Other Practice

• The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?

2,500

• The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.)

45

• ...An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? • Serum potassium • Urine ketones • Urine albumin • Serum protein

A

• The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication? • Irregular pulse • Tachycardia • Chest pain • Urinary frequency

A

• The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first? • Check the TPN solution for cloudiness • Attach the IV tubing to the central line • Set the infusion pump at the prescribed rate • Prime the IV tubing with TPN solution

A

• While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first? • Ask the client when a family member last visited her. • Determine the client's orientation to time and space • Review the client's record regarding social interactions • Reassure the client of her family's love for her

A

20. After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dl. What action should the nurse implement? A. Initiate the urine collection as prescribed. B. Notify the HCP of the results. C. Evaluate the client's serum BUN level. D. Assess the client for signs of hypokalemia.

B

40. A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? Tachycarcia Dyspnea Vomiting Muscle cramps

C

• A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit? • Encourage the family to plan daily activities to keep the client busy • Have friends and family visit the client at a welcome home party • Discuss the importance of continuing the usual at-home activities • Instruct family to monitor the client's choice of television programs

C

• A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? • Infection • Increase intracranial pressure • Shock • Head Injury.

C

• What is the nurse's priority goal when providing care for a 2-year-old child experience... • Stop the seizure activity • Decrease the temperature • Manage the airway • Protect the body from injury

C

• In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis? • infectious process • metastatic process • autoimmune disorder • inflammatory disorder

A

• Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? • Reduce risks factors for infection • Administer high flow oxygen during sleep • Limit fluid intake to reduce secretions • Use diaphragmatic breathing to achieve better exhalation

A

• Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? • A business and professional women's group. • An African-American senior citizens center • A daycare center in a Hispanic neighborhood • An after-school center for Native-American teens

A

• Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)? • Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema • A high ventilation-to-perfusion ratio is characteristic of affected lung fields in ARDS • Functional residual capacity and lung compliance increase as the disease progresses • Interstitial edema that occurs due to capillary fluid shifts is usually more serious than alveolar edema

A

• When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat? SATA • Yogurt. • Processed cheese. • Nuts • Fresh turkey • Fresh chicken

AB

• A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) • Monitor heart, lung, and kidney function. • Notify healthcare provider of serum amylase and lipase levels. • Review client's abdominal ultrasound findings. • Position client on abdomen to provide organ stability • Encourage an increased intake of clear oral fluids

ABC

• A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.) • Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. • T3 and T4 hormone levels are increased • Large protruding eyeballs are a sign of hyperthyroid function • Weight gain is a common complaint in hyperthyroidism • Early treatment includes levothyroxine (Synthroid).

ABC

• The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply • Avoid prolonged standing or sitting • Use recliner for long period of sitting • continue wearing elastic stocking • Maintain the bed flat while sleeping • Cross legs at knee but not at ankle

ABC

• What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? • working together can decrease the risk for back injury • The technique is intended to maintain straight spinal alignment. • Using two or three people increases client safety. • turning instead of pulling reduces the likelihood of skin damage

B

• When implementing a disaster intervention plan, which intervention should the nurse implement first? • Initiate the discharge of stable clients from hospital units • Identify a command center where activities are coordinated • Assess community safety needs impacted by the disaster • Instruct all essential off-duty personnel to report to the facility

B

• Which intervention should the nurse include in the plan of care for a client with leukocytosis? • Avoid intramuscular injections • Monitor temperature regularly • Assess skin for petechiae or bruising • Implement protective isolation measures

B

6. An adolescent, whose mother recently died, comes to the school nurse complain headache. Which statement made by the students should warrant further explanation nurse? A. "I've had dreams about Mon since she died." B. "I've been very sad and cry a lot at night." C. "I miss Mon and would like to go see her'". D. " it's hard to concentrate on my homework"

C

• Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? • Range of Motion • Distal pulse intensity • Extremity sensation • Presence of exudate •

B Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity. Range of motions evaluates the possibility of long term contractures sensation. C evaluates neurological involvement, and exudate. D provides information about wound infection, but this assessment do not have the priority of determining perfusion to the extremity.

