NU222 Final Exam Prep
A 68 year old male patient tells the nurse that he is worried because he does not respond to sexual stimulation the same way he did when he was younger. Which is the nurse's best response to the patient's concern?
"Tell me more about how your reaction has changed."
A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis? Which initial response by the nurse is best?
"Tell me more about what you are thinking regarding dialysis."
the nurse has just finished teaching a hypertensive patient about a newly prescribed drug Ramipril (Altace) which patient statement indicates that more teaching is needed
" I can expect some swelling around my lips and face"
Which question should the nurse ask when assessing a 60 year old patient who has a history of benign prostatic hyperplasia (BPH)?
"Has there been a decrease in the force of your urinary stream?"
Which statement by a 50-year-old female patient indicates to the nurse that further assessment of the thyroid function may be necessary?
"I feel a lump in my throat when I swallow"
The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching?
"I had the flu earlier this week, so I couldn't take the hydrocortisone."
the nurse has started discharge teaching for a patient who is to continue Warfarin( Coumadin) after hospitalization for venous thromboembolism(VTE) which patient statements indicate the need for additional teaching
"I should reduce the amount of green leafy vegetables that I eat"
which statement by a patient with newly diagnosed heart failure indicates to the nurse that teaching was effective?
"I will call the clinic if my weight goes up 5 lb in a week"
The nurse evaluates that discharge teaching about the management of a new permanent pacemaker. The nurse knows teaching has been effective when the patient states:
"I wont lift the arm on the pacemaker side until I see the health care provider."
In preparation for which test should the nurse teach the patient to minimize physical and emotional stress?
A 24-hour urine test for free cortisol
A new nurse reviews their client assignment for the day including a new admission arriving to the unit now. Which client does the nurse assess first?
A newly admitted client with acute flank pain and hematuria
Diagnosis of myasthenia gravis is confirmed by evaluating the client's response to an intravenous injection of the cholinesterase inhibitor edrophonium last. If the client responds positively, what would the nurse expect?
A rapid and dramatic increase in muscle strength
A 20 yr old patient has a mandatory ECG before participating on a college soccer team. The patient is found to have sinus bradycardia rate 52 and blood pressure 114\54 mm Hg. The student denies any health problems. What action by the nurse is appropriate?
Allow the student to participate on the soccer team
A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L The nurse should anticipate the need for which diagnostic test?
Antidiuretic hormone
A client is admitted to the hospital with Cushing's syndrome. Space which nursing interventions are appropriate for this client?
Assess for peripheral edema
A client recovering from a spinal cord injury has a great deal of spasticity. Which medication would the nurse anticipate to relieve spasticity?
Baclofen
A young adult employed as a hair stylist who has a 15 pack-year history of cigarette smoking arrives for an annual physical examination. Which area of increased risk should the nurse plan to teach the patient?
Bladder Cancer
A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect to find on assessment, in this client?
Bradycardia and hypertension
Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?
Calcium gluconate
A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?
Cardiac rhythm
A client has recently experienced an embolic state, and is now stable. The client has been started on dabigatran (Pradaxa). What information should the nurse provide to this client?
Dabigatran helps prevent blood clots from forming in the presence of atrial fibrillation
The nurse is assessing a male patient diagnosed with a pituitary tumor causing panhypopituitarism. Which assessment finding is consistent with panhypopituitarism?
Decreased facial hair
A client has recently experienced an embolic stroke, and is now stable. The client has been started on Dabigatran Pradaxa. What information should the nurse provide to this client?
Defibrillation helps prevent blood clots from forming in the presence of atrial
A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care?
Difficulty in coordination
A 19 yr old patient has genital warts around her external genitalia and perianal area. She tells the nurse that she has not sought treatment until now because "the warts are so disgusting." Which patient problem is consistent with these data?
Disturbed body image
During the physical examination, the nurse cannot feel the patient's thyroid gland. What action should the nurse take?
Document that the thyroid was nonpalpable
The nurse completing a physical assessment for a newly admitted patient is unable to feel either kidney on palpation Which action should the nurse take?
Document the information on the assessment form.
The nurse is assessing a client with a suspected ischemic stroke. What assessment finding is most suggestive of a "brain attack"?
Dysrhythmias
Which client would be most appropriate for the nurse to assign to an unlicensed assistive Personnel UAP for morning care?
Elderly client with COPD who is receiving oxygen therapy for dyspnea
A patient who has chest pain is admitted to the emergency department, and all the following items are prescribed. Which one should the nurse arrange to be completed first?
Electrocardiogram (ECG)
A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dl (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L) Which nursing action should be included in the plan of care?
