit from central supply to the unit D. Evaluate a pts. urinary catheter for proper drainage.
C. Bring a sterile chest drainage unit from central supply to the unit
The RN is preparing to send a pt. to the cardiac cath lab for an angioplasty. Which pt. report is most important for the RN to explore further prior to the start of the procedure? A. Drank a glass of water in the past 2 hours. B. Reports left chest wall pain prior to admission C. Experiences facial swelling after eating crab D. Verbalizes a fear of being in a confined space
C. Experiences facial swelling after eating crab
The RN is caring for a pt. with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the pt. to ease respiratory distress? A. Left lateral position B. Reverse Trendelenburg C. High-Fowlers position D. Supine
C. High-Fowlers position
A pt. with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The clients lab values include: Sodium 129 (136-145), Glucose 54 (74-106), potassium 5.3 (3.5-5.0). When reporting the findings to the provider, the nurse anticipates a prescription for which intravenous med? A. Broad spectrum antibiotic B. Regular insulin C. Hydrocortisone D. Potassium chloride
C. Hydrocortisone
When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority? A. Disturbed body image B. interrupted family processes C. Imbalanced nutrition: less than body requirements D. Noncompliance with treatment regimen
C. Imbalanced nutrition: less than body requirements
The RN is caring for a pt newly diagnosed with emphysema. The RN should prioritize which potential complication? A. Self-care deficit B. Activity intolerance C. Impaired gas exchange D. Ineffective airway clearance
C. Impaired gas exchange
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued bc the pt. is feeling better after taking the meds for the past couple weeks and does not like the side effects. Which response is best for the nurse to provide? A. Tell the pt. to discuss the meds side effects with provider B. Tell the pt. that the meds side effects will most likely dissipate over time C. Inform the pt. that gradual tapering must be used to discontinue the meds D. Remind the pt. that feeling better is the therapeutic effect of the med
C. Inform the pt. that gradual tapering must be used to discontinue the meds
A pt. whose hyperthyroidism has not been responsive to meds is admitted for evaluation. During the admission assessment the pt. reports to the nurse of a sudden onset of feeling apprehensive and nurse notes the pt. is restless and very warm to the touch. Which action should the nurse implement next? A. Access lab results to confirm thyroid crisis B. Obtain a complete set of vitals C. Initiate intravenous access D. Encourage relaxation and slow deep breathing
C. Initiate intravenous access
After receiving a change of shift report for pts. on a med-surge unit, which activity should the nurse delegate to the practical nurse? A. Evaluate and update plans of care for pts. B. Verify the readiness of pts. for discharge C. Insert urinary catheters for uncomplicated pts. D. Receive a post-op pt. and conduct the assessment.
C. Insert urinary catheters for uncomplicated pts.
A UAP is assigned to a pt. with flu-like symptoms on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take? A. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this pt. B. Advise the UAP to wear a standard face mask to obtain vitals, and then get fitted for a filter mask before providing personal care. C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned pt. D. Before changing assignments, determine which staff members have fitted particulate filter masks.
C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned pt.
A pt. who is hypertensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8mcg/kg/min. Which intervention should the nurse implement while administering this med? A. Assess pupillary response to light hourly B. Initiate seizure precautions C. Measure urinary output every hour D. Monitor serum potassium frequently
C. Measure urinary output every hour
The nurse notices that a male pt. is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement? A. Use firmness and direct the pt. to site for awhile B. Suggest to the pt that he take a walk C. Move the pt to a quiet place on the unit D. Encourage the pt to use the punching bag
C. Move the pt to a quiet place on the unit
In evaluating the effectiveness of a postop pt.'s intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A. Palpate all peripheral pulse points for volume and strength B. Monitor the amount of drainage from the pt.'s incision C. Observe both lower extremities for redness and swelling. D. Evaluate the pt.'s ability to use a incentive spirometer.
