Integration Midterm review
A nurse is reviewing a client's laboratory report of blood gas findings : HCO3- 15 mEq / L and PaCO2 30 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings?
decreased pH and and metabolic acidosis
nurse is assessing a client who has acute cocaine toxicity . Which of the following findings should the nurse expect ? ( Select all that apply . )
fever , tremor , agitation
The nurse should monitor for which of the following complications of immobility for an older adult client who had a stroke 4 weeks ago and who is unable to move independently
reddened area over the sacrum
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area.
remove the catheter and insert another into a different site
client becomes very dejected and states , " No one really cares what happens to me . Life isn't worth living anymore . " Which of the following responses should the nurse make ?
" I care about you , and I am concerned that you feel so sad "
nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate .
" It sounds like you are having a difficult time . "
nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation . Which of the following responses by the nurse is appropriate ?
the NB might be actively shedding the virus
nurse in an inpatient mental health unit is planning care for a client who is in restraints . Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit ?
the client follows directions
Know findings that place the patients at risk for pneumonia
■ Client with dysphagia ■ Client with AIDS ■ Client who has a closed head injury and is receiving ventilation ■ Client with Myasthenia Gravis
Know findings that increase the patient's risk for peptic ulcer disease (PUD)
■ Helicobacter pylori ( H. pylori ) infection ■ Nonsteroidal anti - inflammatory drug ( NSAID ) and corticosteroid use ■ Excess alcohol ingestion
A nurse is applying prescribed wrist restraints on a client. What actions should the nurse take?
Secure the restraints using a quick-release tie.
nurse is reviewing the medical record of a client who is to receive the first dose of cefoxitin via intermittent IV bolus . Which of the following findings should the nurse identify as a contraindication for the client to receive cefoxitin :
Severe allergy to amoxicillin
nurse is reviewing data for four children . Which of the following children should the nurse assess first ?
A 10-year-old child who has sickle cell anemia who reports severe chest pain .
nurse is caring for an older adult client who is disoriented and has a history of falls . Which of the following actions should the nurse take ? ( Select all that apply . )
- Check on the client hourly - Instruct the client in the use of the call light - Apply an ambulation alarm to the clients leg
nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? ( Select all that apply . )
- Position the care seat so it is rear -facing . - Secure a safety gate at the top and bottom of the stairs . - Maintain the water heater temperature at 49 ° C ( 120 ° F ) .
nurse is teaching a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include?
- Report muscle pain to the provider - Avoid taking the medication with grapefruit - Expect therapy with medication to be lifelong
A nurse manager is observing the care provided by a nurse who is in orientation to the unit . Which of the following actions by the nurse indicates the nurse manager should intervene ?
- Reviewing the healthcare record of a client assigned to another nurse - Making a copy of a client most current laboratory results for the provider during rounds - Providing information about a clients condition to hospital clergy - Participating in walking rounds that involve the exchange of client related information outside clients rooms .
planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?
- The right person is one of the five rights delegation. The nurse should seek information from the AP about his individual skill level before delegating the task .
nurse is obtaining informed consent from a client who is preoperative . Which of the following actions should the nurse take ? ( Select all that apply . )
- confirm the consent is voluntary - verify the client understand the surgical procedure
A nurse is caring for a client with a tracheostomy . The client's partner has been taught to perform suctioning . How would you know if a patient and family are ready for discharge with a tracheostomy ?
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When assessing the client , who is post op and in a skeletal traction , the nurse should expect which of the following findings that are normal ? ( Select all that apply . )
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Know the situations which requires that the nurse wear gloves ? ( Select all that apply .
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caring for a client who is at risk for falls . Know which actions should the nurse take ? ( Select all that apply .
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nurse is admitting a child who has leukemia . Which of the following clients should the nurse place in the same room with this child ?
A child who has nephrotic syndrome
nurse is admitting a client who is in the manic phase of bipolar disorder . The nurse should plan to make which of the following room assignments for the client ?
A private room in a quiet location on the unit
A nurse is admitting a client who has active tuberculosis to a room on a medical - surgical unit . Know your nursing care .