Encourage 4000 mL of fluids daily
The critical care nurse is monitoring a client who has had a brief loss of consciousness, followed by a period of leing alert and oriented and then a loss of consciousness again. The nurse recognizes that this is a typical presentation for which condition?
Epidural hematoma
A client with MS is admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal?
Establish a timed voiding schedule
The nurse is evaluating an electrocardiogram ECG tracing. Which graphic shows the QT interval?
From the beginning of the QRS until the end of the T wave.
the nurse is caring for a patient who just arrived at a dilemma tree unit after having cardiac catheterization what task should the nurse delegate to a licensed practical or vocational nurse (LPN\VN)
Give the scheduled aspirin and lipid-lowering medication
A client exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the client's injury is causing increased intracranial pressure (ICP). The nurse should gauge the client's LOC on the results of what diagnostic tool?
Glasgow Coma Scale
A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action will provide the patient with rapid temporary relief from the symptoms?
Have the patient rebreathe from a paper bag
On the third day after a partial thyroidectomy a client exhibits muscle twitching and hyperirritability of the nervous system. when questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance commonly follows thyroid surgery?
Hypocalcemia
A patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon?
Increased neck swelling
Which finding indicates to the nurse that the current therapies are effective for a patient who has acute adrenal insufficiency?
Increasing serum sodium levels
A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor?
Ionized calcium
The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan?
Maintaining cardiac output
Which outcome is a priority for the client with Addison's disease?
Maintenance with medication compliance
A nurse is triaging clients in the emergency department. Which client is the highest priority to receive treatment?
Middle-aged adult with hematuria and ecchymosis of the penis 1 hour after a bicycling accident
What action should the nurse take when providing care for a patient who has an adrenocortical adenoma causing hyperaldosteronism?
Monitor the blood pressure every 4 hours
Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care?
Nausea and projectile vomiting
The client is scheduled to have a kidney, ureter, and bladder KUB radio graph. What should the nurse explain to the client about this procedure?
No special preparation is required for this examination
Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)?
Offer the patient hard candies to suck on
A patient recovering from heart surgery develops pericarditis and reports level 6 (0-10 scale) chest pain with deep breathing. Which prescribed PRN medication will be most appropriate for the nurse to give?
Oral ibuprofen (motrin) 600 mg
A nurse is caring for an older client who is admitted with an electrolyte imbalance. Which laboratory value should be a priority concern for the nurse?
PaCO2 51mm Hg
A patient at the clinic says, " I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." What focused assessment should the nurse take?
Palpate for the presence of dorsalis pedis and posterior tibial pulses
Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider?
Patient stopped taking the medication 2 days ago
The nurse who works in the vascular clinic has several patients with venous insufficiency which patient should the nurse assigned to an experienced licensed practical\vocational nurse (LPN\VN)?
Patient who needs wound care for a chronic Venous stasis ulcer on the lower leg
The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first?
Patient with tetany who has a new order for IV calcium chloride
Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (pyridium)?
Phenazopyridine may change the urine color
Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?
Phenazopyridine may change the urine color
Which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?
Phosphate level
A client is experiencing autonomic dysreflexia. What nursing action should be performed first?
Place the patient in Fowlers position?
A male client presents to the clinic complaining of a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized diagnostic sign of this infection that the nurse would note during the assessment of this client?
Positive Kernig's sign
What topic should the nurse plan to teach a 26 year old patient who has been treated for pelvic inflammatory disease?
Potential complication of infertility
A client with Guillain-Barre syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate priority action?
Prepare to assist with intubation
A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient?
Promote rest to decrease myocardial oxygen demand
A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the drug is effective when it:
Relieves muscular spasticity
A client with multiple sclerosis is receiving baclofen. The nurse determines that the drug is effective when it
Relieves muscular spasticity
Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease?
Restriction of iodine intake is needed to reduce thyroid activity
which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease(PAD)?
Satins
Which assessment finding for an adult admitted with Graves' Disease requires the most rapid intervention by the nurse?
Temperature 103.8° F
A 42 year old client with a seizure acute traumatic brain injury has developed a fever. The nurse is aware that the fever should be reversed quickly due to which reason?
The fever increases the brain's metabolic needs
Which information is most important for the nurse to communicate rapidly to the health care provider about a patient possible syndrome of inappropriate antidiuretic hormone (SIADH)?
The patient has a serum sodium level of 118 mEq/L
The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider?
The patient is confused and lethargic
A client is returned to his room after a subtotal thyroidectomy. Space which piece of equipment is most important for the nurse to keep at the client's bedside?
Tracheostomy set
The client, age 33, experienced an episode of heaviness of the right arm and inability to speak that lasted for 3 minutes. Symptoms disappeared and function returned to normal. What category of stroke has this client most likely experienced?
Transient ischemic attack
Which finding indicates to the nurse that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone siadh?