C. Observe both lower extremities for redness and swelling.
Two days after surgical fixation of a fractured femur, a pt. suddenly reports chest pain and difficult in breathing. The RN suspects the pt. had a PE. Which action should the RN take first? A. Notify the provider B. Prepare a continuous heparin infusion per protocol C. Provide supplemental oxygen D. Bring the emergency crash cart to bedside
C. Provide supplemental oxygen
The RN is developing a plan of care for a pt. with type 2 DM. When providing teaching on lowering blood glucose levels and increasing serum high density lipoprotein levels, which instruction should the nurse include? A. Limit calories on days unable to exercise B. Monitor blood glucose levels daily C. Regular exercise with medical approval D. Monthly appointments with the dietitian
C. Regular exercise with medical approval
A female pt. is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The pt tells the nurse that she is experiencing jaw pain. How should the nurse respond? A. Determine how the pt. is administering the meds B. Advise the pt. to gargle with warm salt water twice daily C. Report the pt.s jaw pain to the provider D. Confirm that this is a common symptom of osteoporosis
C. Report the pt.s jaw pain to the provider
The RN is administering multiple prescribed vaccines to a toddler. Which strategy should the RN prioritize to reduce the duration of pain? A. Physical soothing B. Verbal reassurance C. Simultaneous injections D. Supine positioning
C. Simultaneous injections
The school RN is called to the soccer field bc a child has a nosebleed. In which position should the nurse place the child? A. Side lying with the head slightly elevated B. Standing with the head leaning backward C. Sitting up and leaning forward D. Supine with the legs raised
C. Sitting up and leaning forward
The RN is assessing an older pt. who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the pts. home was recently sold and the pt. has just moved in with them. Which nursing response best promotes effective communication with the family? A. If the dementia is a result of Alzheimer's disease, it is often reversible even in late stages B. The pt is exhibiting symptoms of dementia and bc of age, it may be permanent C. The pt.'s delirium may be due to depression and is possibly reversible. D. Delirium is often a sign of underlying mental illness and institutionalization is often necessary
C. The pt.'s delirium may be due to depression and is possibly reversible.
An older pt. with Alzheimer's disease is confused and asking the RN to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement? A. Clarify reality with the pt. about delusional thoughts B. Reduce the pt.'s interaction with others during the day C. Use distraction and therapeutic communication skills D. Awaken the pt. for reality checks every 4hrs a night
C. Use distraction and therapeutic communication skills
In caring for a pt. who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the RN to report to the provider? A. Yellow tinged sputum B. Nausea and headache C. Watery diarrhea D. Increased fatigue
C. Watery diarrhea
The RN is planning to administer two medications to a pt. at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the pt. for drug toxicity? A. Low bioavailability B. short half life C. highly protein bound D. high therapeutic index
C. highly protein bound
The RN is triaging several children as they present to the ER after a school bus accident. Which child requires the most immediate intervention by the nurse? A. 12 yr old reporting neck, arm, and lower back discomfort B. 8yr old with a full leg air splint for a possible broken tibia C. 6 yr old with multiple superficial lacerations of all extremities D. 11 yr old with a headache, nausea, and projectile vomiting
D. 11 yr old with a headache, nausea, and projectile vomiting
A pt. tells the nurse about jogging everyday with the hope of losing weight and sleeping better. The pt. states that it takes hours to fall asleep at night and is experiencing fatigue and sleepiness throughout the day. Which action should the nurse implement? A. Advise the pt that lifestyle changes often takes several weeks to be effective B. Encourage the pt to exercise every day to eliminate bedtime wakefulness C. Determine the amount of weight the pt has lost since increasing activity D. Ask the pt for a description of the exercise schedule that is being followed
D. Ask the pt for a description of the exercise schedule that is being followed
An older pt comes to the clinic with a family member. When the RN attempts to take the pts. health history, the pt. does not respond to questions in a clear manner. Which action should the nurse implement first? A. Provide a printed health care assessment form B. Defer the health history until the pt is less anxious C. Ask the family member to answer the questions D. Assess the surroundings for noise and distractions
D. Assess the surroundings for noise and distractions
When a RN enters the room of a male pt. who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm, but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the RN implement? A. Observe for swelling at the fracture site B. Analyze the cardiac rhythm in another lead C. Obtain a 12 lead electrocardiogram D. Begin chest compressions at 100/min.
D. Begin chest compressions at 100/min.
A 3yrd old boy was toilet trained prior to his admission to the hospital for injuries from a fall. His parents are concerned that the child has regressed in the toileting. Which info should the RN provide the parents? A. Diapering will be provided since hospitalization is stressful to preschoolers B. A retraining program will need to be initiated when the child returns home C. A potty chair should be brought from home so he can maintain toileting D. Children usually resume their toileting behaviors when they leave the hospital
D. Children usually resume their toileting behaviors when they leave the hospital
NGN: Pt. is in the hospital after her house collapsed during a hurricane. Shes been in the ICU for 2 wks and moved today to the surgical floor to continue monitoring respiratory function and complete IV antibiotics. 0900 pain assessment completed; 2/10. Pt. requests sleeping meds, states she has horrible thoughts and says she used to be happy before but all of the sudden she is in a funk. Pt. is using fantasy, isolation, and suppression as defense mechanisms. What treatments might be helpful at this time? (SATA) A. Phototherapy B. Administration of lithium C. Consciousness-raising D. Cognitive behavioral therapy E. Animal therapy F. Electroconvulsive therapy
D. Cognitive behavioral therapy E. Animal therapy
The RN is assigned to provide care for a pt. who is scheduled for a laparoscopic cholecystectomy in 2hrs, at 0900. What nursing action is most important? A. Determine when the pt. last had pain meds B. Offer to assist the pt. to the restroom to void C. Review post-op instructions with the pt. D. Confirm that the pt. has been NPO since midnight.