A room with air exhaust directly to the outdoor environment
A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility . What should nurse manager do ?
Address the concern with specific staff nurse
nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily . Which of the following laboratory values is the priority for the nurse to assess ?
Aspartate aminotransferase ( AST )
nurse is teaching a client who reports taking gingko biloba to improve his memory . Which of the following adverse effects should the nurse include ?
Bleeding gums
nurse is teaching a client who has hypertension and a new prescription for atenolol . Know the adverse effects of this medication ?
Bradycardia
A nurse is planning to perform a blood transfusion for a client . Know how to manage ? ( Select all that apply . )
Check vital signs before transfusion Insert an IV with a 19 - gauge needle Check the expiration date of the blood product with a second nurse .
nurse finds that a client did not receive a scheduled dose of furosemide ( Lasix ) . Which of the following should the nurse include in the incident / variance report ? ( Select all that apply . )
Client's breath sounds clear bilaterally A student nurse is assigned to administer medications to client during this shift .
nurse is having difficulty reading the provider's writing . Which actions should the nurse take ?
Contact the provider to clarify the prescription
nurse is having difficulty reading the provider's writing . Which actions should the nurse take ?
Contact the provider to clarify the prescription .
nurse is completing a medication history for a client who reports using over-the-counter calcium carbonate antacid . Which of the following recommendations should the nurse make about taking this medication ?
Drink a glass of water after taking the medication
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
Dyspnea
nurse in a mental health facility is planning care for a client who has obsessive - compulsive disorder ( OCD ) and is newly admitted to the unit . Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors ?
Plan the client's schedule to allow time for rituals .
client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take ?
Explain the risk the client faces if she leaves the facility
nurse is providing teaching to a 17 - year - old female client who has severe acne about the use of isotretinoin . Which of the following adverse effects should the nurse instruct the client is the priority to report to the provider ?
Feelings of isolation
nurse is assisting with transferring a client from the bed to a wheelchair. What actions should the nurse take?
Firmly grasp the gait belt and gently lower the client into bed
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings .
Flush the NG feeding tube with 30 mL of water immediately following medication administration
nurse is assessing a client in labor who has had epidural anesthesia for pain relief . Which of the following findings should the nurse identify as a complication from the epidural block ?
Hypotension
nurse is teaching about crib safety with the parent of a newborn . Which of the following statements by the client indicates understanding of the teaching?
I should remove extra blankets from my baby's crib
nurse is providing teaching about self - administration of insulin to the parent of a school - age child who has a new of diabetes mellitus . Which of the following statements by the parent indicates a need for further teaching ?
I will be sure my child aspirates before injecting the insulin
nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications . Which of the following actions should the nurse take first to resolve the conflict ?
Identify the problem .
nurse is teaching a newly licensed nurse about reporting suspected child abuse . Which of the following statements indicates an understanding by the newly licensed nurse ?
If suspicion of abuse exist then reporting is mandatory
nurse is teaching the parent of a newborn about car seat use . Which of the following information should the nurse include ?
Position the newborn at a 45 - degree angle in the car seat
A nurse is reviewing information about the Health Insurance Portability and Accountability Act ( HIPAA ) with a newly licensed nurse.
Information about a client can be disclosed to family members at any time.
nurse is assessing a client who has heart failure and is prescribed furosemide . Know the adverse effects of this medication ?
Potassium 2.8
When assessing the client , the nurse notes swelling of the client's arm above the PICC insertion site . Which of the following actions should the nurse take first ?
Measure the circumference of both upper arms
A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. How would you manage?
Monitor sensory perception of the lower extremities. "Sit in straight - back chairs."
Know your nursing actions to take with complications during blood transfusions .
NURSING ACTIONS - Stop the transfusion - Remove the blood tubing from the IV access - Avoid infusing further blood products into the circulatory system - Initiate an infusion of 0.9 % sodium chloride using new tubing - Monitor vital signs and fluid status - Send the blood bag and administration set to the lab for testing .
nurse is caring for a client who has a Clostridium difficile infection . Which of the following cleansing agents should the nurse use for hand hygiene ?