Urinary output is increased
The nurse is developing a plan of care for the client with Guillain-Barre syndrome. Which of the following interventions should the nurse prioritize for this client?
Using incentive spirometer as ordered
A lethal rhythm is identified by the CCU nurse when viewing her patients monitor. Knowing that this Rhythm usually occur in diseased hearts or in patients with hypokalemia and requires immediate treatment to prevent a terminal event the nurse identifies this Rhythm as?
Ventricular tachycardia
Which information from a patient's urinalysis requires that the nurse notify the health care provider?
WBC 20 to 26/hpf
The client has heart failure and is taking a diuretic to promote fluid loss. Which is the most accurate method of determining the extent of a client's fluid loss?
Weighing the client
After completion of peritoneal dialysis, the nurse should assess the client for?
Weight loss
A client is admitted to the healthcare facility with acute chest pain when obtaining the client's health history which question would be most helpful for the nurse to ask?
What were you doing when the pain started
A client is admitted to the healthcare facility with acute chest pain. When obtaining the client's health history which question would be most helpful for the nurse to ask?
What were you doing when the pain started
which patient will need the nurse to plan discharge teaching about prophylactic antibiotics before dental procedures?
a patient who had a mitral valve replacement with a mechanical valve
The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with:
anticoagulants
which actions for a patient at risk for venous thromboembolism could the nurse delegate to a on license assistive personnel (UAP)?
apply sequential compression devices whenever the patient is in bed
Propranolol (Inderal )is prescribed for a patient diagnosed with hypertension the nurse should consult with the healthcare provider before giving this drug when the patient reveals a history of
asthma
A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?
cardiac rhythm
Which medication taken by a patient with decreased renal function will be of most concern to the nurse?
ibuprofen (Motrin)
Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown Origin?
instruct the patient to call for assistance before getting out of bed
the nurse observes the following information from a patient newly diagnosed with elevated blood pressure which finding is most important to address with the patient?
no regular physical exercise
the nurse notes that a patient who was admitted with heart failure has jugular venous distention(JVD) when lying flat which follow-up action should the nurse take?
observe the neck veins with the patient elevated 45 degrees
A 46-yr-old female patient returns to the clinic with continued dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take?
obtain a midstream urine specimen for culture and sensitivity testing.
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism(VTE)?
requires immediate action by the nurse new onset shortness of breath
To prevent recurrence of uric acid kidney stones, the nurse teaches the patient to avoid eating:
sardines and liver
which information from a patient help the nurse confirmed the previous diagnosis of chronic stable angina?
the pain goes away after a nitroglycerin tablet
The nurse is admitting a patient who has chest pain which assessment data suggests that the pain is from an acute myocardial infarction?
the pain has lasted longer than 30 minutes
A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed?
uncontrolled head movement
Which question from the nurse during a patient interview will provide focused information about a possible thyroid disorder?
"Have you had a recent unplanned weight gain or loss?"
Three years ago, a client was diagnosed with multiple sclerosis. He now presents with lower extremity weakness and heaviness. During the admission process, the client present his advance directive that states he doesn't want intubation, mechanical ventilation, or tube feedings, should his condition deteriorate. How should the nurse respond?
"It is important for us to have this information. You should review the document with your physician at every admission."
A client who has received a poor prognosis tells the nurse, "I have not been to church in decades even though I was raised Catholic. Can you arrange for a priest to come in see me?" What is the nurse's best response?
"We will try to get in touch with one and ask him to come and see you."
Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter?
"What medications are you taking?"
After receiving change of shift report, which patient admitted to the ER should the nurse assess first?
A 50 year old patient who is reporting sudden sharp and severe upper back pain
After receiving a change of shift report at 0700, the nurse should assess which Client First?
A 63 year old with multiple sclerosis who has an oral temperature of 101.8 F and flank pain
the nurse and unlicensed assistive personnel(UAP) on the Telemetry unit are caring for 4 patients which nursing action can be delegated to the UAP?
Attaching ECG monitoring electrodes after a patient bathes
Which Laboratory test result will the nurse review to determine the effects of therapy for a patient being treated for heart failure?
B-type natriuretic peptide (BNP)
What finding should the nurse plan to assess for in a patient diagnosed with a pheochromocytoma?
Headache
Identify the following 6 second cardiac Rhythm strip
Sinus Bradycardia
A client admitted to the unit with a diagnosis of end-stage renal disease is scheduled to undergo hemodialysis. The client voices anxiety over shunt placement and management of care at home. A nurse initiates a referral to which members of the interdisciplinary team?
dialysis nurse, physician, and family
Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?
"I need to shop for foods low in sodium and avoid adding salt to food."
