NCLEX STUDY
The nurse is assessing a new mother's efforts to bond with her newly born infant. Identify three (3) factors that can impact effective bonding between mother and infant?
Mother's physical and emotional condition, baby physical condition, over all preparedness of mother, father and other family members.
The nurse is teaching the client about danger signs in the third trimester. What would the nurse include in the danger signs to be reported to the physician immediately?
Signs to report would include: preterm labor, rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push.
Following a hernia repair the client is instructed to avoid increasing intra-abdominal pressure. List three (3) things the nurse will educate the client to avoid increasing intra-abdominal pressure
Splint with pillow when coughing, wear abdominal brace when ambulating, avoid straining to have a bowel movement.
A nurse is communicating with a parent of a child who has a terminal illness. Identify five (5) barriers to effective communication
Blocks or shuts down conversation, Stereotyping or making assumptions about the patient, Unwarranted Reassurance, Advising Patient on what you think they should do or what would be the best course of action
A nurse is caring for a client who is considering use of a hormonal intrauterine system. What information regarding the advantages of an Intrauterine Device (IUD) should the nurse provide?
Can maintain effective for 1-10 years, is reversible, does not affect spontaneity, safe for breastfeeding mothers, 99% effective, and effective Plan B if placed with in 72 hours of unprotected sex.
A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?
Change positions slowly and lie down if dizziness occurs
A nurse is caring for a client with attention seeking behaviors. Describe attention seeking behaviors commonly noted in clients diagnosed with histrionic personality disorder.
Characterized by emotional attention-seeking behavior in which the person needs to be the center of attention; often seductive and flirtatious
A head injury client is being monitored for brain herniation. Which clinical manifestation is noted with brain herniation?
Cheyne-Stokes reparations
A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high calorie, low protein diet. Which of the following meal selections is appropriate for this client?
Chicken breast, mashed potatoes, spinach.
A nurse is caring for a client diagnosed with bipolar syndrome who is prescribed lithium. What dietary education should be reinforced to this client?
Clients must maintain adequate hydration and normal sodium intake when taking lithium.
Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent
Cold stress
List co-morbidities of anorexia nervosa.
depression bipolar disorder panic and anxiety disorders post-traumatic stress disorder(PTSD) obsessive compulsive disorder (OCD) obsessive compulsive personality disorder (which is different from OCD) borderline personality disorder sleep disorders substance abuse or dependence
Aortic stenosis
manifests as Hypotension and weak pulses as a result of decreased cardiac output and A narrowing of the aortic valve cause a characteristic murmur in children who have aortic stenosis.
Following a motor vehicle accident of a 21-year-old male, the client is pronounced brain dead. The family states, "We would like to donate his organs and help someone who needs them." How will the nurse respond knowing their responsibility regarding organ donation?
"I will get you information regarding the next steps to organ donation process, as well as consent forms, feel free to ask me any questions you have throughout this process.
A nurse is caring for a client prescribed the atypical antipsychotic agent clozapine. Which of the following client statements indicates a need for further education?
"I will increase my calorie intake to prevent weight loss."
A nurse is completing an Apgar score on a newborn. What is assessed when obtaining an Apgar score? What does a score of 5 indicate?
- Heart rate: o 0 - No heart rate o 1 - Fewer than 100 beats per minute indicates that the baby is not very responsive. o 2 - More than 100 beats per minute indicates that the baby is vigorous. - Respiration: o 0 - Not breathing o 1 - Weak cry-may sound like whimpering or grunting o 2 - Good, strong cry - Muscle tone: o 0 - Limp o 1 - Some flexing (bending) of arms and legs o 2 - Active motion - Reflex response: o 0 - No response to airways being stimulated o 1 - Grimace during stimulation o 2 - Grimace and cough or sneeze during stimulation - Color: o 0 - The baby's entire body is blue or pale o 1 - Good color in body but with blue hands or feet o 2 - Completely pink or good color - Scores between four and six indicate that some assistance for breathing might be required. Scores under four can call for prompt, lifesaving measures. At the five minute APGAR, a score of seven to ten is normal
Explain the steps involved in providing an intermittent enteral feeding.
- In providing an intermittent enteral feeding, here are the steps. First, prepare the formula and a 60-mL syringe. Next, remove the plunger from the syringe and then hold the tubing above the instillation site. Open stopcock from tubing and insert barrel of the syringe with end up, fill that syringe with 40-50 mL of formula. Hold the syringe high for formula to empty by gravity and refill the syringe until the amount of feeding is instilled. To prevent clogging of the tube, follow up with at least 30 mL of tap water for flushing.
A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this disease process.
- Increase k+ and Ca - Decreased Na - Increased BUN and Creatinie - Decreased cortisol
A nurse is caring for a client following a hypophysectomy. What postoperative nursing actions should be taken for this client?
