Passpoint review- unit 3

A physician orders acarbose, an alpha-glucosidase inhibitor , for a client with type 2 diabetes . Which statement by the client indicates a need for additional teaching?

"If I experience hypoglycemia, I should eat something sweet."

A nurse recognizes that a client with tuberculosis needs further teaching when the client states:

"It will be necessary for the people I work with to take medication."

A nurse has just received report on four clients. Which client should the nurse see first?

A client who underwent a thyroidectomy and has new onset hoarseness.

During an initial shift assessment, a nurse finds a diabetic client who is lethargic and who has rapid, deep respirations. Which action should the nurse take?

Administer a saline bolus as needed.

Which instruction should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy?

Change diapers as soon as they become soiled.

A client with macrocytic anemia has a burn on her foot and reports watching television while lying on a heating pad. Which action should be the nurse's first response?

Check for diminished sensations.

A child is admitted to the hospital with a febrile seizure. What action should the nurse take?

Keep the room temperature low and bedclothes to a minimum.

A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication?

Labetalol

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action?

Observe individuals in the area for large bags or oversized coats.

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

Place a pressure-reducing mattress on the client's bed.

A group of people arrives at the emergency department reporting extreme periorbital swelling, cough, shortness of breath, and tightness in the throat. They report that someone threw a bomb that exploded at their feet. What is the best action by the nurse?

Take them to the decontamination area.

A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client?

Using incentive spirometry every 2 hours while awake.

When the nurse administers IV midazolam hydrochloride, the client demonstrates signs of an overdose. What should the nurse do next?

Ventilate with an oxygenated bag-valve mask.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk?

a 60-year-old Black man

A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which infection control practice does the nurse consider most important for this client?

adhering diligently to aseptic technique

Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?

calcium gluconate

A nurse is caring for a client in addisonian crisis. Which medication order should the nurse question?

potassium chloride

A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which finding has the greatest effect on fluid loss?

rapid, deep respirations

A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?

reserving an antecubital site for a peripherally inserted central catheter (PICC)

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

restricting fluids

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

restricting fluids to 800 ml/day

Immediately following a thyroidectomy, the nurse asks the client to say "hello." The client moves the lips, but is not able to speak the word. What should the nurse do next?

Notify the surgeon.

The nurse is assessing for blood return from a client's implanted port. Which nursing intervention is appropriate to assure that the needle will be flushed with pure saline?

Prevent blood from entering the saline flush syringe.

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

"Test your blood glucose every 4 hours."

Immediately after receiving an injection of bupivacaine, the client becomes restless and nervous and reports a feeling of impending doom. What should the nurse do next?

Assess the client's vital signs.

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care?

Bending and twisting while providing care may cause injury.

Which condition may contribute to hyperparathyroidism?

chronic renal failure

The nurse provides a neonate with an initial feeding. The nurse would suspect a tracheoesophageal fistula if the neonate demonstrated which behavior?

coughing, choking, and cyanosis that occur after several swallows of formula

The nurse is preparing to administer a suppository through a client's colostomy. What supplies will the nurse gather? Select all that apply.

gloves lubricating jelly

The adrenal cortex is responsible for producing which substances?

glucocorticoids and androgens

Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism?

hypercalcemia

The nurse is assessing a client with chronic obstructive pulmonary disease. Which finding requires immediate intervention?

inability to speak

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolbutamide. Which laboratory test is the most important for confirming this disorder?

serum osmolarity

A client has had a radical neck dissection for laryngeal cancer. Which action is the priority for nursing care immediately following this surgery?

suctioning the laryngectomy tube as often as needed

A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to

suggest referral to a sex counselor or other appropriate professional.

A nurse is teaching a client, newly diagnosed with chronic obstructive pulmonary disease (COPD), about the use of a respiratory inhaler. Which statement demonstrates understanding of the medications?

"Albuterol followed by beclomethasone is the correct administration."