Which statement by a 22-yr-old female patient with cystitis indicates to the nurse that instruction regarding prevention of future urinary tract infections (UTIs) has been effective?
"I will empty my bladder every 3 to 4 hours during the day."
After teaching a client about myasthenia gravis the nurse would judge that the client formed a realistic concept of the disease and the treatment plan when the client makes which statement?
"I'll be able to control the disease and enjoy a healthy lifestyle."
A 74 yr old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis?" which initial response by the nurse is best?
"Tell me more about what you are thinking regarding dialysis"
A 29-year-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include?
"The prednisone dose should be decreased gradually."
A client is admitted to the health care facility with acute chest pain. When obtaining the clients health history, which question would be most helpful for the nurse to ask?
"What were you doing when the pain started?"
A client experienced an episode of vision loss and right-sided weakness that lasted 4 hours before totally resolving. What information should the nurse provide to this client?
"While these symptoms have resolved, your risk for a stroke is now higher"
A client with a history of hypertension has just had a total hip replacement. The provider orders Hydrochlorothiazide 35 mg oral solution po / day. The label on the solution reads hydrochlorothiazide 50 mg / 5 ml how many milliliters should the nurse pour to administer the correct dose? Record your answer using one decimal place.
3.5
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first?
A 70-year-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134
A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be helpful for patient problem of disturbed body image related to changes in appearance?
A Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery
A nurse receives a report at the beginning of a day shift. Which client does the nurse assess for?
A client reporting shortness of breath and dyspnea
A nurse cares for several clients who are being monitored by Telemetry. Which client does the nurse assess first?
A client with a rhythm change from atrial flutter to ventricular fibrillation
A nurse cares for several clients who are being monitored by telemetry. Which client does the nurse assess first?
A client with a rhythm change from atrial flutter to ventricular fibrillation
A charge nurse makes assignments for the shift. Which client is best assigned to the novice nurse?
A client with anemia who reports shortness of breath
A charge nurse makes assignments for the shift. Which client is best assigned to to the novice nurse?
A client with anemia who reports shortness of breath
A nurse cares for a client who is 1 hour Post open abdominal surgery and has evisceration of the abdominal wound and the client's intestinal Loops are visible. Place each option in order from first action to last.
A. I'm serve the client for signs of shock B. Place the client in supine position C. Ask another nurse to notify the health care provider D. Cover the wound with gauze moistened with saline. BDCA
A patient with rheumatic fever has subcutaneous nodules, Erythema marginatum, and polyarthritis, the patient reports that joint discomfort prevents favorite activities such as taking daily walks and sewing. What problem should be the focus of nursing interventions?
Activity intolerance
A cardiac patients resistance to left ventricular filling has caused blood to back up in the patients circulatory system. What healthcare problem is likely to result?
Acute Pulmonary Edema
A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to surgical nursing unit. Which collaborative action will the nurse anticipate next?
Administer IV calcium gluconate
A patient is admitted with diabetes insipidus. Which action will be appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)?
Administer prescribed subcutaneous DDAVP
A registered nurse RN prepared a client for surgery. A practical nurse assists with completion of tasks. Which task must the registered nurse perform?
Administering midazolam 5 mg IVP prior to the procedure
Which measure is likely to provide the most relief from the pain associated with renal colic?
Administering morphine
A registered nurse RN delegates care to a practical nurse PN on a medical-surgical unit. The nurse manager rounds on the unit. Which action observed being performed by the PN would require the nurse manager to discuss appropriate delegation with the RN?
Admitting an alert, hemodynamically stable client from the post-anasthesia care unit
A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is important for the nurse to communicate to the health care provider before the test?
Allergies to iodine and shellfish
Which client would be most appropriate nurse to assign to an unlicensed assistive personnel (UAP) for morning care?
An elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea
A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor. What should the nurse anticipate explaining to the patient?
Antiparkinsonian drugs
Which nursing assessment of a 70-year-old patient is most important to make during initiation of thyroid replacement with levothyrox(Synthroid)?
Apical pulse rate
The home health nurse observes the patient for proper use of topical nitroglycerin ointment. Which action by the patient indicates the need for further teaching?
Applies the prescribed ribbon of ointment to the applicator paper and places it on the chest
A client returns from extracorporeal shock wave lithotripsy with ecchymosis over the left flank area. Vital signs are within normal limits, and the client appears to be in no acute distress. Which nursing action is appropriate?
Apply a cold compress to the site
A client has had a cardiac catheterization. The femoral dressing has a bright bloody drainage. What should the nurse do first?
Apply pressure to the site
A client is experiencing the classic signs and symptoms of acute coronary artery disease. Space what is the nurses priority intervention?
Apply supplemental oxygen
Which action should the nurse take when giving the first dose of oral labetalol to a patient with hypertension?