- Monitor electrolytes - Monitor ECG - Monitor for bleeding and cerebrospinal fluid leak - Administer corticoids and stool softeners
What are manifestations of newborn hypoglycemia and what measures should the nurse take if hypoglycemia occurs?
- Poor feeding, tremors, hypothermia, diaphoresis, weak cry, lethargy, flaccid muscle tone. - Obtain a heel stick, maintain skin to skin for warmth, encourage feeding, give IV dextrose.
Short-term memory loss, confusion, and disorientation occurs immediately following the electroconvulsive therapy (ECT) procedure. List three (3) actions the nurse will implement to maintain client safety through the procedure.
- Provide frequent orientation. - Provide a safe environment to prevent injury. - Assist the client with personal hygiene as needed
Electroconvulsive therapy (ECT) is the induction of a grand mal (generalized) seizure through the application of electrical current to the brain and is effective treatment for severe depression, schizophrenia spectrum disorders, and acute manic episodes. List three (3) adverse effects or risks associated with this therapy
- Short term memory loss - Stress on the heart - Risk of injury and aspiration during the seizure
Immediately after rupture of amniotic membranes, a client states that she can feel something in her vagina and the nurse is able to visualize the umbilical cord protruding from the introitus. Discuss emergency nursing care measures the nurse should take.
- The nurse would call for assistance immediately, Notify the provider, Put on sterile gloves, insert two fingers into the vagina and apply finger pressure on either side of the cord, Apply a warm, sterile, saline-soaked towel to the visible cord, provide continuous fetal monitoring, Administer oxygen to improve fetal oxygenation, Initiate IV access
A nurse is providing education about cough etiquette to a client with an upper respiratory infection. What information should the nurse include?
- Turning your head away, coughing into your elbow, not hand, and covering both your mouth and nose to prevent spreading of illness through droplets, and always washing your hands after.
Vaso-occlusive crisis
- a painful episode, acute can include; severe pain, usually in the bone joints and abdomen, swollen joints hands and feet, hematuria, obstructive jaundice and visual disturbances.
Nursing care for a child with Hemophilia
- avoid all unnecessary punctures, use subcutaneous rather than IM whenever possible, vein punctures are preferred over fingers sticks for sampling, monitor for bleeding, control any localized bleeding that occurs. the nurse should apply pressure for 5 min after injections, venipuncture, or needle sticks. It will feel like an eternity!
Expected finding of physical neglect
- failure to thrive, malnutrition, lack of hygiene, frequent injuries, dull affect, school absences, self-stimulating behaviors.
The nurse is reviewing the lab on a client admitted to the labor unit with a medical diagnosis of preeclampsia. What are reportable laboratory finding in the client with preeclampsia?
- liver function tests, kidney function tests and also measure your platelets, urinalysis, fetal ultrasound, nonstress test and Biophysical profile.
A nurse is admitting a new client on the mental health unit. During the conversation the nurse should be aware that countertransference can occur if the nurse display what feeling?
-Countertransference occurs when a health care team member displaces characteristics of people in her past onto a client. Strong personal feelings would be indict of this.
A nurse is caring for a client with glomerulonephritis. What interventions regarding nutritional intake and restrictions should be taken?
-Encourage adequate nutritional intake. -Possible restriction of sodium and fluid. -Restrict foods high in potassium during periods of oliguria. -Provide small, frequent meals of favorite foods due -to a decrease in appetite. -Refer the child for dietary consultation if indicated. -Avoid added salt and salty foods such as chips
A nurse is caring for a client with a spinal trauma who is experiencing neurogenic shock. What manifestations and nursing care measures should the nurse expect and take?
-Low blood pressure- monitor and give fluids and meds as prescribed -Slowed HR- monitor ECG -Dizziness and n/v -Report changes to HCP
lease describe the five rights of delegation including an example of each:
-Right Task- tasks that require little supervision, are low risk, are repetitive, mostly noninvasive, and have a predictable outcome. -Right Circumstance- appropriate patient setting, available resources, and other relevant factors like the environment, acute vs long term care. -Right person- delegating to the right person for the task -Right Direction/Communication- clear description of ask, and expectations as well as limits. Ongoing and open communication during the completion of the task, ex progress reports. -Supervision/Evaluation- appropriate monitoring for the task, evaluation, and intervention as needed, as well as feedback.
Aspirin for RA
.Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases.
What are five (5) risk factors that affect female fertility?
1. Age 2. Smoking 3. Sexual history- past STI's/STD's 4. Weight 5. Alcoholism
A nurse is providing community education regarding risk factors for ovarian cancer. Identify five (5) risk factors associated with the development of ovarian cancer. (Review the Med Surg RM)
1. BRCA 1 and/or 2 gene mutation 2. Full tem pregnancy after 35 years old 3. Hormone replacement therapy 4. Obesity 5. Family history of ovarian or breast cancer
A nurse is providing education to a new mother regarding storage of breast milk. Identify five (5) teaching points to discuss with the new mother regarding storage of breast milk.