D. Confirm that the pt. has been NPO since midnight.
The RN is setting up the equipment to assist with a sigmoidoscopy while the practical nurse positions the pt. in a flat prone position. Which action should the nurse implement? A. Arrange for UAP to assist the PN during procedure B. Acknowledge that the PN has positioned the pt. safely and correctly C. Assume care of the pt and assign the PN to the care of a different pt. D. Demonstrate to the PN how to position the pt. more effectively for the procedure
D. Demonstrate to the PN how to position the pt. more effectively for the procedure
A pt. with persistent low back pain has received a prescription for a TENS unit. After the RN applies the electrodes and turns on the power, the pt. reports feeling a tingling sensation. How should the nurse respond? A. Remove electrodes and observe for skin redness B. Decrease the strength of the electrical signals C. Check the amount of gel coating on the electrodes D. Determine if the sensation feels uncomfortable
D. Determine if the sensation feels uncomfortable
The nurse manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? A. Potential changes in employee benefits B. Changes in job descriptions C. New managements expectations D. Employees job security
D. Employees job security
When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. What intervention should the nurse implement? A. Review transcutaneous bilirubin levels with a bilirubinometer B. Observe and palpate newborns breast tissue for enlargement C. Assess for signs of fluid retention and bilateral pedal edema D. Explain to the mother that the finding is due to increased androgen
D. Explain to the mother that the finding is due to increased androgen
When the parents of a 6yr old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened it we sought treatment sooner!". Which intervention should the RN provide? A. Refer the parents to the chaplain to provide grief counseling B. Tell the parents that blaming each other wont change the situation C. Assure the parents that a terminal diagnosis is inevitable D. Explain to the parents that anger is a common response to grief.
D. Explain to the parents that anger is a common response to grief.
NGN: An older pt. is admitted to the ICU, unconscious after several days of vomiting and diarrhea. Vitals: BP 80/60, HR 110 Ph-7.34, PaCO2- 34 (35-45), HCO3- 20 (21-28), pO2-90. Sodium 130 (136-145), Potassium 2.5 (3.5-5), Chloride 95 mEq/L (98-106). The RN inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the RN implement first? A. Initiate continuous dopamine infusion at 2 mcg/kg/min. B. Administer promethazine 25 mg slow IV push every 4 hr C. Begin potassium chloride 10 mEq over 1 hr per secondary infusion. D. Give a bolus of 0.9% sodium chloride 1,000 ml over 30 min.
D. Give a bolus of 0.9% sodium chloride 1,000 ml over 30 min.
An older pt with a history of heart failure and admitted to the medical unit after falling at home and has become increasingly confused. The pts. spouse is designated as the pts. power of attorney. When reporting to the healthcare provider using SBAR communication, which information should the nurse provide first? A. Currently prescribed meds B. Fall at home as reason for admission C. Pts. healthcare power of attorney D. Increasing confusion of the pt.
D. Increasing confusion of the pt.
A pt. is being urgently transported to radiology for a CT after a sudden decrease in LOC. The pt. is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take? A Secure chest tube to the stretcher for transport B. Administer PRN pain meds prior to transport C. Mark the amount of chest drainage on the container D. Keep chest tube container below the site of insertion
D. Keep chest tube container below the site of insertion
The RN is assessing a 4 yr old child with eczema. The child's skin is dry and scaly, and the mother reports that the child scratches the lesions to the point of bleeding. Which guideline is indicated for care of this child? A. Apply baby lotion to the skin twice daily. B. Bathe the child daily with bath oil C. Allow the child to wear only 100% cotton clothing D. Keep the nails trimmed short
D. Keep the nails trimmed short
The RN is caring for a pt. after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the RN report to the healthcare provider immediately? A. Dullness bilaterally on percussion B. Serosanguinous drainage from the chest tube C. Diminished breath sounds in the left lower lobe D. Mediastinal shift to the right
D. Mediastinal shift to the right
Which breakfast selection should a RN recommend for a 16 yr old with diarrhea? A. Buttered whole wheat toast and coffee B. Sausage, poached eggs, and milk. C. Granola, strawberries, and tea D. Oatmeal, banana, and herbal tea
D. Oatmeal, banana, and herbal tea
After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care? A. Administer IV opioids as needed for pain B. Teach how to use incentive spirometry C. Monitor for confusion and restlessness D. Observe for signs of increased bleeding
D. Observe for signs of increased bleeding
The RN is caring for a pt. admitted with an acute exacerbation of COPD who reports a pounding headache. Which action should the nurse take? A. Elevate head of bed no higher than 30 degrees B. Affirm blood glucose is below 160 mg/dL C. Check for a stat intravenous diuretic prescription D. Obtain a manual blood pressure measurement
D. Obtain a manual blood pressure measurement
A pt. with possible acute kidney injury is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the RN implement? A. No specific nursing action is required B. Collect a clean catch urine specimen C. Instruct the pt to empty the bladder D. Obtain vitals and breath sounds
D. Obtain vitals and breath sounds
A male pt. reports to the on-call clinic RN that he took 2 tablets of 10mg lisinopril by mouth 2 hrs ago and his skin now feels flush. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take? A. Instruct the pt. to increase his intake of oral fluids until the skin flushing is relieved B. Advise the pt. to place one nitroglycerin tab under his tongue as a precaution C. Tell the pt. to have someone bring him to an ED immediately D. Reassure the pt. that facial flushing is a common side effect of the med.
