Pass_point
Which heart defect can potentially causes a cyanotic defect from right-to-left shunting of blood?
"Pulmonary valve atresia is a rare abnormality and accounts for only 1 to 3% of cardiac defects. The pulmonary valve is atretic, and there is no exit from the right ventricle. All of the blood flows into the left atrium via the foramen ovale, and the lungs are only perfused via a very wide ductus arteriosus. The other three illustrated defects, ventricular septal defect, atrioventricular septal defect and a patent ductus arteriosus are associated with left-to-right shunting. Left-to-right shunt defects are noted as acyanotic lesions while the right-to-left shunt defects are cyanotic."
The nurse on a medical unit is caring for a 61-year-old male client with multiple myeloma who presents with coughing, fever, and chills. For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined.
Breath sounds: improved Oxygen saturation: improved Heart rate: improved Respiratory rate: improved Reports of cough: improved Abdominal assessment: declined Serum creatinine: no changes Serum calcium: declined
A 39-year-old female presents to the clinic with reports of unexplained weight gain over the past six months. The client has tried a low-calorie diet and exercise activities with no success. The client reports that the weight gain is centrally distributed to the abdomen. Reports additional symptoms of hair loss, fatigue, and muscle weakness. The client lives at home alone and is employed as a school teacher. Client is on a regular diet but reports cutting down on portion sizes over the last few months. Denies use of tobacco, alcohol, and other drugs. Denies medical and surgical history. BMI 32. Click to highlight the findings that require the nurse to follow-up.
Centrally distributed obesity noted, with thin extremities. Facial rounding with dorsocervical fat pads noted. Client endorses thinning hair on head. occasional premature ventricular contractions polyuria and excessive thirst easy muscle weakness and fatigue Purple striae noted to abdomen and thighs.
A nurse is caring for a preschool-age child. The client's documentation includes the following entry: Progress notes10/15 1115 Blood pressure 132/85 mm Hg HR 115/bpm and regular RR 22 breaths/min Parent reports child is unusually fatigued for past several weeks; resting hand tremors noted bilaterally; diaphoresis noted.
Facilitate testing of the child's T3 and T4 levels.
The nurse on a medical unit is caring for a 61-year-old male client with multiple myeloma who presents with coughing, fever, and chills. The nurse is reviewing the Nurse's Notes and Laboratory Results from day 1 at 0900 and 0930, respectively. Which assessment finding(s) requires follow up? Select all that apply.
Fever Breath sounds Sputum production Respiratory rate Heart rate
The nurse formulates a plan of care to address negative feeding patterns for a 5-month-old infant diagnosed with failure to thrive. To meet the short-term outcomes of the infant's plan of care, the nurse should expect to implement which intervention(s)? Select all that apply.
Observe the parent-child interactions. Instruct the parents on proper feeding techniques. Provide support to decrease parental anxiety.
A client is scheduled for electroconvulsive therapy (ECT). In what sequence will the nurse perform these interventions?
Obtain signed consent for treatment. Make client NPO. Remove dentures and jewelry. Have client empty the bladder.
The nurse received emergency verbal orders on a client. The client is now stable. What action is necessary when transcribing the verbal orders given during the emergency? Select all that apply.
The health care provider signs the orders, including time signed. The health care provider reviews the orders for accuracy. The health care provider's name and title are included when signing the orders. Generic drug names are included in the transcribed orders.
A 39-year-old female presents to the clinic with reports of unexplained weight gain. Complete the following sentence(s) by prioritizing from the lists of options. The nurse knows that the client is likely experiencing
The nurse knows that the client is likely experiencing Cushing syndrome as evidenced by dorsocervical fat pads
A 21-year-old female has given birth in the hospital. Drag words from the choices below to fill in each blank in the following sentence.
The nurse knows to notify the provider and anticipate orders, in order to continue proper care for the client.
A home health nurse is caring for a client in the home setting. Client presents to the office with reports of fatigue x 3 months. Client states they have not been seen by a provider "in about 2 years." Home health nurse presents to client's home to perform an admission assessment. Client notes that they are having numbness and tingling in both of their feet. Nurse prepares to test vibratory sensation on client's bilateral feet.
The nurse should first tap the tuning fork on the heel of the hand and then place the tuning fork firmly over the tip of the patient's great toe
The nurse is reconciling medications with a client who is being discharged. Which information indicates there is a discrepancy?