The nurse is evaluating a client with hyperthyroidism who is taking propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance therapy. Which statement from the client indicates the drug is effective?

"I'm able to sleep and rest at night."

A client with diabetes is explaining to the nurse how to care for the feet at home. Which statement indicates that the client understands proper foot care?

"It's important to dry my feet carefully after my bath."

During a well-baby visit, a toddler's parent states that the parent keeps all medications out of the toddler's reach in the kitchen cabinet. Which is an appropriate response by the nurse?

"Medications should be kept in a locked location."

A client diagnosed with thyroid cancer signed a living will that states the client doesn't want ventilatory support if the condition deteriorates. As the client's condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best?

"What exactly do you mean by wanting 'everything' done for you?"

The healthcare provider orders a new medication for a 5-year-old client. The nurse educator asks the student, "What is a medication dose affected by?" What is the best response by the student? Select all that apply.

"disease state" "weight"

A client reports having difficulty voiding to the nurse. What question(s) will the nurse ask the client? Select all that apply.

-"Are you waking up in the middle of the night to void?" -"How much fluids are you drinking in the late evenings?" -"What are your usual voiding patterns?"

The nurse is teaching a client with type I diabetes self-administration of insulin. Which statement by the client would be an expected outcome of the teaching session? Select all that apply.

-"I need to make sure that I eat my meals and snacks on time after I take my insulin." -"If I monitor and control my blood glucose levels carefully, there is less likelihood of suffering long-term complications." -"If I exercise more than is normal, there is a risk that I might become hypoglycemic."

The home care nurse is working with an older adult client who was discharged from a rehabilitation facility after experiencing a hip fracture from a fall at home. The client lives alone and utilizes a walker to ambulate. What statements by the client lead the nurse to determine that additional home safety education is needed? Select all that apply.

-"I will use a chair with a back as my stepstool." -"I will wear my slippers in the house." -"I will not be able to use the walker in the bathroom."

An obese client, age 65, is diagnosed with type 2 diabetes. When educating this client about the diagnosis, the nurse knows that more education is needed when the client says which statement? Select all that apply.

-"If I follow my diet and exercise, I won't have diabetes any more." -"I can never eat a hot fudge sundae again." -"I guess I will need to stop meeting my friends at the coffee shop."

A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When the nurse informs the client that the physician has ordered a wound care nurse to examine the wound, the client asks why should anyone other than the staff nurse care for the wound. The client states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." Which responses made by the nurse would be appropriate? Select all that apply.

-"We're very concerned about your foot and we want to provide the best possible care for you." -"You could possibly lose your foot without proper care." -"The wound nurse is specially trained to care for diabetic wounds."

A coworker asks another nurse if a client received their pathology report. The coworker is not directly involved in the care of the client. How should the nurse respond? Select all that apply.

-"You need to review the hospital policy related to client privacy." -"I'm sorry, but I'm not at liberty to give you that information." -"Information can only be shared if you're involved in the client's care.

The healthcare provider orders a new medication for a 5-year-old client. The nurse educator asks the student, "What is a medication dose affected by?" What is the best response by the student? Select all that apply.

-"disease state" -"weight"

The client refuses to wear a name band on the arm during the hospital stay. The client is scheduled for surgery. What actions will the nurse take to ensure safe client identification? Select all that apply.

-Explain the need to have an identification name band. -Apply the name band to the client's leg.

The nurse working the mother-baby unit teaches the client about the facility's measures to prevent infant abduction. What precautions does the nurse discuss? Select all that apply.

-Infant footprints and a color photograph are taken soon after birth. -Only let staff wearing an appropriate ID badge transport your baby. -Notify the staff about anyone who appears unusual.

The client has been recently diagnosed with type 2 diabetes and is taking metformin two times per day, 1,000 mg before breakfast and 1,000 mg before supper. The client is experiencing diarrhea, nausea, vomiting, abdominal bloating, and anorexia on admission to the hospital. The admission prescriptions include metformin. What should the nurse do? Select all that apply.