Nonantimicrobial soap
a client who is dying of metastatic breast cancer . She has a prescription for an opioid pain medication PRN . The nurse is concerned that administering a dose of pain medication might hasten the client's death . Which of the following ethical principles should the nurse use to support the decision not to administer the medication ?
Nonmaleficence
nurse is caring for a 17 - year - old client who is experiencing a relapse of leukemia and is refusing treatment . The client's mother insists that the client receive treatment . Which of the following actions should the nurse take ?
Notify the provider of the situation
nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin . For which of the following results should the nurse notify the provider ?
PT 45 secs
A nurse is teaching a group of health care workers about hand hygiene to prevent infection. What should be included in the teaching ?
Performing hand hygiene frequently and consistently use chlorohexedine to wash hands if the client is immunocompromised
nurse is admitting a child who has suspected epiglottitis . Which of the following actions should the nurse take first ?
Place the child on droplet precautions
nurse on the postpartum unit is caring for a group of clients with assistive personnel ( AP ) . Which of the following tasks should the nurse plan to delegate to the AP ?
Provide a sitz bath to a client who has a fourth degree laceration and is 2 days postpartum .
A nurse is planning care for a client who has an absolute neutrophil count ( ANC ) less than 1,000 / mm3 . Know your interventions
Report a temperature of 38.3 °C (101 ° F) or greater .
nurse is assessing an older adult client who is receiving digoxin . Know the findings that are a manifestation of digoxin toxicity ?
Report of anorexia
nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches . Which of the following instructions should the nurse include ?
Report of swelling of the eyelids after the dosage
nurse is preparing an in - service about fire safety . Place the steps in the in which they should be performed in the case of a fire emergency . Fire
Rescue Clients Pull Fire Alarm Isolate the Fire Extinguish the Fire
nurse is assessing a client who received magnesium sulfate to treat preterm labor . Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider ?
Respiratory Depression
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
Respiratory Rate
A nurse is monitoring a client who is on telemetry. What different between sinus rhythm and sinus bradycardia?
The P wave falls before the QRS complex
A nurse is caring for a client whose family member requests to view the client's medical record . Which of the following responses should the nurse make ?
The client must provide permission to share the records with you
nurse is observing a nurse insert an indwelling urinary catheter into a female client . For which of the following actions by the nurse should the charge nurse intervene ?
The nurse separates the client's labia with her dominant hand .
nurse is planning care for a group of clients . The nurse should identify which of the following clients as having a contraindication for restraints ?
client who is recovering from a heroin overdose having severe suicidal tendencies , having dementia , and not being able to tolerate decreased stimulation
nurse is preparing a client who is in active labor for epidural analgesia . Which of the following actions should the nurse take?
The nurse should obtain a 20-30 min EFM strip before induction of the spinal anesthesia . The strip should be evaluated as baseline information . After induction , fetal heart rate and pattern is assessed and documented every 5 - 10 min and emergency care is provided for fetal distress , such as bradycardia or late decelerations .
nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol . The nurse should suspect that the client may be experiencing tardive dyskinesia . Know the symptoms .
Tongue thrusting and lip smacking Facial grimacing and eye blinking Repetitive involuntary movement
nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler . Which of the following actions should the nurse take ?.
Use a 1.8 mm ( 0.5 in ) needle
nurse is assessing a client who is 48 hr postoperative following abdominal surgery . Which of the following findings should the nurse report to the provider ?
Yellow - green drainage on the surgical incision yellow - green drainage is indicative of an infection
nurse who works in a psychiatric unit is caring for a client who has bipolar disorder . The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately Which of the following responses by the nurse is appropriate ?
You must be very upset about something .
In terms of valve disease , when auscultating heart sounds , an extra heart sound is heard , how do we document it or call it .
_ Heart Murmur - gallop that occurs after S2 " Ken - tuck - y " - atrial gallop - gallop that occurs before S1 " Ten - es - see "