• A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? • Explain that it may take several weeks for the medication to be effective • Confirm the desired effect of the medication has been achieved. • Notify the health care provider than a change may be needed. • Evaluate when and how the medication is being administered to the client.

B Rationale: Trazodone o Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep

4. During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all that apply) A. Canned fruit in heavy syrup. B. Plain, air-popped popcorn. C. Cheddar cheese cubes. D. Natural whole almonds. E. Lightly salted potato chips

BD

• A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? • Review the surgical consent with the client • Explain that vomiting can occur during surgery • Remove the food from the client • Withhold the preoperative medication

BD

• A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication? • increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure • the antagonistic interaction among the various blood pressure medications has reduced their effectiveness • The additive effect of multiple medications has caused the blood pressure to drop too low • the synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension

C

• Based on principles of asepsis, the nurse should consider which circumstance to be sterile? • One inch- border around the edge of the sterile field set up in the operating room • A wrapped unopened, sterile 4x4 gauze placed on a damp table top. • An open sterile Foley catheter kit set up on a table at the nurse waist level • Sterile syringe is placed on sterile area as the nurse riches over the sterile field. •

C Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1-inch border (A). A sterile objects become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface.

• An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? • 9 % • 18 % • 36 % • 45 %

C • Rational: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equals 36% TBSA, other options are incorrect.

• When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? • Resume normal physical activity • Drink electrolyte fluid replacement • Give a dose of regular insulin per sliding scale • Measure urinary output over 24 hours.

C • Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and self-administer a dose of regular insulin per sliding scale.

• The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? • Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. • Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. • Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container • Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

D Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis

• When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? • The client is too obese • Palpating in the wrong abdominal quadrant • Deeper palpation technique is needed • The gallbladder is normal

D • Rationale: a normal healthy gallbladder is not palpable

A client is receiving an IV of heparin sodium 25000 units in 5% dextrose injection 500 ml at 14 ml/hour...verify that the client is receiving the prescribed amount of heparin. How many units is the client receiving?

• 700 • Rationale: 25000/500x14=700

• Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? • Sudden dysphagia • Blurred visual field • Gradual weakness • Profuse diarrhea

A

• A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication? • Nausea and indigestion. • Hypersalivation • Eyelid and facial twitching Increased appetite

A

• A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? • Observe aspiration site. • Assess body temperature • Monitor skin elasticity • Measure urinary output

A

• When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has • A collapsed lung • A history of COPD • A chronic lung infection • Normally functioning lungs

A

• A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? • 0.9% sodium chloride solution (normal saline) • 0.45% sodium chloride solution (half normal saline) • 10% Dextrose in 0.45% sodium chloride • 5% dextrose in 0.2% sodium chloride

A

5. A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? A. Regular insulin. B. Hydrocortisone C. Broad spectrum antibiotic D. Potassium chloride

A

• A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size? • Thready brachial pulse. • Respirations of 24/minute • Right foot cool to touch • Swelling at the site of injury

A

• A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest? • Malignancy • Bacterial infection • Viral infection • Lymphangitis

A

• A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? • Cardiac rhythm and heart rate. • Daily intake of foods rich in potassium. • Hourly urinary output • Thirst ad skin turgor.

A

• A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? • Allopurinol (Zyloprim) • Aspirin, low dose • Furosemide (lasix) • Enalapril (vasote)

A

• A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend? • Drink chamomile tea at breakfast and in the evening. • Eat food high in garlic with the evening meal • Join a yoga class that meets at least weekly • Increase cocoa in the diet and drink before bedtime

A

• A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement? • Negative pressure environment • Contact precautions • Droplet precautions • Protective environment

A

• A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? • Negative pressure environment • contact precautions • droplet precautions • protective environment

A

• Which client is at the greatest risk for developing delirium? • An adult client who cannot sleep due to constant pain. • an older client who attempted 1 month ago • a young adult who takes antipsychotic medications twice a day • a middle-aged woman who uses a tank for supplemental oxygen