-Inform the client that adverse effects of diarrhea, nausea, and upset stomach gradually subside over time. -Assess the client's renal function. -Monitor the client's glucose value prior to each meal.

The nurse is teaching a client how to self-administer epinephrine using an EpiPen autoinjector. What information should be included in the teaching? Select all that apply.

-Jab the EpiPen autoinjector firmly into the outer thigh. -After administering the injection, massage the area for 10 seconds. -Hold the EpiPen autoinjector against the thigh for 10 seconds.

A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. What should the nurse do in order of priority from first to last? All options must be used.

-Monitor for suicide and self-mutilation. -Monitor sleeping and eating behaviors. -Discuss the issues of loneliness and emptiness. -Discuss her housing options for after discharge

The unlicensed assistive personnel (UAP) records a capillary blood glucose of 253 mg/dL (14.04 mmol/L) and the nurse administered insulin for coverage to the client. The UAP reports to the nurse that the blood glucose was incorrect. What actions should the nurse take? Select all that apply.

-Obtain a current blood glucose level. -Observe the client for hypoglycemia. -Report the incident to the healthcare provider. -Complete an incident report.

The nurse is administering a tuberculin skin test. Place the steps for administering the tuberculin skin test in the correct order. All options must be used. Obtain a tuberculin syringe, a half-inch, 26-gauge needle, and purified protein derivative. Clean forearm area with alcohol. Draw up intermediate-strength purified protein derivative. Inject 0.1 ml of the purified protein derivative. Create a wheal that is 6 to 10 mm in diameter. Remove the tuberculin syringe and dispose of the tuberculin syringe

-Obtain a tuberculin syringe, a half-inch, 26-gauge needle, and purified protein derivative. -Draw up intermediate-strength purified protein derivative. -Clean forearm area with alcohol. -Inject 0.1 ml of the purified protein derivative. -Create a wheal that is 6 to 10 mm in diameter. -Remove the tuberculin syringe and dispose of the tuberculin syringe.

A nurse is preparing a client with type 1 diabetes for discharge. The client can perform self-care; however, the client has had a problem with unstable blood glucose levels in the past. Which intervention should the nurse include for this client's safe discharge? Select all that apply.

-Refer the client to a dietitian. -Give the client sample meal plans. -Review proper insulin administration.

Which information should the nurse include about hypoglycemia when teaching a client newly diagnosed with type 2 diabetes mellitus? Select all that apply.

-Regular meals and a bedtime snack will decrease the incidence of hypoglycemia. -Symptoms of hypoglycemia can include irritability, hunger, shaking, and sweating. -A carbohydrate food source should be available during strenuous exercise. -Alcohol consumption can increase the incidence of hypoglycemia.

A client is prescribed exenatide. What should the nurse instruct the client to do? Select all that apply.

-Review the one time set-up for each new pen. -Inject in the thigh, abdomen, or upper arm. -Administer the drug within 60 minutes before morning and evening meals.

A nurse is caring for a client who is being discharged after a thyroidectomy. Which discharge instructions would be appropriate for this client? Select all that apply.

-Take thyroid replacement medication as ordered. -Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin, and report these changes to the physician.

The charge nurse is completing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in airborne precautions? Select all that apply.

-a client diagnosed with tuberculosis -a client diagnosed with chicken pox

The nurse should review the glucose level of which clients who are going to surgery today? Select all that apply.

-a client with diabetes mellitus controlled by diet -a client with a high stress response to surgery -a client receiving corticosteroids for the past 3 months

Multiple casualties have been brought to the emergency department after a bus accident. The triage nurse is determining who will need immediate care. Place the clients in order of priority. All options must be used.