Ask the patient to request assistance before getting out of bed
A client's electrocardiogram (EKG) tracing shows normal sinus rhythm followed by three premature ventricular contractions (PVCs) and a return to normal sinus rhythm. What is the priority action of the nurse?
Assess the client's apical-radial pulse rate
A client with a history of cardiac problems reports severe chest pain what should be the nurse's first response?
Assess the clients pain
A client in the emergency department has symptoms of anxiety, the racing heart, and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122 what is the most appropriate action of the nurse?
Assess the clients vital signs and O2 saturation
After undergoing a cardiac catheterization a client has a large puddle of blood under his buttocks. What is the nurses priority action?
Assess the groin site
Arrived on the unit after a thyroidectomy. Which action should the nurse take first?
Assess the patient's respiratory effort
The nurse is conducting a focused neurologic assessment. When assessing the client's cranial nerve function, the nurse would include which of the following assessments?
Assessment of the gag reflex
A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action should the nurse include in the plan of care?
Assist with active range of motion (ROM).
Treatment for a 69 year old patient admitted with symptomatic sinus bradycardia would involve the following parameters and priorities for the Cardiac Care nurse including.
Atropine and pacing if the patient is hemodynamically compromised
A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry hacking cough. Which action should the nurse take first?
Auscultate the breath sounds
The healthcare provider prescribes an infusion of Heparin and daily partial thromboplastin time(PTT) testing for a patient with venous thromboembolism (VTE) which action should the nurse include in the plan of care?
Avoid giving IM and medications to prevent localized bleeding
A client recovering from a spinal cord injury, has a great deal of spasticity. Which medication would the nurse anticipate to relieve spasticity?
Baclofen
The nurse is caring for a client whose spinal cord injury has caused recent muscle pasticity. What medication would the nurse expect to be ordered to control the spasticity?
Baclofen (Lioresal)
When caring for a client who's being treated for hyperthyroidism, the nurse should?
Balance the clients periods of activity and rest
he nurse is caring for a patient following an adrenalectomy. What is the highest priority in the immediate postoperative period?
Balancing fluid and electrolytes
A young adult employed as a hair stylist who has a 15 pack-year history of cigarette smoking arrives for an actual physical examination. Which area of increased risk should the nurse plan to teach the patient?
Bladder cancer
Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm?
Blood pressure medication
A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. What topic should the nurse plan teach the patient?
Calcium supplements to normalize serum calcium levels
A client was admitted to the emergency department after a traumatic brain injury. Current assessment included a decrease in Glascoma Coma Scale by 1 point and development of a fixed and diluted pupil on the left. What should be the priority nursing action at this time?
Call the HCP immediately
A client has sudden, severe pain in the back and chest accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The heath care provider suspects the client is experiencing a dissection aortic aneurysm. The nurse should assess the client for which potential complication of a dissecting aneurysm?
Cardiac tamponade
A client has recently experienced an embolic stroke, and is now stable. The client has been started on Dabigatran Pradaxa. What information should the nurse provide to this client?
Dabigatran helps prevent blood clots from forming in the presence of atrial fibrillation
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. What should the nurse plan to do next?
Defibrillation
A nurse discusses discharge instructions with a client and his family after being diagnosed with a concussion. The client is instructed to return to the Emergency Room when which of the following symptoms develop?
Difficulty walking or staggering Difficulty speaking or slurred speech Blurry vision, double vision
A client who is receiving multiple medications for a myocardial infarction reports severe nausea. Assessment reveals that the heartbeat is irregular and slow. The nurse should recognize these symptoms as toxicity related to which medication question?
Digoxin
A client who is receiving multiple medications for a myocardial infarction reports severe nausea. Assessments reveal that the heartbeat is irregular and slow. The nurse should recognize these symptoms as toxicity related to which medication?
Digoxin
Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus?
Disturbed sleep pattern
The rapid response team arrives in the room of a client who has had a cardiac arrest the nurse should first apply which piece of monitoring equipment?
Electrocardiogram ECG electrodes
A nurse is caring for a client with a complete tea 5 spinal cord injury. Apply an assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 174 over 100 m m HG. Which nursing intervention is most appropriate for this client?
Elevate the head of the bed 45 degrees
Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos?
Elevate the head of the patient's bed to reduce periorbital fluid
patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. What additional effect of the medication should the nurse monitor?
Elevated serum potassium
A 58-yr-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present, based on these findings?
Excess fluid volume
A client with amyotrophic lateral sclerosis (ALS) is admitted with weight loss and malnutrition. He can swallow without difficulty. While caring for the client, the nurse discovers that his weight loss is related to his refusal to eat. The client states to the nurse that he would rather die than remain alive with this disease. How should the nurse intervene?