1. Breast milk can be stored at room temperature under clean conditions up to 8 hrs. 2. It may be refrigerated in sterile bottles for use within 8 days. 3. It may be frozen in sterile containers for up to 6 months. 4. it may be stored in a deep freezer for up to 12 months. 5. Do not refreeze thawed milk
A nurse is caring for a client with multiple risk factors for peripheral vascular disease. List four (4) risk factors associated with peripheral vascular disease.
1. Diabetes 2. Overweight/ obese 3. Hypertension 4. High LDL cholesterol
What are five (5) essential components of therapeutic communication when responding to a client who is postoperative following a mastectomy?
1. Good listening 2. Repeat things back for clarification 3. Be empathetic not sympathetic 4. Sit down or come down to their level 5. Allow for pauses or silence for them to reflect in between questions.
A nurse is providing education to a client with polycystic kidney disease (PKD). What are the four (4) disease management areas to review with this client?
1. Monitor blood pressure and weight daily 2. To notify HCP if they have a fever 3. Low sodium diet 4. Notify HCP is there are changes to urine or bowel movements
Provide three (3) possible manifestations of hypokalemia.-Suggested Med-Surg Learning Activity: Fluid and Electrolyte Imbalances
1. Muscle cramps/ spasms 2. GI upset/ abdominal distention 3. Heart palpitations/ rhythm changes ST sagging, T depression
A nurse is providing pre-procedural instructions to the client having a barium swallow. What instructions should be included in this teaching? Select all that apply.
1. NPO after midnight- yes 2. No smoking after midnight- yes 3. Stools will be white for 24 to 72 hours post procedure- yes 4. The feeling of abdominal fullness is normal post procedure 5. Client can have a regular diet before the procedure
An 8-year-old client has been admitted for a vaso-occlusive crisis secondary to sickle cell anemia. Identify three (3) priority nursing actions that will be necessary to manage this client's care
1. The triad of treatment for a client experiencing a sickle cell crisis is: hydration, oxygenation, and pain management. Hydration will provide more circulating volume for the sickled cells to move through. Supplemental oxygen will provide more oxygen molecules to attach to the red cells, providing more oxygen to the tissue and joints. Pain management is typically the primary reason this client presents for treatment. The pain becomes unbearable. Other interventions such as nutrition and keeping the client safe from infection should be addressed but are not priorities.
urine specific gravity
1.010 to 1.025
Magnesium
1.3-2.1 mEq/L HIGH- monitor for soft tissue calcifications, monitor for facial flushing, administer LOOP diuretics LOW- administer oral or IV mag, encourage foods high in mag, discontinue loop diuretics
What are three (3) points the nurse should educate the parents of an epileptic client on regarding seizure medications?
1.Educate on the need for rest 2.Adherence to the medication schedule- missing a dose may put the child a higher risk for having a seizure 3.Education on avoiding things that trigger the child seizure, flashing lights, stress, lack of sleep and so on.
Identify four (4) points to discuss with parents of a preschooler regarding nutrition to ensure a balanced and healthy diet.
1.Minimum 2 servings of dairy 2.Minimum 2 servings of fruit and vegetables a day 3.Lean meat such as poultry and sea food, eggs and legumes 4.Whole grains should also be included, whole wheat bread and cereals
A child was sent home from school with head lice. The child's mother has called the help line nurse for guidance. What are three (3) measures the nurse will inform the mother about to address the infestation of pediculosis capitis?
1.Use 1% permethrin shampoo Spinosad 0.9% topical suspension. 2.Remove nits with a nit comb 3.Wash clothing, bedding in hot water with detergent difficult cases: use malathion 0.5%
Identify three (3) clinical manifestations of hydrocephalus in an infant.
1.bulging fontanel, which is the soft spot on the surface of the skull. 2.a rapid increase in head circumference 3.eyes that are fixed downward.
Sodium
135-145 mEq/L HIGH- report to HCP, administer HYPOtonic fluids, administer diuretics, implement seizure precautions. LOW- report to HCP, administer HYPERtonic fluids, encourage sodium intake, implement seizure precautions
Cardioversion
1Sedatives are generally administered to clients prior to cardioversion to reduce anxiety and minimize the discomfort associated with the procedure. Anticoagulants can be beneficial during cardioversion due to their ability to prevent blood clots that can be released into the client's circulatory system after cardioversion. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion because these medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion.
Albumin levels
3.4 to 5.4 g/dL
Potassium
3.5-5 mEq/L HIGH- monitor for weakness, irritability, restlessness, Provide a K restricted diet, administer IV fluids with dextrose and regular insulin, monitor for oliguria. Cardiac monitoring. LOW- encourage K intake, monitor for weakness, irritability, restlessness, observe for shallow ineffective respirations. Cardiac monitoring
A nurse is providing triage at the scene of an industrial fire. An adult client has sustained burns to the head and neck, anterior trunk and left arm and hand. Using the rule of nines, what percentage of this client's body surface should the nurse document as burn injury?