-a client with loss of consciousness and bleeding from the ears -a client with severe lacerations involving open fractures of major bones -a client with closed fractures of major bones -a client with partial-thickness (second-degree) burns covering 10% of the body -a client with pain from whiplash and soft-tissue injuries

A nurse is assessing a client who is postoperative and unable to verbally answer questions. Which non-verbal behavior(s) should the nurse interpret as the client having pain Select all that apply.

-clenching -restlessness -grimacing

The nurse is assisting a community to develop primary prevention strategies for its disaster management plan. What action should the nurse recommend? Select all that apply.

-creating a risk map -developing a resource map -planning an evacuation route

A nurse is caring for an older adult client who is admitted with an electrolyte imbalance. Which laboratory values should be a priority concern for the nurse? Select all that apply.

-pH 7.32 -potassium 5.8 mEq/L

The nurse is instituting a falls prevention program. Which personnel should be involved in the program? Select all that apply.

-registered nurses -unlicensed assistive personnel -housekeeping services -family members -client

A client with syndrome of inappropriate antidiuretic hormone (SIADH) is experiencing lethargy, weakness, headache, and muscle aches. Which intervention is the nurse's priority?

Initiate seizure precautions.

The nurse reviews the medical record of an adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure (see exhibit). Based on these findings, what action should the nurse take?

Notify the health care provider (HCP).

The nurse is assessing a pregnant client using Leopold's maneuvers. Which of the following nursing actions are appropriate for this assessment? Select all that apply.

Palpate the client's upper abdomen using both hands. Note the shape and consistency of the palpated part. Note the mobility of the palpated part.

A client infected with human immunodeficiency virus (HIV) has a low CD4+ level. What intervention should the nurse implement?

Place the client in reverse isolation.

A nurse is teaching accident prevention to the parents of a toddler. Which instruction is appropriate for the nurse to tell the parents?

Place toxic substances out of the child's reach.

The nurse is caring for a client in active labor and notes minimal variability on the external fetal monitor tracing. What are the nurse's priority interventions?

Position to left lateral, O2 per nonrebreather mask at 10 L.

A 22-year-old client with quadriplegia in supine position is apprehensive and flushed, with a blood pressure of 210/100 mmHg and heart rate of 50 bpm. Which nursing intervention should be done first?

Raise the head of the bed immediately to 90 degrees

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose?

Reduced serum ammonia levels.

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?

Report the incident to risk management.

The client is taking 50 mg of lamotrigine daily for bipolar depression. The client shows the nurse a rash on his arm. What should the nurse do?

Report the rash to the health care provider (HCP).

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate?

Return to the car and call the police.

A nurse explains to a client with thyroid disease that the thyroid gland normally produces

T3, thyroxine (T4), and calcitonin.

A nurse is caring for a client with hypothyroidism. The client is extremely upset about altered physical appearance. The client doesn't want to take the medication because "it isn't doing any good." What should the nurse do?

Tell the client that as the medication corrects the hormone deficiency, improvement in appearance can be expected soon.

The nurse working with a group of nursing students. What breaches in client care require the nurse to intervene to protect client privacy? Select all that apply.

Transporting a client to radiology on the public elevator Discussing clients in the cafeteria with other hospital staff

A client with a partial thickness burn injury has had Biobrane applied 2 weeks ago. The Biobrane is now separating from the wound. What nursing intervention is appropriate?

Trim away the Biobrane that has separated from the wound.

A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for:

Vertigo

After a thyroidectomy, the client develops a positive Trousseau's sign. What is the nurse's priority action?

administer calcium gluconate

A client with thrombocytopenia has just had a bone marrow aspirate performed to monitor for treatment effectiveness. Which nursing intervention takes priority?

applying pressure to the puncture site for a full 10 minutes

The client with leukemia presents to the IV therapy clinic for chemotherapy. The nurse asks the client to roll up a sleeve to look for an IV access site. Which vein can the nurse access for this therapy? Select all that apply.

cephalic antebrachial basilic

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus?

droplet precautions

A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances?