A

• The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) •

Answer: 12160 • Rationale: 4ml x 67kg x 40 (bsa) =12,160 ml

22. The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A. Stopper port located above the water-seal level B. Plastic tubing located at the chest insertion site C. Rubberized port at the bottom of collection chamber D. Tubbing located on the top of the suction chamber

B

23. While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Apply ice first, then a warm compress to the IV site B. Discontinue the painful IV after a new IV is inserted C. Review the medical record for the date of insertion D. Document that the medication was not administered

B

• In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? • Lactate • Glucose • Hemoglobin • Creatinine

B

• A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important? • Review record of recent analgesia • Provide frequent pulmonary toilet • Prepare the client for intubation • Obtain STAT arterial blood gases

C

• A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? • capillary glucose • urine specific gravity • Serum calcium • white blood cell count

C

• A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan? • Weigh every morning • Eat a high protein diet • Perform range of motion exercises • Limit fluid intake to 1,500 ml daily

A

• A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include? • Wash hands before cleaning exit site • Keep the head of the bed flat at night • Feel for a thrill and a distal pulse nightly • Do not get up if fluid is left in the abdomen

A

• A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement? • Overlook the client's behavior. • Distract client to interfere with the ritual. • Ask why the client checks the pulse. • Hold client's hand to stop the behavior.

A

• A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? • Prepare the skin for procedure. • Identify client's pulse points • Witness consent for procedure • Check telemetry monitoring

A

• A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition? • Stroke • Renal failure • Left ventricular hypertrophy • Pulmonary hypertension

A

• A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? • Hypernatremia • Excessive thirst • Elevated heart rate • Poor skin turgor

A

• The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? • Jaundice • Nausea • Fever • Fatigue

A

• A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client? • Pulse increase of 10 beats/minute • Proteinuria • Glucosuria • Fundal height 0f 22 centimeters

A

• A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse? • Hypotension. • Fever and chills • Dizziness • Headache

A

• The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: • Restlessness • Clenched Fist • Increased pulse rate • Increased respiratory rate. • Increased temperature • Peripheral pallor of the skin

ABCD

• A client with superficial burns to the face, neck, and hands resulting from a house fire...which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...? • Expiratory stridor and nasal flaring • Mucous membranes cherry red color • Carbonaceous particles in sputum

B

• The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? • Case management and screening for clients with HIV. • Regional relocation center for earthquake victims • Vitamin supplements for high-risk pregnant women. • Lead screening for children in low-income housing.

C • Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental.

• A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? • Allow the client to use a bedpan. • Assist the client to the bathroom • Perform a sterile vaginal exam • Explain the fetal head is descending.

C • Rationale: When a client in active labor suddenly expresses the urge to have a bowel movement, a sterile vaginal exam should be performed to determine if the fetus is descending.

• A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? • Increased Glasgow coma scale score. • Nuchal rigidity and papilledema. • Confusion and papilledema • Periorbital ecchymosis.

C • Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.

• Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? • Neutrophils • Lymphocytes • Eosinophils • Monocytes •

C Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms.

19. A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Identify local support HIV support groups. B. Assess for symptoms of AIDS dementia. C. Observe for adverse drug reaction. D. Monitor for secondary infections.

D

• A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? • "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best" • " I never use the inhaler unless I am feeling really short of breath" • I always shake the inhaler several times before I start" • "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away"

D

• The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? • Rebound tenderness in the upper quadrants • Hypoactive bowel sounds in the lower quadrants • Tympany with percussion of the abdomen • Light colored gastric aspirate via the nasogastric tube

a

• The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth)

• 0.4 • rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml

• The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is....which action should the nurse take to ensure adequate filling of the drip chamber? • Lower the IV bag to a flat surface • Compress the drip chamber • Open the roller clamp Squeeze the bag of IV solution

B

• The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and tells the nurse, "I just don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain? • Cognitive • Affective • Comprehension • Psychomotor

B

• While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? • "How old do you think I am?" • "We need to stay focused on the topic." • "I think I am qualified to teach this group." • "Do you think you can teach it any better?"