Explore the client's feelings about dealing with
The nurse discovers that his weight loss is related to his refusal to eat. The client states to the nurse that he would rather die than remain alive with this disease. How should the nurse intervene?
Explore the client's feelings about dealing with ALS using open- ended questions
A client with a spinal cord injury says he is having difficulty recognizing the symptoms of a urinary tract infection UTI. Which assessment finding is an early symptom of UTI in a client with a spinal cord injury?
Fever and change in urine clarity
A patient on the telemetry unit develops atrial flutter rate 150, with associated this dyspnea and chest pain. Which action that is included in the agency dysrhythmia protocol should the nurse do first?
Give supplemental O2 at 2 to 3 L/min via nasal cannula.
the nurse is admitting a patient with possible rheumatic fever which question on the admission health history focuses on a pertinent risk factor for rheumatic fever ?
Have you had a recent sore throat?
he nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis(IE) which question by the nurse helps identify a risk factor for IE?
Have you had any dental work done recently?
Which assessment findings indicate to the nurse that a patient with infective endocarditis has decreased cardiac output?
Have you had dental work recently?
An 85 year old woman is admitted for observation after a fall at a party which resulted in her injuring her head. Due to her age, the nurse knows that the client is at increased risk for what compliçation of her injury?
Hematoma
A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication?
Hemoglobin level 13 g/dL
The nurse is caring for a patient with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. information about the patient is important to discuss with the health care provider before the test?
History of renal insufficiency
A client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statement by the client indicates that client teaching has been effective?
I need to call my healthcare provider to discuss my steroid needs before I have dental work
Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective?
I will measure my urinary output each day to calculate how much I can drink
The nurse is teaching a client how to apply nitroglycerin topical ointment. Which statement indicates that the client needs additional clarification of the instructions?
Ill carefully massage the ointment into the skin
The nurse is teaching a client how to apply nitroglycerin topical ointment. Which statement indicates that the client needs further education on applying nitroglycerin topical ointment?
Ill carefully massage the ointment into the skin
Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care pr administering levothyroxine (Synthroid)?
Increased thyroxine (T4) level
A young adult patient who is being seen in the clinic has excessive secretion of the anterior pituitary hormones Which laboratory test result should the nurse expect?
Increased urinary cortisol
After obtaining the information shown in the accompanying figure regarding a patient with Addison's disease, which prescribed action will the nurse take first? Assessment Reports fatigue BP 76/40 mm Hg Heart rate 126 beats/min Sodium 123 mEq L Bronze-colored skin Poor skin turgor Respirations 24 breaths/min Potassium 5.1 mEq/L Glucose 62 mg/dl. Oxygen saturation 94%
Infuse 5% dextrose and 0.9% saline
A patient hospitalized with a new diagnosis of Guillain Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate?
Infusion of immunoglobulin
Which information will the nurse include when teaching a 50 year old male patient about somatropin genotropin?
Inject the medication subcutaneously every day
What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?
Inquire about urinary tract problems.
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymosis around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?
Insert a nasogastric tube to low suction
A 76 yr old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the healthcare provider should the nurse implement first?
Insert an indwelling urinary catheter
As a member of the stroke team, the nurse knows that thrombolytic therapy (t-PA) carries the potential for benefit and for harm. The nurse should be cognizant of which contraindications for thrombolytic therapy? SELECT ALL THAT APPLY
Intracranial hemorrhage on CT symptom onset greater than 3 hours prior to admission INR above 3.0
What emergency procedures would the nurse anticipate being implemented during a myasthenia gravis crisis?
Intubation with mechanical ventilation
A hospitalized patient who has possible renal insufficiency after coronary artery bypass surgery will have a creatinine clearance test. Which item will the nurse need to obtain?
Large container
A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication?
Mannitol (Osmitrol)
When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is appropriate for the nurse to include?
Monitor labs for levels of streptococcal antibodies
The nurse is caring for a client in the ICU who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use" What would be an appropriate intervention for this diagnosis?
Monitor serum electrolytes
A client with possible hacterial meningitis is admitted to the ICU. What assessme inding would the nurse expect for a client with this diagnosis?
Neck flexion produces flexion of the knees and hips
An older adult patient who had a mitral valve replacement with a mechanical valve is taking warfarin. What should the nurse include in the discharged teaching?
Need for frequent laboratory blood testing
Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action?
New-onset changes in the patient's voice
The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. What should the nurse explain to the client about this procedure?
No special preparation is required for the examination
The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. What should the nurse explain to the client about this procedure?
No special preparation is required for the examination.
A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient?