early defibrillation in cases of ventricular fibrillation

The nurse is instructing a college student with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which situation?

having wisdom teeth extracted

The health care provider has prescribed salicylates for an older adult client with osteoarthritis to relieve pain. The nurse knows to assess the client for what potential adverse reaction?

hearing loss

The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

lungs and kidneys

A laboring client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. Which medication would the nurse anticipate for these symptoms?

magnesium sulfate

During surgery, a patient develops hypothermia. The circulating nurse would monitor the patient closely for which finding?

metabolic acidosis

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the health care provider immediately?

moderate intercostal retractions

Which nursing intervention is appropriate for a client with an arm restraint?

monitoring circulatory status every 2 hours

As a nurse begins the shift on the obstetrical unit, there are several new admissions. The client with which condition would be a candidate for induction?

preeclampsia

A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of

profound neuromuscular irritability.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

runs of ventricular tachycardia

Which equipment should the nurse plan to use to help prevent external rotation of the client's right leg postoperatively?

sandbags

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of

sodium and potassium abnormalities.

Propylthiouracil (PTU) is prescribed for a client with Graves' disease. Which symptom should the nurse teach the client to report?

sore throat

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

sweating, tremors, and tachycardia

A client with hypothyroidism (myxedema) is receiving levothyroxine, 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug?

tachycardia

A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next?

temperature.

A client is going to receive an insulin pump prior to discharge and the nurse has done extensive teaching. Which statement indicates that the client has a good understanding about the pump?

"I will need to monitor blood glucose levels multiple times a day while on the insulin pump."

The nurse reviews insulin administration with a client. Which statement best indicates that the client will continue to perform the procedure correctly?

"I wrote down the steps in case I forget what to do."

The parent of a school-age client with diabetes tells the nurse that she does not want the school to know about her daughter's condition. Which is the nurse's best response?

"What is it that concerns you about having the school know about your daughter's condition?"

A 12-year-old client who has had type 1 diabetes since infancy tests his glucose level before lunch and has a reading of 245 mg/dL (13.6 mmol/L). What will the nurse do next? Select all that apply.

-Ask client to take the prescribed bolus dose plus additional aspart insulin per the sliding scale. -Ensure the client's lunch tray is present on the unit prior to giving insulin.

A nurse is caring for a 14-year-old client who was admitted with cellulitis and has been ordered warm compresses. The nurse delegates the treatment to the unlicensed assistive personnel (UAP). The compress causes a first-degree burn to the area. Which actions should the nurse initiate? Select all that apply.

-Complete an incident report regarding the event. -Notify the healthcare provider of the injury.

A client with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the following: a temperature of 103°F (39.4°C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order from first to last should the nurse perform the actions? All options must be used. Open the airway. Start an IV access site. Explain the situation to the family. Call the health care provider (HCP).

-Open the airway. -Start an IV access site. -Call the health care provider (HCP). -Explain the situation to the family.

A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris and a hemoglobin A1C of 10%. Which actions should the nurse take? Select all that apply.

-Prepare to schedule a trans-esophageal echo (TEE). -Evaluate the client's diabetic management regimen. -Obtain a blood sample for a troponin level.

A client receives 12 units of intermediate- or long-acting insulin and 6 units of fast-acting insulin each morning. Place the following actions in chronological order of how the nurse would demonstrate how to mix insulins. Use all options.

-Wipe off the vials with an alcohol swab. -Inject 12 units of air into the intermediate- or long-acting insulin vial. -Inject 6 units of air into the fast-acting insulin vial. -Withdraw 6 units of fast-acting insulin. -Withdraw 12 units of intermediate- or long-acting insulin .