B

• While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement? • Encourage the client to continue verbalize his anxiety • Attempt to distract the client with general conversation • Explain the procedure in detail while removing the staples Reassure the client that this is a simple nursing procedure

B • Rational: Distract is an effective strategy when a client experience anxiety during an uncomfortable procedure. (A & D) increase the client's anxiety.

• In early septic shock states, what is the primary cause of hypotension? • Peripheral vasoconstriction • Peripheral vasodilation • Cardiac failure • A vagal response

B • Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.

• The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? • Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle • Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. • For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. • Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours.

B • Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided specimen invalidate the test.

• A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement? • Schedule a home visit in the afternoon to assess the son and client role as caregiver. • Acknowledge the client's stress and suggest that she consider respite care. • Provide feedback to the client about her atonement for guilt about her son's impairment. • Teach the client to problem-solve for herself and establish her own priorities.

B • Rationale: When this amount of disclosure is offered, the client is usually seeking information focuses on the client's expression of worry, concern and stress and addresses the client's need to initiate a request for assistance with respite care.

• A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? • Administer naloxone (Narcan) per PNR protocol • Initiate seizure precautions • Obtain a serum drug screen • Instruct the family about withdrawal symptoms.

B • Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client.

• The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client's 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply) • Maintain current caloric intake • Avoid use of alcohol as a sleep aide at bedtime • Reduce intake of dairy products • Start a weight loss program • Set a goal of increasing BMI (Body Mass Index)

BD

• The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? • Give the child syringes or hospital mask to play it at home prior to hospitalization. • Include the child in pay therapy with children who are hospitalized for similar surgery. • Provide a family tour of the preoperative unit one week before the surgery is scheduled. • Provide doll an equipment to re-enact feeling associated with painful procedures.

C Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking

• The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement? • Obtain a second IV access. • Decrease the room temperature. • Give the prescribed antiemetic. Insert an indwelling catheter

C

• What is the nurse's priority goal when providing care for a 2-year-old child experiencing seizure... • Stop the seizure activity • Decrease the temperature • Manage the airway • Protect the body from injury

C

• When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? • Include the family in client's care • Request the chaplain's presence • Ask the family to identify a specific spokesperson • Page the healthcare provider to speak with family.

C

• While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? • Tinea corporis • Herpes zoster • Psoriasis • Drug reaction

C

• When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client? • Doubt • Observation • Confrontation • Reflection

D

• A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks: • Administer Oxygen via face mask • Apply an internal fetal heart monitor • Notify the healthcare provider • Use a vibroacoustic stimulator

A

• A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse? • Uncontrollable drooling • Inability to raise voice • Tingling of extremities • Eyelid drooling

A

• Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? • Ensure that the knot can be quickly released. • Tie the knot with a double turn or square knot. • Move the ties so the restraints are secured to the side rails. • Ensure that the restraints are snug against the client's wrist.

A

• A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide? • Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed. • Encourage the client to seek genetic counseling to determine his risk for mental illness. • Informed the client that his mother schizophrenic has affected his psychological development. • Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.

A

• During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement? • Stop the transfusion start a saline • Observe for a maculopapular rash • Report the fever to the blood bank • Give a PRN dose of acetaminophen

A

• A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? • Altered consciousness within the first 24 hours after injury. • Cushing reflex and cerebral edema after 24 hours • Fever, nuchal rigidity and opisthotonos within hours • Headache and pupillary changes 48 hours after a head injury

A

• After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? • Capillary refill of 8 seconds • bruises on arms and legs • round and tight abdomen • pitting edema in lower legs

A

• In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents? • avoid smoking in the house • stop smoking immediately • decrease the number of cigarettes smoke daily • obtain nicotine patches to assist in smoking sensation

A

• A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? • Reduced level of pain • Full volume of pedal pulses • Granulating tissue in foot ulcer Improved visual acuity

A

• A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement? • Measure vital signs • Auscultate breath sounds • Palpate the abdomen • Observe the skin for bruising