36
The following clients have been admitted in the emergency department. Which of the following clients requires immediate attention?
48 year-old male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVC's.
Calcium
9.0-10.5 mg/dL HIGH- monitor for bone pain and constipation, administer NS. LOW- administer oral or IV calcium, encourage adequate fiber and leafy green vegetables.
A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?
A 90 degree angle
aneruysm precautions
A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights.
Cushing triad
A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure
A registered nurse (RN) is preparing to delegate client care to a licensed practical nurse (LPN). Identify client care activities that are in the LPNs scope of practice.
A nurse cannot delegate, teaching, assessing and administer IV medications and high-risk meds unless the LPN is certified in IVs. LPNs can assist in administering oral medications, getting vitals, assisting with ADL's.
What is a submersion injury? Identify three (3) nursing care measures for a client with this injury
A submersion injury is when a person becomes hypoxic due to submersion in water. Oxygen as need, may need mechanical ventilation (et tube), chest physiotherapy, monitor for Complications that can occur 24 hr after (ex; cerebral edema, resp. distress)
Hypertonic dehydration
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. Sodium greater than 145 mEq/L, can be an indication of excessive free water loss resulting in hypertonic dehydration.
A client with osteoporosis is prescribed alendronate. What client education should the nurse provide to ensure optimal absorption of the medication?
Advise the client to take the medication on an empty stomach with at least 8 oz of water.
ABCDE
Airway Breathing Circulation Disability Exposure
A nurse is caring for a client admitted with wheezing and coughing due to an allergic reaction to a newly prescribed medication. Which of the following medications should be administered first?
Albuterol 3 mL via nebulizer
A nurse is caring for a client with delirium. What is the onset and clinical manifestations of this disorder?
Altered level of consciousness Restlessness, agitation, and fluctuating mood is common. "Sundowning" (confusion during night) may occur. Behaviors may increase or decrease daily. Personality change is rapid. Some perceptual disturbances may be present (hallucinations and illusions)
ECG with hypokalemia
Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.
A nurse is placing an IV line on an older adult client. List three (3) considerations the nurse should take when placing an IV line in this client?
Always assess patients for allergies to iodine, latex, and adhesives. Attempted the Distal vein first in nondominant hand Insert and IV at a 15-20 degree angle
A nurse has an order to administer mannitol to a critical care client. What should the nurse expect following mannitol administration?
An increased blood glucose, mannitol is a sugar alcohol.
A nurse is caring for several clients prescribed heat/cold therapies. Which of the following clients are at risk of injury from these therapies?
An older adult client prescribed heat therapy for hip pain., A client with diabetes prescribed cold therapy for a fractured toe., A fair-skinned, school age client prescribed heat therapy after a soccer injury., A cognitively impaired older adult prescribed alternating heat and cold therapy.
The client states that she is going through a divorce and her anxiety is extremely high. The nurse needs to assess the client's ability to adapt and cope with this situation. What would this includes?
Assessing the clients ability to adapt and cope would include health status and functional abilities, living arrangements and employability, personality factors,client, caregiver, and family assessments, levels of information, and medication use and Supplemental services
A client is prescribed propranolol. Which of the following client history findings would require the nurse to clarify this medication prescription?
Asthma
A nurse is preparing to participate in change of shift report. What should be included in this report and where should it be done?
At the bed side, include the patient, include any important information, baseline vitals and LOC of the patient and any tests or procedures to be done as well as medication that need to be given.
A nurse is caring for a client with dysrhythmias. Identify what cardioversion is and its application to manage dysrhythmias. Identify dysrhythmias that can be cardioverted
Atrial fibrillation, atrial flutter, atrial tachycardia, ventricular tachycardia
A client diagnosed with nephrotic syndrome is experiencing increasing edema. What abnormal laboratory values does the nurse expect that is causing the edema?
Decreased plasma albumin causes edema.
What behaviors would indicate to the charge nurse that one of the nurses could be experiencing countertransference?
Displaced emotions typically anger with the client and avoiding being by them
A nurse is preparing to administer ipratropium by metered dose inhaler. What adverse effects should the nurse instruct the client to monitor for?
Dizziness, headache, nervousness, blurred vision, sore throat, bronchospasm, cough, hypotension, palpitation, n/v, rash and allergic reactions.
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take when administering this medication?
Do not expel the air bubble from the prefilled syringe
A nurse is preparing to educate a client with gout who has a new prescription for allopurinol. What should the nurse include in the client instructions?
Do not take this during an acute attack, have an annual eye exam, monitor for n/v, rash and increased gout pain.