The nurse in the emergency department is triaging victims of an airplane crash. Prioritize the clients in the order in which they should be treated from first to last. All options must be used. 14-year-old with a 2-inch (5.1-cm) laceration to the chin, history of asthma, respirations 26 breaths/min, audible wheezing a 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused a 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm a 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minute

-a 14-year-old with a 2-inch (5.1-cm) laceration to the chin, history of asthma, respirations 26 breaths/min, audible wheezing -a 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused -a 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes -a 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm

The nurse is reviewing the content of a prescription before giving it to a client. The nurse determines that the prescription is accurately written when which information is included on the prescription? Select all that apply.

-healthcare provider signature -frequency -dose

A client arrives to the emergency department (ED), with reports of chest pain. Electrocardiograph (ECG) exhibits an elevated ST segment. What are the priority actions by the nurse? Select all that apply.

-improving myocardial oxygenation -relieving pain -reduce cardiac output

A client in the intensive care unit has a critically low potassium level of 1.9 mEq/l (mmol/l). What would be the best way to replace this client's potassium?

Administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each

A client newly admitted to a skilled nursing facility has diabetes and has been experiencing episodes of hypoglycemia. Place in chronological order the steps of evening care for this client. All options must be used.

Assess orientation. Assess blood glucose level. Provide evening meal. Assess percentage of meal eaten. Administer 15 units of insulin aspart insulin. Provide an evening snack.

The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first?

Check the function of the suction equipment.

A nurse hears a staff member giving incorrect information to the family of a client newly diagnosed with diabetes mellitus who is being discharged to home. The nurse wants to make sure the family has the proper information before the client is discharged. What should the nurse do?

Have the nurse step outside of the room, discuss the situation, and use it as a learning opportunity.

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding?

Note the finding on the assessment record.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities.

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes, and her cervical exam is dilated 3 cm, 100% effaced, and station −1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. What is the nurse's the priority action?

Notify the provider of the pain and request an assessment for potential abruption.

The nurse is administering a tuberculin skin test. Place the steps for administering the tuberculin skin test in the correct order. All options must be used. Clean forearm area with alcohol. Draw up intermediate-strength purified protein derivative. Inject 0.1 ml of the purified protein derivative. Remove the tuberculin syringe and dispose of the tuberculin syringe. Obtain a tuberculin syringe, a half-inch, 26-gauge needle, and purified protein derivative. Create a wheal that is 6 to 10 mm in diameter.

Obtain a tuberculin syringe, a half-inch, 26-gauge needle, and purified protein derivative. Draw up intermediate-strength purified protein derivative. Clean forearm area with alcohol. Inject 0.1 ml of the purified protein derivative. Create a wheal that is 6 to 10 mm in diameter. Remove the tuberculin syringe and dispose of the tuberculin syringe.

A client with depression is exhibiting a brighter affect, ability to attend to hygiene and grooming tasks, and is beginning participation in group activities. The nurse asks the client to identify three of her strengths. After much hesitation and thinking, the client can state she is usually a nice person, a good cook, and a hard worker. What should the nurse do next?

Reinforce the client for identifying and sharing her strengths.

A nurse is assigned to a client who is using an insulin pump. The nurse has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first?

Request information about nursing responsibilities in caring for a client with a pump.

The client who has undergone a bilateral adrenalectomy is concerned about persistent body changes and unpredictable moods. What should the nurse teach the client about these changes?

The body and mood will gradually return to normal.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?

The client is able to refuse medications.

Several children were admitted yesterday. Place the children in the order of priority, from first to last, that the nurse will assess them. All options must be used.

a 12-year-old child newly admitted with a fractured femur and lacerated liver a 3-year-old child with acute pyelonephritis and a temperature of 102.5° F (39.2° C) a 10-month-old infant with pneumonia and respiratory rate of 38 breaths/minute a 3-month-old infant with respiratory syncytial virus and stable vital signs

A client presents with a congenital heart defect and increased pulmonary blood flow. Which signs or symptoms will alert the nurse that congestive heart failure is occurring? Select all that apply.