A

• An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? • Delirium • Depression • Dementia Psychotic episode

A

• An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can...to exhibit? • Irritability and a high-pitched cry • Lethargy and poor suck • Facial abnormalities and microcephaly • Low birth weight and intrauterine growth retardation

A

• A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mothers enter the labor suite and says in a loud voice, "I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!" what action should the nurse take? • Request the mother to leave the room • Tell the mother to stop speaking for the client • Request security to remove her from the room • Notify the charge nurse of the situation

A

• A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? • How many departments can use this equipment? • Will the equipment require annual repair? • Is the cost of the equipment reasonable? • Can the equipment be updated each year?

A

• A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action? • Allow several minutes for the client to respond • Ask social services to find a Korean interpreter • Repeat the question slowly and distinctly • Establish direct eye contact with the client

A

• A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care? • Monitor urine output hourly. • Assess for back muscle aches • Record drainage from drain • Obtain body weight daily

A

• The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? • Diabetic ketoacidosis and titrated IV insulin infusion • Emphysema extubated 3 hours ago receiving heated mist • Subdural hematoma with an intracranial monitoring device • Acute coronary syndrome treated with vasopressors

A

• The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? • Yogurt and/or buttermilk. • Avocados and cheese • Green leafy vegetables • Fresh fruits

A

• The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? • Examine the genitalia as the last part of the total exam. • Use soothing statements to facilitate cooperation • Allow the child to keep underpants on to examine genitalia • Work slowly and methodically so not to stress the child

A

• The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit? • Dyspnea, cough, and fatigue. • Hepatomegaly and distended neck veins • Pain over the pericardium and friction rub. • Narrowing pulse pressure and distant heart sounds.

A

• The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? • Antibiotics • Anticoagulants • Antihypertensive • Anticholinergics

A

• The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? • High pitched or fine crackles. • Rhonchi • High pitched wheeze • Stridor

A

• The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) • Murmur • s1 s2 • pericardial friction rub • s1 s2 s3

A

• The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? • Increase the oxygen flow via nasal cannula if dyspnea is present. • Place in a Trendelenburg position to increase cerebral blood flow • Monitor capillary glucose measurements hourly during transfusion. • Encourage increased intake of oral fluid to improve skin turgor.

A

• The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention... • Determine the availability of two units of packed cells in the blood bank for client B • Increase the oxygen flow rate to 4 liters/minute per face mask for client A • Remove any foods, such as banana or orange juice, for the breakfast tray for client C • Inform client D that surgery is likely to be delayed until the infection responds to antibiotics

A

• The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? • Exercise at least three times weekly • Monitor blood glucose levels daily • Limit intake of foods high in saturated fat • Learn to read all food product labels

A

• The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? • Protect joint function • Improve circulation • Control tremors • Increase weight bearing

A

• The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? • Heat loss • Hypoglycemia • Fluid balance • Bleeding tendencies

A

• The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? • What food does your baby usually eat in a normal day? • What was the baby's weight at the last well-baby clinic visit? • The baby is below the normal percentile for weight gain • Your baby is gaining weight right on schedule

A

• What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? • Initiate the dosage lockout mechanism on the PCA pump • Instruct the client to use the medication before the pain becomes severe • Assess the abdomen for bowel sounds. • Assess the client ability to use a numeric pain scale

A

• Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)? • Body mass index • Level of consciousness • Self-description of pain • Breath sounds

A

• Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? • Avoid exposure to respiratory infections • Use relaxation exercises when anxious • Plan short, frequent rest periods • Continue physical therapy at home

A

• A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? • Hypokalemia • Ketonuria. • Peripheral edema • Elevated blood pressure

A Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias

• A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain? • Presence of bruising, weakness, or fatigue • Therapeutic exercise included in daily routine. • Average amount of protein eaten daily • Existence of gastrointestinal discomfort

B

• An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? • Multiple organ dysfunction syndrome (MODS) • Disseminated intravascular coagulation (DIC) • Chronic obstructive disease. • Acquired immunodeficiency syndrome (AIDS)

A • Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.