A nurse is to instill ear drops to a 2 year-old child. To straighten the ear canal, the nurse should pull the auricle of the ear:
Down and backward
A nurse is caring for a client scheduled for a chorionic villus sampling (CVS) procedure. What client education should the nurse provide prior to the procedure? Identify potential complications associated with CVS.
Education: Tell the patient what it is; Chorionic villus sampling (CVS) is assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance. CVS is a first-trimester alternative to amniocentesis with one of its advantages being an earlier diagnosis of any abnormalities. Complications: Spontaneous abortion, Risk for fetal limb loss, Miscarriage, Chorioamnionitis and rupture of membranes.
Glasgow Coma Score
Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken, but inappropriately. 2 = Sounds are made, but no words. 1 = Vocalization does not occur. Motor (M) - The best motor response, with responses ranging from 6 to 1 6 = Commands are followed. 5 = Local reaction to pain occurs. 4 = There is a general withdrawal to pain. 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. 1 = Motor response does not occur. Responses within each subscale are added, with the total score quantitatively describing the client's level of consciousness. E + V + M = Total GCS
A client taking lithium should be cautioned about drug interactions with which below medication?
Fluoxetine
What action should a nurse implement to prevent clogging of the NG tube after medication administration?
Flush the NG tube with water after each medication and at the end of medication administration
A nurse is caring for client who is 24 hr postoperative following a below-the-knee amputation of his right leg. What postoperative measures should the nurse provide to the client to avoid hip or knee flexion contractures?
Have the client lie in a prone position.
Bryant traction
Having the buttocks elevated slightly off of the bed is appropriate. The child's hips are flexed at a 90° angle with the legs suspended by pulleys and weights. The weights must hang freely from the bed to maintain alignment.
A client with hearing loss has been fitted for a hearing aid. Which of the following teaching points are important for the nurse to discuss with the client?
Hearing Aid Nursing Considerations Use the lowest setting that allows hearing without feedback. To clean the ear mold, use mild soap and water while keeping the hearing aid dry. When the hearing aid is not in use, turn it off or remove the batteries to conserve battery power. Keep replacement batteries on hand. The correct answer is: Use mild soap and water to clean the ear mold.
A client is experiencing shortness of breath, fatigue, and jugular vein distention. The nurse auscultates a third heart sound (S3). What should the nurse anticipate as the cause of these signs and symptoms?
Heart Failure
Disulfiram is taken by a client daily for abstinence maintenance. What is an adverse effect of this therapy?
Hepatoxicity
A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?
Hourly rounding by the nurse.
A nurse is caring for an adolescent client diagnosed with mononucleosis. Which of the following statements by the client's parent indicates a need for further education?
I will give him aspirin as needed for fever and discomfort."
A nurse has provided education to a client with hypothyroidism who has a new prescription for levothyroxine. What statements by the client would indicate they understand the instructions?
I will take my med daily on an empty stomach an hour before breakfast. I should call my HCP if I experience angina, palpitations and dysrhythmia.
Which of the below is an example of secondary prevention level health care goal to control communicable diseases?
Implement partner notification with communicable disease exposure.
What are some common complications related to internal pacemaker insertion?
Infection, hematoma, pneumo/hemothorax, improper pacing, arrhythmias, myocardial damage, electrolyte imbalances, battery dysfunction, incorrect settings.
A nurse is providing care to a client with staphylococcus epidermidis, who is prescribed vancomycin. Identify the adverse effect associate with this antibiotic therapy?
Infusion reaction
The nurse is teaching the parents of an infant with tonsillitis caused by group A B-hemolytic streptococcus about the importance of compliance with antibiotic therapy. What teaching regarding this infection is important to share with the parents?
Instruct the family to seek medical attention when the child presents with manifestations of tonsillitis, or worsening symptoms such a flank pain. Instruct to take the entire prescribed dose even if the child seems to feel better.
A nurse is caring for a client undergoing infertility testing. The client asks why a hysterosalpingography has been ordered. What is the nurse's best response?
It is an x-ray that assess the patency of the fallopian tubes
List three (3) client teaching points following permanent pacemaker insertion
Keep medical card with you at all times, do NOT raise your arm above your head for 2 weeks after insertion, can NOT have MRIs after insertion.
A client with schizophrenia presents with alogia. How would one describe alogia?
Lack of thought and speech.
A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness and scaling at the treatment area. Which of the following should the nurse instruct the client to do?
Liberally apply prescribed lotion to the area.
A nurse is caring for a hypokalemic client. Identify three (3) potential causes of hypokalemia.
Loss in urine due to prescription medications, vomiting, diarrhea, and not consuming enough potassium in your diet.
A menopausal client is having difficulty getting to sleep and asks what actions she should incorporate in her daily routine to promote sleep. The nurse would encourage, which of the below measures to promote sleep?