There is a lack of congruence between a client's home medication list and current medication prescriptions.
The nurse finds a confused client with soft wrist restraints in place (see figure). What should the nurse do first?
Untie the restraint, and resecure it to the bed frame using a quick-release knot.
The nurse-manager of a home health facility includes which item in the capital budget?
a $1,200 computer upgrade
The nurse is making the client assignment for a group of clients. The personnel include the registered nurse (RN), a licensed practical/licensed vocational nurse (LPN/LVN), and an unlicensed assistive personnel (UAP). Which client would the nurse assign to the LPN/LVN?
a client who is undergoing femoropopliteal bypass graft surgery this morning and needs the preoperative checklist completed
A nurse has received a report on four clients. Which client would the nurse visit first?
a client with tuberculosis who raised 50 mL of sanguineous sputum over the past 2 hours
What is the most important nursing intervention for a child with lead poisoning who must undergo chelation therapy with intramuscular edetate calcium disodium? The nurse should prepare the child for:a large number of injections.
a large number of injections.
The nurse is educating a client with a new colostomy on how to regain bowel control. Which action would the nurse emphasize as a priority?
an irrigation routine of the ostomy
When teaching an antepartum client about the passage of the fetus through the birth canal during labor, the nurse describes the cardinal mechanisms of labor. Using a teaching pelvis and fetus, the nurse demonstrates which sequence during birth? Place these events in the proper sequence. All options must be used.
descent flexion internal rotation extension external rotation expulsion
A 39-year-old female presents to the clinic with reports of unexplained weight gain. The nurse wants to educate the client about the process of diagnosing Cushing's disease. In order to do this, the nurse tells the client that a diagnosis of Cushing syndrome is achieved by
dexamethasone suppression test followed by 24-hour urine free cortisol level
The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown below. Which finding is expected when assessing this client?
dysfunction of bowel and bladder
A school-age child with Down syndrome has an upper respiratory infection (URI). The nurse assesses and finds upper lobe wheezing bilaterally, a respiratory rate of 28 breaths/min, and oxygen saturation of 97% on room air. What are the nurse's priority actions? Select all that apply.
providing fluids that the child likes to drink restricting visitation by ill family members ensuring that child is as active as possible
A client with a history of bronchial asthma is prescribed propranolol to control hypertension. Before administering propranolol, which initial action should the nurse take?
question the provider about the order
The nurse creates a safety plan with a client who is at risk for suicide. Which measures should be included in the plan? Select all that apply.
removing firearms from the home identifying the warning signs that a crisis may be developing listing effective coping strategies identifying people and social situations that can provide distraction listing people and places to call for help
A client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To help the client manage a manic episode, the nurse should suggest that the client:
reorganize a kitchen cabinet.
A client who is blind is admitted for treatment of gastroenteritis. Which intervention takes highest priority for this client?
replacing fluid volume
A client admitted with a diagnosis of dementia becomes agitated and violent. The nurse is reviewing the client's medication record. Which prescribed medication would be expected to reduce agitation?
risperidone
A client who is 2 months pregnant has hyperemesis gravidarum. Which expected outcome will the nurse set as a goal for this client?
"Client will exhibit uterine growth within the expected norms for gestational age."
The client is being monitored by the healthcare provider for ulcerative colitis (UC). The healthcare provider orders hydrocortisone therapy. What information should the nurse include in the teaching of a client receiving hydrocortisone therapy? Select all that apply.
"Do not abruptly stop taking the medication." "Avoid exposure to infections." "Wear a medical alert."
The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) would indicate that the client has understood the nurse's instructions? Select all that apply.
"I should always cover my mouth and nose when sneezing." "I should use paper tissues to cough in and dispose of them promptly."
A client is newly diagnosed as having human immunodeficiency virus (HIV). How would the nurse advise the client to prevent transmission to family members with whom the client lives?
"Keep your razor separate from family members' toiletries."
The nurse on a medical unit is caring for a 61-year-old male client with multiple myeloma who presents with coughing, fever, and chills. The nurse is developing a plan of care for this client. Which potential nursing intervention(s) would the nurse include? Select all that apply.
Administer a broad-spectrum antibiotic. Teach pulmonary hygiene. Provide supplemental oxygen. Administer an antipyretic. Provide instruction to avoid infection.