coughing tachypnea with feeding coarse breath sounds

A client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

metabolic acidosis

The nurse should teach the diabetic client that which is most indicative of hypoglycemia?

nervousness

A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client?

nitroprusside

Laboratory studies indicate a client's blood glucose level is 185 mg/dl (10.2 mmol/L). Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use?

serum glycosylated hemoglobin (Hb A1c)

A client has been hospitalized for 3 days and is now experiencing symptoms of pneumonia, confirmed by chest X-ray. Which action is a priority for preventing this type of pneumonia?

staff education for prevention of hospital-acquired pneumonia (HAP)

The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. When conducting a focused assessment, what should the nurse should assess the client for?

tachycardia

A client has been diagnosed with metabolic alkalosis. The nurse should anticipate what finding from the client's arterial blood gases?

serum bicarbonate of 28 mEq/L

A female client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in

serum glucose level.

When educating the client with type 1 diabetes, the nurse knows that more education is needed when the client says:

"I will be able to switch to insulin pills when my sugar is under control."

The nurse is teaching a client about levothyroxine. Which instruction should a nurse offer the client?

"Take the drug on an empty stomach."

A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. What should the nurse tell the client?

"Taking ginseng will increase the risk of hypoglycemia."

A nurse is caring for an infant who requires intravenous therapy. The nurse notes that the only available IV pump is in a toddler's room. In which order should the nurse complete the following actions? 1. Remove pump from toddler's room. 2. Clean the pump. 3. Take pump into infant's room. 4. Use the pump.

1, 2, 3, 4

A client has been ordered vancomycin 1400 mg I.V. The medication is placed in 250 mL of normal saline. At which rate should the nurse set the pump to infuse the medication over 90 minutes? Record your answer using a whole number.

167

A client receiving intravenous heparin has developed hematuria and petechiae. What is the nurse's best action?

Administer protamine sulfate.

The nurse is evaluating a hemodynamically unstable client with an arterial line and notes that the client has tachycardia, cool and clammy skin, a pericardial friction rub, and the arterial waveform shows an inspiratory systolic pressure that is 15 mm Hg less than the expiratory systolic pressure. What is the priority intervention by the nurse?

Contact the health care provider.

The nurse caring for a client with an arteriovenous (AV) fistula notes that the fingers distal to the fistula are cold to the touch and the capillary refill time is greater than 3 seconds. What is the priority action by the nurse?

Contact the healthcare provider.

A client is informed by his healthcare provider that a tumor has been found. When the nurse sees the client later, the client states that no one knows what is wrong with him. The nurse determines that the client is experiencing which of the following?

Could be in denial

A child with hemophilia is brought to the clinic with spontaneous soft tissue bleeding of the right knee. Immediately on the child's arrival, what should the nurse do?

Elevate the right knee.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next?

Return the residual and begin the feeding.

After administering prescribed medications to clients, which client requires immediate intervention?

a client taking digoxin who has a morning potassium level of 3.0 mEq/L

The nurse is concerned about poor nutritional status of several clients on the unit. The nurse recommends placement of a gastrostomy tube for feeding as most appropriate for which client?

a client with dysphagia from a stroke 1 month ago and awaiting extended care

The nurse is assessing a client who has been admitted with impaired arterial circulation in the lower extremities due to diabetes mellitus. What findings would be expected?

absence of dorsalis pedis pulse, coolness, and decreased sensation in the feet

A client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that their spouse sleeps in another room because the client's snoring keeps the spouse awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia?

acromegaly

The nurse is assigned a client with a nasogastric (NG) tube. What intervention will the nurse include in the client's plan of care?

assessment of lung sounds every 4 hours

The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history?

atrial fibrillation and a mild stroke one month ago

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to

auscultate bowel sounds.