Measures to promote sleep include: Exercise regularly; limit exercise at least 2 hr before bedtime. Establish a bedtime routine and a regular sleep pattern. Arrange the sleep environment for comfort. Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime. Limit fluids 2 to 4 hr before bedtime. Engage in muscle relaxation if anxious or stressed. The correct answer is: Limit alcohol and nicotine prior to bedtime.
What are the indications for prescribing hormone replacement therapy (HRT) for a menopausal client?
Medication are used to reduce hot flashes, vaginal dryness and dyspareunia and other symptoms of menopause.
A nurse is caring for a client with obsessive compulsive disorder (OCD). Define this disorder and the common pharmacological therapies to assist with management of this disorder.
Medications may be Buspirone (atypical anxiolytic), paroxetine (SSRI)
A client has been prescribed oxybutynin for treatment of overactive bladder and has been experiencing anticholinergic side effects. List two (2) actions the client will take to prevent adverse effects of the medication therapy.
Monitor EKG due to risk for prolonged QT Anticholinergic effects cause "drying up" so increase fluid and fiber and avoid driving if blurred vision or other impairment.
A nurse is caring for a client with hyperemesis gravidarum. Describe nursing care and medication therapy for the client diagnosed with hyperemesis gravidarum
Monitor I&O, skin turgor, vital signs, weight, IV LR, vitamin B6 and other supplements as prescribed. Administer antiemetic and corticosteroids and monitor baby as able.
An antepartal client is Rh negative and understands that she will receive a RhoGAM injection during her pregnancy. The client asks the nurse if she will also receive a RhoGAM injection after the birth of her baby. The client will receive RhoGAM after the birth if blood tests are:
Mother Rh negative; Coombs negative; baby Rh positive
An oncology client is prescribed filgrastim. What are the indications for this therapy?
Neutropenia and myelodysplastic syndrome
Central Venous pressure
Normal 2-8 low indicated fluid deficiency high indicates fluid over load
The nurse is educating a client post lumbar laminectomy. What are three (3) potential complications of this procedure?
Orthostatic hypotension, neurogenic shock, and spinal shock
A client has been prescribed raloxiphine. As the nurse you know that raloxiphine is used to treat:
Osteoporosis
A 55-year-old client has levothyroxine ordered. Which of the below past medical history concerns may contraindicate with her medication management of hypothyroidism?
Osteoporosis Caution should be used to prevent overtreatment with levothyroxine and monitor drug levels. Chronic overtreatment can cause atrial fibrillation and an increased risk of fractures from bone loss, especially in older adults.
What is a contributing factor associated with conduct disorder for an 11-year-old client that the nurse should be aware of?
Parent with a history of psychological illness Conduct disorder has an association with parental history of psychological illness. The other options do not have a direct correlation to conduct disorder. Clients who have conduct disorder demonstrate a persistent pattern of behavior that violates the rights of others or rules and norms of society. Categories of conduct disorder include the following.
A nurse is instructing a client who has a new prescription for nitroglycerin transdermal patch about administration. What instructions should the nurse include?
Patches should never be cut, placed on hairless section of the skin and rotate sites to prevent irritation, and wash skin with mild soap and water after removing old patches. Remove patches at night to attempt to avoid tolerance build up.
A client with peptic ulcer disease takes cimetidine. Which of the below outcomes can occur if H2-receptor antagonists, such as cimetidine are taken long term?
Pneumonia
A nurse is assisting a client with his meal that is at risk for aspiration due to a stroke. What interventions should the nurse take to prevent aspiration?
Position the client in Fowler's position., Instruct the client to tuck his chin when swallowing., Keep the client in semi-Fowler's position for at least 1 hour after the meal., Support client's upper back, neck and head during feeding.
A client has been prescribed vasopressin for the treatment of diabetes insipidus. What is the expected pharmacological action of this medication?
To increase reabsorption of water in the renal tubules.
A nurse is preparing to administer a rubella vaccination. What are contraindications to this immunization?
Pregnancy, Immunocompromised household members, Hypersensitivity, Allergy to gelatin.
A nurse is caring for a client who has a new prescription for raloxifene. What are contraindications for this medication that the nurse should discuss with the client?
Pregnancy, history of venous thromboembolism, stop 3 days before period.
A 52-year-old client with a history of angina has been prescribed transdermal nitroglycerin. Which of the following adverse effects is not seen with this therapy
Productive cough
A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux.
A nurse is caring for a client following a sexual assault. Which of the following tasks should the RN delegate to the LPN?
Providing emotional support to the client.
A nurse is helping parent's select appropriate independent activities for their 8 year old child. Which of the following would be an appropriate activity?
Providing frequent trips to the library
A nurse is reviewing labs for a newly admitted client with polycythemia vera. Which lab value trends would be seen with this disorder?
RBC 7.4 million/uL RBC 7.4 million/uL is present with polycythemia. The values for iron, hemoglobin and platelets do not correlated with the values seen with polycythemia vera.