• The client with which type of wound is most likely to need immediate intervention by the nurse? • Laceration • Abrasion • Contusion • Ulceration

A • Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut.

• When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? • To reduce abdominal pressure on the diaphragm • to promote retraction of the intercostal accessory muscle of respiration • to promote bronchodilation and effective airway clearance • to decrease pressure on the medullary center which stimulates breathing

A • Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing.

• The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? • Auscultate the client's bowel sounds • Observe for edema around the ankles • Measure the client's capillary glucose level • Count the apical and radial pulses simultaneously

A • Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds

• An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? • Start an intravenous (IV) infusion of normal saline • obtain a serum potassium level • administer the client's usual dose of insulin • assess pupillary response to light

A • Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance.

• A multigravida, full-term, laboring client complains of "back labor". Vaginal examination reveals that the client's 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement? • Turn the client to a lateral position • Apply counter-pressure to the sacral area • Notify the scrub nurse to prepare the OR • Ambulate the client between contractions

B

• Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. • Prepare medication reversal agent • Check oxygen saturation level • Apply oxygen via nasal cannula • Initiate bag- valve mask ventilation. • Begin cardiopulmonary resuscitation

ABC • Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary.

• The nurse is preparing to discharge an older adult female client who is at risk for hy...nurse include with this client's discharge teaching? • Report any muscle twitching or seizures • Take vitamin D with calcium daily • Low fat yogurt is a good source of calcium • Keep a diet record to monitor calcium intake • Avoid seafood, particularly selfish

ABCD

• A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) • Monitor abdominal girth. • Increase oral fluid intake to 1500 ml daily. • Report serum albumin and globulin levels. • Provide diet low in phosphorous. • Note signs of swelling and edema.

ACE • Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.

• A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? • Move to welcome and accommodate a new person • Ask the new person to move belonging to accommodate others • Tell the new person to move belongings because of limited space • Bring in additional chairs so that all staff members can be seated

B

• A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) • Collect multiple site screening culture for MRSA • Call healthcare provider for a prescription for linezolid (Zyrovix) • Place the client on contact transmission precautions • Obtain sputum specimen for culture and sensitivity Continue to monitor for client sign of infection

ACE • Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated9D) based on the client's history is a wound infection.

• A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? • Fingerstick glucose assessment q6h with meals • Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose • Review with the client proper foot care and prevention of injury • Do not contaminate the insulin aspart so that it is available for iv use • Coordinate carbohydrate controlled meals at consistent times and intervals • Teach subcutaneous injection technique, site rotation and insulin management

ACEF

28. A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

B

• A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? • Beta blockers • Bronchodilators • Corticosteroids • Beta-adrenergics

B

• A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? • Abnormal responses for cranial nerves I and II • Persistent coughing while drinking • Unilateral facial drooping • Inappropriate or exaggerated mood swings

B

• A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement? • Hold the next dose of antibiotic until contacting the healthcare provider • Teach the client how to use a dry heating pad over the painful area • Encourage the client to practice pelvic floor exercises every hour • Assist the client to splint the site by applying an abdominal binder

B

• The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? • Opening the package • Picking up the second glove • Picking up the first glove • Positioning of the table

B

10. A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol. C. Give IV dose of adenosine rapidly over 1-2 seconds. D. Deliver another defibrillator shock.

C

21. Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? A. Blood tinged sputum B. Expiratory wheezing C. Upper airway stridor D. Oxygen saturations 90%

C

29. When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? A. Ignore the behavior and hang the IV antibiotic B. tell the client to stop the inappropriate behavior C. Leave the room and close the door quietly D. Complete an unusual occurrence report

C

• A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? • Supplemental hormonal therapy will probably be unnecessary • The thyroid will regenerate to a normal size within a few years. • The client will be restricted from eating seafood • The remainder of the thyroid will be removed at a later date.