D. Reassure the pt. that facial flushing is a common side effect of the med.
A pt. who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The RN determines that the pt.'s nipples are inverted. Which action should the nurse implement? A. Encourage the use of ice on the areola B. Teach about the use of a breast pump C. Offer supplemental formula feedings D. Recommend using a breast shield
D. Recommend using a breast shield
Following morning care, a pt. with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first? A. Administer a prescribed PRN dose of hydralazine B. Assess the pt.'s BP every 15 min C. Teach the pt. to recognize the symptoms of dysreflexia D. Relieve any kinks of obstruction in the pt.'s foley tubing.
D. Relieve any kinks of obstruction in the pt.'s foley tubing.
A female pt. is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25lbs in the last four months. During the admission assessment, the pt tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first? A. Anxiety as evidenced by abdominal complaints secondary to depression B. Imbalanced nutrition as evidenced by 25lb weight loss in four months C. Chronic low self-esteem as evidenced by feelings of worthlessness D. Risk for self-directed violence as evidenced by feelings of hopelessness
D. Risk for self-directed violence as evidenced by feelings of hopelessness
A pt. with DI has an average urinary output of 500ml of dilute urine every hour for the last 4hrs. Which lab test is most important for the nurse to monitor? A. WBC B. Capillary glucose C. Urine specific gravity D. Serum sodium
D. Serum sodium
A pt. receives a prescription for itraconazole. Which information provided by the pt. requires additional instruction by the nurse? A. Report any difficulty with breathing B. Monitor for changes in stool color C. Avoid the consumption of grapefruit juice D. Take the meds with antacids
D. Take the meds with antacids
A pt. who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What info should the RN share with her? A. The diaphragm should be inserted 2-4 hrs before intercourse B. The most effective form of contraception is a diaphragm C. Vaseline lubricant can be used when inserting the diaphragm D. The diaphragm must be refitted after childbirth.
D. The diaphragm must be refitted after childbirth.
The mother of a 2 day infant girl expresses concern about a "flea bite" type rash on her daughter's body. The RN identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? A. The rash is due to distended oil glands that will resolve in a few weeks. B. This rash is characteristic of a medication reaction C. The healthcare provider is being notified about the rash. D. This is a common newborn rash that will resolve after several days.
D. This is a common newborn rash that will resolve after several days.
The RN has completed the diet teaching of a pt. who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the pt. indicates that the teaching was effective? A. A salad with 3 kinds of lettuce and fruit B. Veggie soup, crackers, and milk C. Peanut butter sandwich, soda, and cookies D. Tuna fish sandwich with chips and ice cream
D. Tuna fish sandwich with chips and ice cream
While changing a pts. post-op dressing, the nurse observes purulent drainage at the wound. before reporting this finding to the healthcare provider, the nurse should note which of the pts. lab values? A. Hematocrit B. Platelet count C. Creatinine level D. WBC
D. WBC
A mother calls the RN to report that at 0900 she administered an oral dose of digoxin to her 4 month old infant, but at 0920 the baby vomited the meds. Which instruction should the RN provide to the mother? A. Administer a half dose B. Give another dose C. Mix the next dose with food D. Withhold this dose
D. Withhold this dose
A pt. who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? A. Dizziness reported after initial dose B. A change in the sleep-wake cycle C. mild sedation D. somnambulism
D. somnambulism
NGN: For each client statement, click to highlight the statements below that require follow up teaching by the RN. A. "I am at high risk for PTSD bc I have acute stress." B. "I can use holistic approaches like meditation to help my symptoms." C. "I can learn to manage my thoughts better through therapy." D. "Many people have the same response to a stressful situation as I having." E. "This diagnosis means that I am crazy." F. "I will probably need to be on medication for the rest of my life."
E. "This diagnosis means that I am crazy." F. "I will probably need to be on medication for the rest of my life."
