Hurst Review 1.2
A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at
"Come to the clinic now so that we can help you."
Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary?
"I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol."
An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication?
"I will have to watch my intake of salads, something that I really love."
A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful?
"I will not elevate the head of the bed."
The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse best begin this discussion?
"Please tell me how I can best help you control your pain."
A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse?
"There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain
An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed?
"When caring for a client who has a suppressed immune response, a N95 mask should be worn."
The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease?
"Yesterday, when I ate a hamburger and french fries, my belly really hurt."
A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. Transferred to surgical suite per stretcher with side rails up, in stable condition.
1., 3, & 5. These are written correctly with complete, concise and objective information for each statement pertaining to the client.
The nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been successful? "Exhale completely before using my inhaler." "Inhale slowly and push down firmly on the inhaler." "Rinse my mouth with water after using my inhaler."
1., 3. & 4. The client should exhale completely before using the inhaler; this response indicates the teaching was effective. The client should inhale slowly and push down firmly on the inhaler when administering the medication; therefore, the teaching was effective. The client should rinse the mouth after using the inhaler to prevent thrush.
Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit?
10 year old paraplegic in for bowel training. 7 year old in Buck's traction for a femur fracture.
Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report to the primary healthcare provider?
1Parent states infant tastes salty. Frequent coughing with thick, blood-streaked sputum. Foul-smelling, greasy stools. No weight gain since last check-up.
As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index (BMI). Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number. Enter the answer for the question below.
29.95 or 30
A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment?
4 mm Hg
The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number.
90 mg/day
The nurse is caring for a client with chronic renal failure who receives dialysis treatment. Which findings would indicate to the nurse that the client's AV shunt is patent?
A bruit is heard with a stethoscope. A thrill is felt on palpation.
A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? 1. Maintain continuous cardiac monitoring. 2.. 3. Provide alprazolam 0.25 mg PO PRN. 4. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr.
Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn
A client has been taking enoxaparin 40 mg subcutaneous once a day for 1 week. Which action should the nurse take? exhibit: Hgb - 15 g/dl (2.3 mmol/l) Hct - 42% Platelets - 110,000/ mm3 aPTT - 110 seconds INR - 1.2
Administer protamine sulfate 50 mg over 10 minutes.
A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take?
Administer the digoxin.
A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan?
An absence of corneal irritation
The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client?
An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends.
What side effects would the nurse expect to find in a client who has received too much levothyroxine?
Angina. Heat intolerance. Tremors
A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider?
Anxiety.
A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic?
Are you feeling afraid now?
The nurse is planning care for a newly admitted client who has an Arabic surname and whose spouse is wearing a traditional head covering. After verifying that the client prescriptions include a regular diet as tolerated, how would the nurse best meet the religious dietary needs for this client?
Ask the client about dietary preferences needed to meet religious guidelines.
What task by the RN should be performed first?
Assessing a newly admitted client.
The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache?
Assisting the client into a side lying position. Providing a back massage. Providing heat therapy. Using distraction techniques.
Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure?
Bibasilar crackles. Orthopnea.
What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis?
Bicycle riding. Swimming
A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child?
Blood cultures times two
A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client?
Broiled white fish, baked potato, mixed salad and tea.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain?
Carbon dioxide used intraperitoneally is irritating the phrenic nerve.
The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include?
Check shoes for rough spots in the lining, file toenails straight across, and break in new shoes gradually.
A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include?
Checking your vital signs frequently. Examining the dressing for bleeding. Listening to and percussing your lungs. Palpating around the incision site for air under the skin.
Which client should the charge nurse assign to a new RN? \
Child needing pre-operative medication prior to reduction of a fracture.
Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit?
Client diagnosed with seizure disorder
Which client should the nurse, working the Emergency Department (ED), see first?
Client with adrenal insufficiency who feels weak
Which task would be appropriate for the charge nurse to assign to a LPN/VN?
Collect data on a new client admit. Bolus feeding a client who has a gastrostomy tube.. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.
The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection?
Color Changes. Drainage. Odor. Fever. Increased Pain
The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective?
Decreased anxiety Relief of chest pain. Lowered blood pressure.
When caring for young adult clients, which developmental tasks would the nurse expect to see?
Developing meaningful and intimate relationships Giving and sharing with an individual without asking what will be given or shared in return.
A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take?
Discuss client rights with the primary healthcare provider.
What should the nurse include when educating a client about the use of nitroglycerin sublingual.
Do not swallow nitroglycerin. The medication may burn when taken. Sit or lie down when taking this medication.
A client arrives at the emergency department with a pneumothorax. A chest tube is inserted and placed to 20 cm of suction. Two hours later, the nurse notes tidaling in the water-seal chamber. Based on this data, what intervention should the nurse initiate?
Document the finding.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment?
Dramatic decrease in pain after beginning medications.
A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood?
Elevated reticulocyte count.
The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority?
Examine the client's feet for signs of injury.
What symptoms does the nurse expect to see in a client with bulimia nervosa?
Feelings of self-worth unduly influenced by weight. Recurrent episodes of binge eating. Recurrent inappropriate compensatory behavior to prevent weight gain.
A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation?
Ferrous sulfate.
A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client?