An intoxicated client has been placed in leather restraints for violent behavior. The nurse notes during an assessment that the client has a reddened area where one of the restraints touches the client's wrist. What should the nurse do?
Apply a cuff liner to the restraint.
A transfusion of packed red blood cells has been prescribed for a 1-year-old with sickle cell anemia. The infant has a 25-gauge IV infusing dextrose with sodium and potassium. Using the situation, background, assessment, and recommendation (SBAR) method of communication, the nurse contacts the health care provider and makes which recommendation?
using the existing IV, but changing the fluids to normal saline for the transfusion
A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. Which fetal heart rate pattern would the nurse find is most concerning?
sinusoidal pattern
While assessing a neonate at age 24 hours, the nurse observes several irregularly shaped, red, flat patches on the back of the neonate's neck. The nurse interprets this as which finding?
stork bite
A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect child abuse?
the child doesn't cry when the shoulder is examined.
A client with human immunodeficiency virus/acquired immunodeficiency disorder (HIV/AIDS) reports to the nurse a loss of 15 pounds in the past month and asks, "Do you think that I could use marijuana to help get my appetite back?" Assuming that medical maijuana is legal in the area, what is the nurse's best response?
"There are medications in addition to medical marijuana that can stimulate your appetite and help you to regain weight."
A client being admitted to hospital is asked to sign a statement confirming that the client understands the rights to communicate information related to life support and resuscitation. The client asks the nurse why signing such a statement is necessary. What is the best response by the nurse?
"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them."
The student nurse is administering medications to the clients. The nurse educator asks the student, "Which of the medication orders have the potential to cause a medication error?" What is the best response by the student? Select all that apply.
"cc" "QOD" "MgSO4"
A 21-year-old female has given birth in the hospital. The client is a 21-year-old G1 P0 with appropriate prenatal care beginning at 7 weeks gestation.. 1720: Lochia is present in a small amount with no odor. Fundus is firm below umbilicus. Episiotomy site is clean and dry with intact sutures. Slight redness at incision borders and mild edema. Client states a pain level of 5/10 before pain medication administration. Pain level is stated as a 3, 1 hour after pain medication administration and client appears comfortable. Day 2 0400: Lochia is present in a small amount with no odor. Fundus is firm below the umbilicus. Episiotomy site presents with edema and redness around the sutures with pale yellow drainage. Client states a pain level of 7 and appears to be uncomfortable. Which vital(s) and assessment(s) does the nurse identify as concerning?
Heart rate of 112 beats per minute Respiratory rate of 35 breaths per minute Temperature of 101.0°F (38.4°C) Edema, redness and yellow drainage present at the episiotomy site
The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent makes which statement?
I can borrow a special feeding table to use."
As the nursing supervisor walks past a client's room, they hear a family member berate and threaten the nurse if they do not change what they are doing to provide care for the client. The nurse apologizes and tries to explain what they are doing, but the family member only becomes more aggressive and hostile. What action should the nursing supervisor take first?
Inform the family member this is verbal abuse and must stop.
A client who gave birth to a healthy newborn 24 hours earlier asks the nurse, "Can you take the baby to the nursery while I go down to the cafeteria?" The client then adds, "Your turn to take the little frog!" and chuckles. How should the nurse respond?
"I was hoping we could take this time to talk a bit about how you're feeling about being a new parent."
A 39-year-old female presents to the clinic with reports of unexplained weight gain. The nurse is evaluating the client's understanding of Cushing syndrome. Select the two (2) client statements that indicate education was successful and there is a proper understanding of Cushing syndrome.
"I will wear a medical identification bracelet." "I will avoid processed foods when possible."
A pregnant client who has become frustrated by the insomnia that she experiences tells the nurse midwife that she is taking a low dose of melatonin at bedtime. What is the most therapeutic response by the nurse?
"It is not known if melatonin will harm an unborn child."
The nurse on a medical unit is caring for a 61-year-old male client with multiple myeloma who presents with coughing, fever, and chills. The nurse has received orders from the health care provider and is implementing the plan of care. Which intervention(s) will the nurse implement?
Instruct the client to avoid crowds. Teach the client to wash hands frequently. Teach the client to perform cough and deep-breathing exercises. Encourage increased fluid intake.
A young child has been brought to the emergency department with a burn to the right arm after a firework accidentally exploded. Which action should the nurse prioritize?