C

• A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? • Crutches with 2 point gait. • Crutches with 3 point gait. • Crutches with 4 point gait. • A quad cane

C

• A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care? • Adhere to a bland diet whenever planning to eat out • Decrease fluid intake at meal times • Avoid foods that caused gas before the colostomy • Eliminate foods high in cellulose

C

• A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect? • Decrease in serum T4 levels • Increase in blood pressure • Decrease in pulse rate • Goiter no longer palpable

C

• A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? • Administer epinephrine IV • Give an IV bolus of amiodarone • Provide immediate defibrillation • Prepare for synchronized cardioversion

C

• An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? • Addiction • Phobia • Compulsion • Obsession

C

• Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication? • Arterial ischemia • Tissue necrosis • Fat embolism • Nerve damage

C

• On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take? • Encourage the nurse to purchase reading glasses in the hospital gift shop • Request another nurse to assist the staff nurse with her documentation • Ask the nurse to return home and get her prescription eyeglasses for work. Tell the staff nurse to take a day off and change her weekly work schedule

C

• The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is • Two days postoperative bladder surgery with continuous bladder irrigation infusing. • One day postoperative laparoscopic cholecystectomy requesting pain medication. • Three days postoperative colon resection receiving transfusion of packed RBCs. • Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12 hours.

C

• When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? • Arrange to transport the client to the hospital • Instruct the client to keep a food journal, including portions size. • Review the client's use of over the counter (OTC) medications. • Reinforce the importance of keeping the feet elevated.

C Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology

• A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? • Headache • Joint stiffness • Persistent fever • Increase hunger and thirst

C • Rationale: Enbrel decrease immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider.

• The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? • An adult female who has been depress for the past several month and denies suicidal ideations. • A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. • A young male with schizophrenia who said voices is telling him to kill his psychiatric. • An elderly male who tell the staff and other client that he is superman and he can fly.

C • Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk.

• While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? • Ask the mother what she usually uses on the child's lips and nose • Apply a petroleum jelly (Vaseline) to the child's nose and lips • Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips • Use a water soluble lubricant on affected oral and nasal mucosa

D

• An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement? • Ask a family member to sit with the client • Apply bilateral soft wrist restraints • Assign staff to check client q15 minutes • Install a bed exit safety monitoring device

D

• Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? • Review the immunization records of all children in the elementary school • Report the measles outbreak to all community health organizations • Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated children. • Restrict unvaccinated children from attending school until measles outbreak is resolved.

D

• Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? • Maintain adequate cardiac output • Promote adequate tissue perfusion • Promote rest and sleep • Reduce the risk for injury

D

• In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? • Note the appearance and patency of the client's peripheral IV site. • Palpate the volume of the client's right radial pulse • Auscultate the client's breath sounds bilaterally. • Observe the amount and dose of morphine in the PCA pump syringe.

D

• Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution? • Place the dropper on the upper outer ear canal and instill the medication slowly. • Warm the medication in the microwave for 10 seconds before instilling. • Keep the medication refrigerated between administrations. • Have the child lie with the ear up for one to two minute after installation.

D

• The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? • Finger stick blood glucose 120 mg/dL post exchange • Arteriovenous (AV) graft surgical site pulsations. • Anorexia and poor intake of adequate dietary protein • Cloudy dialysate output and rebound abdominal pain

D

• The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? • Early treatment is very effective • I will clean my hot tub better • These warts are caused by a fungus • I need to have regular pap smears

D

• The nurse note a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? • Encourage the client's family to visit more often • Schedule a daily conference with the social worker • Encourage the client to participate in group activities • Engage the client in a non-threatening conversation.

D • Rationale: Consistent attempts to draw the client into conversations which focus on non-threatening subjects can be an effective means of eliciting a response, thereby decreasing isolation behaviors. There is not sufficient data to support the effectiveness of A as an intervention for this client. Although B may be indicated, nursing interventions can also be used to treat this client. C is too threatening to this client.

A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only).

• 18 • Rationale: 450000/25000=18

• The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

• 75 • Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour

• A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

• Answer 83 • Rationale: 1000 ml-----12hr. • Xml ---------1hr. • 1000/12 = 83.33 = 83.