Notify the health care provider about symptoms such as shortness of breath
A client is scheduled for surgery at 8 a.m. 08:00. while completing the preoperative checklist the nurse sees that the surgical consent form isn't signed. It's time to administer the preoperative analgesic which nursing action takes the highest priority in this situation?
Notify the surgeon that the client hasnt signed
The nurse has just received morning change of shift report on four clients. In what order from first to last should the nurse perform the actions? All options must be used. A. Notify the healthcare provider about a client who has a serum potassium level of 6.2 meq/l. b. Assess the client who has been vomiting according to the report from the Night Nurse. see. Discuss the plan for the day with the unlicensed assistive personnel UAP. d. Begin discharge paperwork for a client who is eager to go home.
Notify, Assess, discuss, begin
A client is scheduled for cardiac surgery at 0800. While competing the pre operative checklists, the nurse sees that the surgical consent form isn't signed, it's time to administer the pre operative analgesic. Which nursing immediate action takes the highest priority in this situation?
Notifying the surgeon that the client hasn't signed the consent form
The nurse is caring for a client with increased intracranial pressure (ICP). The client has: nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis?
Obeys commands with appropriate motor responses
A 46 old female patient returns to the clinic with continued dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take?
Obtain a midstream urine specimen for culture and sensitivity testing
A nurse educator is discussing neoplasms with a group of recent nursing graduates. The educator explains that the effects of neoplasms are caused by the compression and filtration of normal brain tissue. The physiologic changes that result, can cause what pathophysiologic events? SELECT ALL THAT APPLY
Papilledema Obstruction of the flow of cerebrospinal fluid (CSF) Increased ICP
A patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. What should the nurse anticipate will be tested next?
Parathyroid hormone
A patient who has chronic heart failure tells the nurse. "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" How should the nurse document this finding?
Paroxysmal nocturnal dyspnea
The nurse is evaluating the pin insertion site of a client's skeletal traction. Which finding indicates a complication?
Pin moves slightly at insertion sight
Which nursing intervention is a priority for the client who has been placed in a halo vest?
Place an appropriate wrench on or near the client
A patient has pain due to acute pericarditis. What is an appropriate nursing intervention for this problem?
Place patient in the Fowler's position, leaning forward on the table
A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?
Place the patient on a cardiac monitor
A client is admitted to the hospital with an exacerbation of multiple sclerosis after an MRI revealed Progressive demyelination. Space the nurse should assess for which symptom?
Progressive weakness of the extremities
A nurse is caring for a 71 year old male client who complains that he cannot pass urine. A bladder scan reveal 600 mL of urine present in the bladder. A serum prostate-specific antigen PSA test indicates a level of 29 G/l . The Physician place has an indwelling catheter and a urine analysis returns positive for nitrates oh, leukocytes, and bacteria. Which conditions should the nurse suspect?
Prostate enlargement and a urinary tract infection UTI
A post-operative client is receiving Heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of Heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to Heparin. Which agent fits this description?
Protamine sulfate
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
Protamine sulfate
A nurse is completing management rotation in the Intensive Care Unit and is working with an experienced Icu nurse. One clients work supervisor calls to "check up" on the client. The nurse offers to transfer the call to the client's family members. The experienced Icu nurse recognizes this action as?
Protection of the clients privacy
A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to o days. Which teaching strategy is likely to result in effective patient self- management at home?
Provide written reminders of information taught
The critical care nurse is admitting a client in myasthenic crisis to the ICU. Which of the following intervention does the nurse prioritize as the action in the immediate care of this client in crisis?
Providing ventilator assistance
The nurse is assessing a five-year-old child who was admitted to the emergency department after being struck by a motor vehicle. Which of the following assessment would be a priority for the nurse based on the type of injury?
Pupil reaction
The nurse reports that a trauma client's pupils are "blown." What has the nurse assessed in this client?
Pupils are dilated and nonreactive
A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment?
Purplish streaks on the abdomen
A client with a T2-to-T3 spinal cord injury suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first?
Raise the head of the bed
Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30?
Rapid, deep respirations
What should the nurse ask the patient about to determine possible causes of acute glomerulonephritis?
Recent sore throat and fever
An adult patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect?
Recent weight gain
An adult patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect?
Recent weight gain
After the insertion of an arteriovenous graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take?
Report the patient's symptoms to the health care provider
After the insertion of an arteriovenous graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take?
Report the patient's symptoms to the health care provider.
A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 90 minutes ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?
Risk for ineffective breathing pattern
A client has just been diagnosed with Parkinson's disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family?
Risk for injury
A client with Parkinson's disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method?
Semisolid food with thick fluids
A client with Parkinson's disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method?
Semisolid food with thick liquids
Which laboratory result should the nurse check before administering calcium carbonate to a patient with chronic kidney disease?