Keep the wound moist until it is properly cleansed.
A nurse is caring for a client she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:
euphoria and constricted pupils.
A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. The client has a history of smoking. What information is important to include in discharge teaching? Select all that apply.
Learn how to suction. Have communication rehabilitation with a speech pathologist. Attend a smoking cessation program. Provide humidity at home.
A physician prescribes 150 mg of ibuprofen for a toddler whose temperature did not decrease after receiving acetaminophen. The oral suspension available contains 100 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using one decimal place.
7.5
There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which client(s) should be transported immediately to a burn center for treatment? Select all that apply.
8-year-old client with third-degree burns over 10% of the body surface area (BSA) 20-year-old client who inhaled the smoke of the fire 50-year-old client with diabetes who has first- and second-degree burns on their left forearm (about 5% of the body surface area [BSA])
A 39-year-old female presents to the clinic with reports of unexplained weight gain. For each assessment finding, click to specify if it indicates Cushing syndrome, diabetes mellitus, or hypothyroidism. Each finding may support more than one diagnosis.
Cushing Syndrome: Purple striae, Polyuria, Fatigue, Thinning hair, Facial rounding, Dorsocervical fat pads Diabetes Mellitus: Polyuria Hypothyroidism: Fatigue, Thinning hair
A client loses control and throws two chairs toward another client. What should the nurse do next?
Call for assistance to restrain the client and administer a PRN intramuscular tranquilizer.
The nurse is preparing to initiate enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What intervention(s) will the nurse include in the client's plan of care? Select all that apply.
Change tubing and bag every 24 hours. Ensure patency of the tube prior to enteral feedings.
A RN is delegating client care responsibilities to a licensed practical/vocational nurse (LPN/VN). Which nursing responsibilities would be appropriate to delegate to the LPN/VN? Select all that apply.
Changing the client's decubitus foot ulcer dressing. Reinforcing the teaching of proper diabetic diet. Obtain a bedside glucose specimen test at 1100.
The client's family is concerned about pressure wound care costs with a current twice a day prescribed wound care. What are appropriate nursing actions to guide the client's rights with medical costs? Select all that apply.
Contact the hospital business office to discuss the current bill. Ensure the client that the claims are filed with the current insurance carrier.
A 39-year-old female presents to the clinic with reports of unexplained weight gain. The client is inquiring about the potential diagnosis. What education topic(s) about Cushing syndrome might the nurse expect to discuss with the client? Select all that apply.
Early morning blood draw Urine collection order High-protein, high-potassium, low-calorie, low-sodium diet Prevention for infections Osteoporosis
A 17-year-old female client with severe nodular acne is considering treatment with isotretinoin. What does the nurse instruct the client to do prior to beginning the medication?
Enroll in a risk management plan.
A 21-year-old female has given birth in the hospital. The nurse recognizes that care needs to be prioritized. Select the four (4) most important care tasks.
Episiotomy wound care with site culture. Notify the provider of abnormal findings. Administer pain medication as ordered. Draw labs
A toddler admitted in respiratory distress keeps pulling at the oxygen mask, trying to remove it. Which intervention(s) are initially indicated? Select all that apply.
Have the parent read to the child. Encourage the parent to hold the child.
The nurse on a medical unit is caring for a 61-year-old male client with multiple myeloma who presents with coughing, fever, and chills. For each assessment finding, click to specify if the finding indicates pneumonia, pleuritis, or myocarditis.
Pneumonia: Cough, Pleural friction rub, Fever, Tachypnea, Crackles, Sputum production Pleuritis: Pleural friction rub, Fever, Tachypnea Myocarditis: Fever, Tachypnea
A client has been diagnosed with deep vein thrombosis (DVT). Suddenly, the client develops chest pain and severe dyspnea. Which priority actions should be taken by the nurse? Select all that apply.