A nurse is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a BMI of an overweight client?
Rationale: Body mass index (BMI) of 25 Healthy weight is indicated by a BMI of 18.5 to 24.9. Overweight is defined as an increased body weight in relation to height. It is indicated by a BMI of 25 to 29.9. Obesity is an excess amount of body fat. It is indicated by a BMI greater than or equal to 30. BMI = weight (kg) ÷ height (m2) The correct answer is: 25
List three (3) actions to take during the analysis or data collection step
Recognize patterns in the data collected, compare the data with the expected standards and/or ranges, make conclusions that guide nursing care
A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the below clients?
Reference: RM Pharm RN 6.0 Chp 7 A client with glaucoma.
The charge nurse takes a telephone order for morphine 50 mg IVP every 3 hours. After hanging up the phone, the nurse feels this order is not safe. List three (3) strategies to prevent errors of miscommunication when receiving telephone orders.
Repeat the order at the end of phone call, verify the patient name and date of birth before and after, clarify dosage and route.
A nurse has just administered a wrong medication to a client. Which of the following actions should the nurse take next?
Report error to the provider.
A nurse manager is providing staff education on the correct use of restraints. Which of the following should be included in this education? Select all that apply.
Restraints should never interfere with treatment., Restraints should never be used because of short staffing., Staff must document type and location of the restraint and time applied., Assess neurovascular and neurosensory status every 2 hours.
A critical care client is in need of adenosine. What is the indication of this medication and how is this medication administered?
SVT, administer with an IV bolus with NS following.
Which of the following agents is used for motion sickness?
Scopolamine Scopolamine is an anticholingeric that interferes with the transmission of nerve impulses traveling from the vestibular apparatus of the inner ear to the vomiting center of the brain
A nurse is caring for a client with a spinal cord injury. What are possible causes of autonomic dysreflexia that the nurse should monitor for?
Severe headaches, flushing of the face and neck, bradycardia, and hypertension.
A client has a new prescription for salmeterol. The nurse is teaching the client about adverse effects of the medication. What instructions should the nurse include in thus education?
Side effects of salmeterol include headaches, nervousness, heart palpitations, tachycardia, abdominal pain, diarrhea, n/v, muscle spasms, general soreness, trembling. A paradoxical side effect can be bronchospasm and cough.
What are the expected physical growth mile markers for a 6 months infant?
Stranger danger and being upset when removed from parents are evident, fruit juices and food can be added to the child's diet around 6months of age, get seasonal influenza vaccine starting at 6months of age.
A nurse is caring for a client experiencing hypovolemic shock. How should the nurse position this client?
Supine with legs elevated
A 45-year-old client is taking methylprednisolone. What pharmacological action should the nurse expect with this therapy?
Suppression of airway mucus production.
A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?
Take the medication on an empty stomach to maximize absorption.
What to do for a client reporting a throbbing head ache after a lumbar puncture
The client who has had a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and increasing fluids will facilitate resolution of the headache. The client should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid.
Lab values with chronic kidney disease
The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg
Thyroid storm
The nurse should expect the client to have a fever because of the excessive thyroid hormone release. The nurse should expect one of the early manifestations of thyroid storm to include systolic hypertension because of the excessive thyroid hormone release. The nurse should expect the client to have tachycardia because of the excessive thyroid hormone release.
possible complication following subtotal thyroidectomy
The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia.
A client's lab values indicate a serum sodium level of 150 mEq/L. How could this affect the client's vital signs?
This is considered hypernatremia (normal range is 135-145), typically with this condition you see dehydration and thirst, as well as fatigue. The patient's vital signs may show high heart rate and low blood pressure.
When working with an interpreter in communicating care needs to the client, which action by the nurse is inappropriate?
Use a family member to communicate care needs.
A nurse is providing discharge education to the parents of a child experiencing acute diarrhea secondary to gastroenteritis. Which of the following should the nurse include?
Use prepared oral replacement solutions (ORS).
Meningitis types
Viral there is no vaccine against this fungal typically from the sinuses from the organism Cryptococcus neoformans. Bacterial typically from organisms like; Neisseria meningitis, streptococcus pneumoniae, or haemophilus influenzea. Monitor patients intercranial pressure throughout course of disease. Droplet precautions are needed until after 24 hours of antibiotics/treatments.
Right hemispheric stroke symptoms include;
Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke. Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke.One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.
vitamins for wound healing
Vitamin A is correct. Vitamin A is important for tissue synthesis, wound healing, and immune function. Vitamin B12 is incorrect. Vitamin B12 assists in the development of red blood cells and maintenance of nerve function but has no specific role in wound healing. Vitamin C is correct. Vitamin C is important for capillary formation, tissue synthesis, and wound healing. Vitamin D is incorrect. Vitamin D functions in maintaining serum levels of calcium and phosphorus, but has no specific role in wound healing. Vitamin E is correct. Vitamin E functions as an antioxidant to protect from cell damage, and enhances Vitamin A utilization
Compare and contrast the manifestations of left-sided and right sided heart failure
a. Right sided- fatigue, increased peripheral venous pressure, ascites, distended jugular veins, weight gain, dependent edema, GI upset and anorexia. b. Left sided- Sleep apnea, elevated capillary wedge pressure, pulmonary congestion (cough, crackles, tachypnea), restlessness, confusion, orthopnea, tachycardia, cyanosis.