Firm, nodular liver. Increased ALT and AST levels. Bleeding from the GI tract
A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. Remove the client from the room. Close the door to the client's room. Activate the fire alarm. Obtain the fire extinguisher. Extinguish the fire.
First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client's room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire.
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect?
Flail chest
What should the nurse include when teaching a client in renal failure about peritoneal dialysis?
Following the prescribed dwell time, lower the bag to allow the fluid to drain out. The fluid that is returned should be clear in appearance. A sweet taste may be experienced when peritoneal dialysis is used.
The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP?
Hang a familiar object on the door to enhance room recognition.
An alert client presents to the emergency department with vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has?
Hypokalemia. Metabolic alkalosis.
The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications?
I may expect increased sweating while taking this drug.
The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement?
I will wear long sleeves and a hat when I go for my afternoon walks
What impaired functions does the nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain?
Impaired speech. Decreased concentration.
The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials?
In a chemotherapy sharps container.
The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway?
Jaw thrust maneuver.
The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body?
Lowers the blood glucose. Provides more energy.
A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement?
Maintain a low level of stimuli. Remove all dangerous objects from environment. Convey a calm attitude toward the client.
The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?
Metabolic acidosis.
A client is admitted to the hospital with a platelet count of 132,000 mm3 and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement?
Monitor stools for occult blood. Place on fall prevention. Restrict venipunctures.
When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism?
Nervousness Exophthalmos. Hot and sweating
A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the primary healthcare provider in applying a short arm cast, the nurse identifies which action as a priority in discharge planning?
Notify social services to arrange a home visit.
The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety?
Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. Stop the medication on the client's medication administration record.Check the client's allergy band against the list of client allergies documented in the medical record.
A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client?
Notify the primary healthcare provider.
During shift change the night charge nurse reports to the day charge nurse that a client, admitted with an ingestion of unknown drugs, received a prescription for physical restraint at 3:00 am because the client was incoherent, combative, and attempting to leave the facility. On last assessment at 7:00 am, the client was still combative. What is the best action by the day shift charge nurse?
Obtain a prescription from the primary healthcare provider.
The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase?
On-going support from weight-loss program personnel. Periodic weigh-ins with the nurse. Relapse prevention plan. Continued peer support.
A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with?
Pre-term labor client with twins at 28 weeks gestation.
The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth?
Presence of a carotid pulse with each compression.
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first?
Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke."
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea?
Progesterone
In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients?
Promote maximal stability by utilizing a wide base of support. Maintain a low center of gravity. Use both the arms and the legs when performing strenuous activity. Obtain assistance from other nurses or nurse assistants as needed.
A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance?
Provides "just in time" posters outlining the importance of pain assessment. Conducts brief in-services for each shift. Counsels nurses when pain level scale is not utilized. Ensures that a complete and clear performance standard exists. Assesses nurses' reasons for not using pain level scale.
Which nurse is providing cost effective care to a client?
Providing palliative care to a terminally ill client. Beginning discharge planning on admit. Counseling clients on cigarette smoking cessation. Educating a group of parents on the importance of childhood immunizations.
The primary healthcare provider (PHP)has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's best first action?
Question prescription with primary healthcare provider
The nurse is caring for a client on the medical unit. The client has an IV of 1000 mL D5W with 50,000 units heparin. The infusion is to run at 60 mL per hour. How many units/hour is the client receiving? Round answer to the nearest whole number. Enter the answer for the question below.
Rationale Step 1 50,000 units: 1000 mL=x units: 60 mL 1000x = 50,000 (60) 1000x = 3,000,000 1000 1,000 x = 3,000 units/hr
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action?
Read about formalin on the Material Safety Data Sheet (MSDS).
After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first?
Receiving treatment for dehydration, and is now picking at bedding and IV tubing.
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair?
Removing the hair with clippers. Using a depilatory cream.
A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance?
Respiratory alkalosis.
The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching?
Salami.
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action?
Scared and lonely and grabs the nurse's hand for comfort.
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult?
Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery.
What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition?
Suggest client eat several small meals a day, with the largest at breakfast.
The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside?
Surgical scissors.
A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother?
Takes offense to the abrupt nature of the treatment
A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate?
Tell me what the voices are saying to you
A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence?
Tenderness over the kidney
These clients have arrived at the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated first?
The client with a sucking chest wound and tension pneumothorax.
The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client?
Treat a mild episode with 10-15 grams of carbohydrate.
The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility?
Turn every two hours. Place a pillow between legs when turning. Encourage fluid intake. Encourage ankle and foot exercises.
A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client?
Use simple words.
The nurse is caring for a client prescribed vancomycin for Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. What nursing intervention is appropriate?
Verify that the client's BUN and creatinine are within normal range.
The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client?
Warm the finger prior to the stick
The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points?
When the client stops talking about suicide, the risk has increased. Warning signs, even if indirect, are generally present prior to a suicide attempt. One suicide attempt increases the chance of future suicide attempts. Report sudden behavioral changes.
What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia?
White blood cell count of 3,800. Platelet count of 90,000/µL. . Red blood cell count of 3.0 million/mcL.
Which client diagnosis would require the nurse to initiate droplet precaution?
Whooping cough