Position in Fowler's position, initiate oxygen, and notify the physician Auscultate for abnormal breath sounds and encourage deep breathing Assess vital signs and obtain oxygen saturation
The nurse in the acute care setting is caring for a 32-year-old client being treated for a deep vein thrombosis (DVT) with heparin infusion on day 3 of treatment. Temperature, 97.8°F (36.5°C), 80 beats/min; 20 breaths/min, 118/72 mm Hg. Pulse oximetry on room air: 98%. Skin warm and dry. DVT site left lower leg, skin intact. Slight swelling noted in left lower leg compared to right lower leg. Denies any pain or discomfort. Bilateral capillary refill brisk. Hair growth noted bilaterally on lower extremities. Able to move toes and extremities without discomfort. Abdomen soft, nontender. Bowel sounds present in all quadrants. Regular diet tolerated well. Voiding without difficulty. Last bowel movement (BM) this morning with a formed stool. Heparin infusion 16 units/kg/hr. intravenous (IV) based on last activated partial thromboplastin time (aPTT) readings: aPTT 50 seconds. Current aPTT results: 82 seconds.
Stop the heparin infusion. Decrease the heparin dose upon resumption. bleeding risk aPTT levels blood pressure
The nurse on a medical unit is caring for a 61-year-old male client. The nurse is reviewing the Nurse's Notes and Laboratory Results of 0900, day 1, with the health care provider who has diagnosed the client with pneumonia. Complete the following sentence by choosing from the lists of options.
The client is at highest risk for developing recurrent infections as evidenced by absolute lymphocyte count (ALC)
A 21-year-old female has given birth in the hospital. After analyzing the concerning assessment data, what conclusion can the nurse make regarding the client?
The client is developing an infection at the episiotomy site.
A nurse manager is working with a newly hired nurse in the emergency department (ED). ED nurse manager is preparing to fit a new nursing hire with an N-95 mask. Nurse manager is educating the new nurse on the process for N95 testing. New nurse applies the N95 mask by placing the mask on their face and pulling the bottom strap over the head and below the ears and then the top strap over the head and on the back of the head, near the crown. Nurse manager notes that the new nurse's glasses fog during heavy exhalation.
The nurse manager should now choose a new mask size because there is an air leak.
A 21-year-old female has given birth in the hospital. Complete the following sentence(s) by choosing from the lists of options.
The nurse should first perform episiotomy wound care with site culture
A nurse is developing a teaching plan for a child with acute poststreptococcal glomerulonephritis. What is the most important point to address in this plan?
blood pressure monitoring
The client with acquired immunodeficiency syndrome (AIDS) has developed Mycobacterium Avium Complex. Which interventions should be included in the nursing plan of care? Select all that apply
daily weights intake and output hemoglobin level
A client with a history of heart failure is receiving a lidocaine I.V. infusion at 2 mg/minute to treat runs of ventricular tachycardia. The client experiences hypotension, dyspnea, and irregular heartbeats. Which action can the nurse expect the physician to take first?
decreasing the lidocaine infusion to 1 mg/minute
The nurse is caring for a client in the newborn nursery. What appropriate actions can the nurse take that will help to prevent neonatal infection? Select all that apply.
good hand washing technique isolation of infected infants with communicable disease hand sanitizer with points of contact
A nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination
immediately after her menses.
The nurse is providing care for a school-age child with hypopituitarism. What is the nurse's priority intervention?
interventions to enhance the child's self-esteem
The nurse enters a client's room in the obstetrical unit and notices that the bassinet is empty. The maternal parent does not know where the infant is located. The nurse should first
maternal parent does not know where the infant is located. The nurse should first search the entire unit for the missing infant and notify hospital security with a description of the infant
A client with chronic bowel inflammation reports abdominal cramping and diarrhea for the past 4 days. The nurse would anticipate which test based on the client's concerns?
occult blood and organisms
A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time?
preparing for immediate delivery
A nurse is caring for a client who is on a continuous cardiac monitor. When evaluating the client's rhythm strip, the nurse notes that the QRS interval has increased from 0.08 second to 0.14 second. Based on this finding, the nurse should withhold continued administration of which drug?
procainamide
A client with bipolar disorder has been taking lithium carbonate, as prescribed, for the past 3 years. Family members have brought this client to the hospital. The client hasn't slept, bathed, or changed clothes for 4 days; has lost 10 lb (4.5 kg) in the past month; and woke the entire family at 4 a.m. with plans to fly them to Hawaii for a vacation. Based on this information, the nurse understands that:
the client's lithium level should be measured before receiving the next lithium dose.
The nurse is caring for a postoperative client who has undergone a transsphenoidal hypophysectomy. Which assessments would be most important for this client? Select all that apply.
urinary output fluid and electrolyte balance visual assessment