Serum phosphate
A patient who has heart failure has recently started taking digoxin (Lanoxin) in addition to furosemide ( Lasix) and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?
Serum potassium level 3.0 mEq\L after 1 week of therapy
A patient with Parkinson's disease has bradykinesia. Which action should the nurse include in the plan of care?
Suggest that the patient rock from side to side to initiate leg movement.
A patient who has hyperthyroidism is treated with radioactive iodine (RAI) What information should the nurse include in discharge teaching?
Symptoms of hypothyroidism will occur as the RAI therapy takes effect
The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?
Take antihypertensive medication as ordered
A staff member says she is really busy and asks the charge nurse to double-check a dose of insulin which she has drawn up the nurse holds up a bottle of lente insulin but the charge nurse notices a bottle of Lantus insulin on the medication car. This nurse has made multiple medication errors in the charge nurse is concerned that she isn't safe. What should the charge nurse do?
Tell the nurse that she'd like to start at the beginning to be on the safe side
A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching?
The RN palpates the neck to assess thyroid size
Which assessment finding in a patient who had a bilateral adrenalectomy requires the most rapid action by the nurse?
The blood pressure (BP) is 88/50 mm Hg
A nurse on the neurologic unit is providing care for a client who has a spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurolog and functional status should the nurse consider?
The client will require full assistance for all aspects of elimination
Which assessment data for a patient who has Guillain Barré syndrome will require the nurse's most immediate action?
The patient is continuously drooling
A patient gives the admitting nurse health information before a scheduled intravenous pyelogram (IVP) Which item requires the nurse to intervene before the procedure?
The patient lists allergies to shellfish and penicillin.
Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective?
The periorbital and peripheral edema are resolved
Which additional information will the nurse need to consider when reviewing the laboratory results for a patient's total calcium level?
The serum albumin
A registered nurse (RN) is observing a student nurse who is assessing a patient. Which action observed by the RN requires immediate intervention?
The student nurse palpates both carotid arteries simultaneously to compare pulse quality
Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the pituitary gland?
Thyroid-stimulating hormone (TSH) level
A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?
To remove atherosclerosis plaques blocking cerebral blood flow
he nurse has received laboratory results for a patient who developed chest pain 4 hours ago and maybe having a myocardial infarction which Laboratory test result should be most helpful in indicating myocardial damage?
Troponins
The client is having peritoneal dialysis. During the exchange, the nurse observes that the flow of dialysate stops before all the solution has drained out What should the nurse do next?
Turn the client from side to side
The client is having peritoneal dialysis. During the exchange, the nurse observes that the flow of dialysate stops before all the solution has drained out. What should the nurse do next?
Turn the client from side to side
And unemployed client cannot afford prescription medications and has not taken the prescribed levothyroxine for some time. The client reports I've been getting sick or by the day which symptom is most likely related to not taking this medication?
Tympanic temperature of 94
A client with a new ileal conduit asks what the disadvantages are to this type of stoma. The nurse explains that the client may experience which disadvantage?
Urine drains from it continuously
The client with a head injury receives Mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect?
Urine output increases
A 62 year old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?
Urine output over an 8-hour period is 2500 mL
A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?
Urine output over an 8-hour period is 2500 mL.
which assessment findings indicate to the nurse that a patient with infective endocarditis has decreased cardiac output?
Urine production of 25ml\hr
Cardiac Telemetry shows that a client who is up to the bathroom has converted from a normal sinus rhythm with a rate of 72 BPM to atrial fibrillation with a ventricular response rate of 100 BPM. In what order from first to last should the nurse perform the following interventions. All options must be used.
a. Assess the client to bed b. Assess Vital Signs c. Obtain a stat 12 lead electrocardiogram EKG d. Initiate intravenous access Assess the client in bed, assess vital signs, initiate IV access, obtain 12 lead EKG
Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction(MI)?
ask about chest pain
while assessing an older adult patients the nurse notes jugular vein distention (JVD) with the head of the patient's bed elevated 45° what does this finding indicate?
increase right atrial pressure
Which patient statement indicates that the nurse teaching about Carvedilol (Coreg) For preventing anginal episodes has been effective?
it is important not to suddenly stop taking that Carvedilol
A 67 year old patient admitted to the medical surgical unit with acute dyspnea is newly diagnosed with restrictive cardiomyopathy the nurse reviews a laboratory data NA138 K 4.0 MG 2.0 CA 9.6 which information will the nurse plan to teach the patient?
notify the health care provider about symptoms such as shortness of breath
The nurse plans discharge teaching for a patient with chronic heart failure who has a prescription for Digoxin (Lanoxin) And Hydrochlorothiazide. Which instruction should the nurse include?
notify the healthcare provider if nausea develops