The nurse is caring for a child with epiglottitis. What are three (3) expected findings during the assessment of this client? List three (3) nursing interventions the nurse will be expected to carry out.
a.Expected- Tongue protruding, inspiratory stridor, anxiety with respiratory distress, sore throat, high fever, restlessness, sit with chin pointing out, and mouth open. b.The nurse should not examine throat or use tongue blade. Use oxygen and high, monitor resp status
Hirschsprung disease
also known as aganglionic megacolon and is characterized by an area of the large intestine without nerve innervation. The child will probably require two surgeries over an 18- to 24-month period before normal bowel function is obtained. The initial surgery creates an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest
Rheumatic fever
an inflammatory disease that begins with a strep throat from a streptococcal infection and can progress to rheumatic heart disease, which is a condition in which the heart valves are damaged by rheumatic fever. Auscultating heart sounds is the priority assessment because tachycardia and cardiac murmur indicate cardiac involvement, which can result in serious, life-threatening, and life-long complications.
A nurse is caring for a client prescribed digoxin. Which the following should alert the nurse to possible digitalis toxicity?
anorexia and weakness
A nurse is caring for a client that exhibits signs and symptoms of aspiration during their enteral feeding. What is a priority intervention the nurse should carry out?
first stopping the feeding, then turn the patient to the side for positioning, suction the airway, provide oxygen if indicated or needed, monitor vital signs for temperature rising or rapid respiratory rate, monitor for decreased oxygen saturation, auscultate breath sounds for increased congestion, notify the provider, and obtain a chest x-ray.
Wilms' tumor
is nephroblastoma, tumor on the kidney. This tumor is encapsulated, and palpation can cause it to rupture, which would allow seeding of the tumor into the pelvic cavity. do not palpate abdomen
Describe tertiary prevention measures and provide one (1) example
prevent the long-term consequences of a chronic illness or disability and to support optimal functioning for the patient. An example of this would be preventing pressure ulcers on a patient unable to independently adjust their weight.
A client who is taking ciprofloxacin has called the nurse and stated that she is having pain, swelling and redness at the Achilles tendon region. What priority action should the nurse implement?
· The side effects are generally mild, all fluoroquinolones can cause tendon rupture, usually of the Achilles tendon. Have the patient wrap ankle in an ace wrap, ice and elevate for swelling, and come into the clinic to be assessed by a health care provider and may be prescribed a new antibiotic.
Meconium aspiration
syndrome where meconium in breathed into the lungs during utero or during the baby's first few breaths. This condition can result in the air entering but not leaving the lung creating over extended alveoli that may result in rupture or pneumothorax.
BMI levels
underweight: less than 18.5 normal: 18.5-24.9 overweight: 25-29.9 obese: more than 30
What is one common adverse effect of an inhaled anticholinergic, such as ipratropium? Provide two (2) points for a nurse to include when teaching the client on this medication.
· Adverse effects are dizziness, headache, nervousness, dry mouth, blurred vision, sore throat, bronchospasms, cough, hypotension, and palpitations. · Education- take medication as directed, if missed dose don't double dose take as soon as you remember and space remaining doses out evenly. Use lozengens and sugar free gum to deal with sore throat and dry mouth.
A client with severe asthma is on long-term corticosteroid therapy. Identify four (4) adverse effects of prednisone? How can these effects be prevented or minimized?
· GI upset- take medication with meal · Adrenal suppression- take in the morning · Increased risk of infection- good hand hygenine and avoid other who are sick · Increased blood glucose for diabteics- closely monitor blood glucose and take insulin to maintain good levels.
List the six (6) Quality and Safety Education for Nurses (QSEN) competencies and explain their importance.
· Patient-centered care, Evidence-based practice, Teamwork and collaboration, Safety, Quality improvement, Informatics. The QSEN competencies were developed to be a tool to promote better education for nurses in healthcare quality and safety. To develop a safe and high-quality system of care requires that all healthcare professionals take responsibility to learn and apply skills associated with improving the wider system of care
What are defined gross motor skills for a 4-year-old client who is a preschooler?
•Becoming more skilled at running, jumping, early throwing, and kicking •Catching a bounced ball •Pedaling a tricycle (at 3 years); becoming able to steer well at around age 4 •Hopping on one foot (at around 4 years), and later balancing on one foot for up to 5 seconds •Doing a heel-to-toe walk (at around age 5)