The nurse is caring for a client prescribed a tocolytic agent. The nurse takes immediate action based on what assessment finding?

bilateral crackles on lung auscultation

A nurse notices that a client with obsessive-compulsive disorder washes the hands for long periods each day. How should the nurse respond to this compulsive behavior?

by setting aside times during which the client can focus on the behavior

A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which is the appropriate nursing intervention?

contacting the physician

A school-age child is admitted to the hospital with acute rheumatic fever with chorea-like movements. Which eating utensil should the nurse remove from the meal tray?

fork

A client who is 12 hours post total thyroidectomy reports tingling around the mouth. Which assessment is the priority?

calcium level

A nurse has just been trained in how to use and care for a new blood glucose monitor. Which nursing intervention demonstrates proper use of a blood glucose monitor?

calibrating the machine after installing a new battery

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

confusion and seizures

The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The health care provider orders lab work and a dexamethasone suppression test. Which parameter would the nurse assess on the dexamethasone suppression test?

cortisol levels before and after the system is challenged with a synthetic steroid

The nurse is planning care for an infant with bronchiolitis who requires monitoring for fluid balance. What is the most accurate assessment the nurse can perform to determine the total body water volume of the infant?

daily weight

Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?

daily weight

The nurse should institute which measure to prevent transmission of the hepatitis C virus to health care personnel?

decreasing contact with blood and blood-contaminated fluids

A client has had a bilateral adrenalectomy. For which potential complication should the nurse assess the client?

delayed wound healing

The nurse teaches the client with type 1 diabetes mellitus about the importance of maintaining stable blood glucose levels. The nurse should suggest the client include which type of food to minimize the rise in blood glucose level after meals?

dietary fiber

A client has her first prenatal visit at 15 weeks' gestation. The client weighs 144 lb (65.5kg) and states this is a 4-pound weight gain. Which assessment finding requires further investigation?

fundal height of 18 cm

Which of the following objects poses the most serious safety threat to a 2-year-old client in the hospital?

side rails in the halfway position

A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, the physician connects a 10-ml syringe to the catheter and withdraws a sample of blood. The physician then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. The nurse should

turn the client on the left side and place the bed in Trendelenburg's position.

The student nurse is learning about pain. The nurse educator asks the student, "Pain is best described as what?" What is the student's most appropriate response? Select all that apply.

unpleasant subjective

The nurse instructs a group of colleagues on actions to take to prevent back injuries when providing client care. Which statement by a colleague indicates that additional teaching is required?

"A back belt prevents injuries."

The nurse is caring for a client following a motor vehicle incident with head trauma. Diabetes insipidus is suspected. Which nursing intervention is appropriate?

Measure and record urinary output.

The nurse is assessing a client with somatic symptom disorder who reports a fall. The nurse finds the client rubbing the left knee. How should the nurse best intervene?

Assess the client's injury, notify the healthcare provider, and document the incident.

The nurse finds a visitor unconscious with spontaneous breathing sitting in a chair in the waiting room. What priority action(s) will the nurse implement? Select all that apply.

Attempt to identify the visitor. Call a rapid response team.

A client has just returned from having a central venous catheter placed and is prescribed I.V. solution to run at 100 ml/hr. What is the appropriate action by the nurse?

Review the x-ray results to ensure correct catheter placement.

The nurse is teaching the client how to administer insulin. Which instruction should the nurse include?

"First withdraw clear, then cloudy insulin when mixing insulins in the same syringe."

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

"Gloves are required for standard precautions."

The nurse assigned to telephone triage returns a call from a parent whose teenager experienced a hard tackle last night. The parent reports, "He seemed dazed after it happened and the coach had him sit out the rest of the game, but he's fine now." What is the most appropriate instruction for the nurse to give?

"He can't return to play until he has been evaluated by a health care provider."

A client is admitted with an eating disorder. Which client response should the nurse address first?

"I feel dizzy and light-headed when I get up."

A client who has had AIDS for years is being treated for a serious episode of pneumonia. A psychiatric nurse consult was arranged after the client stated, "I'm tired of being in and out of the hospital. I'm not coming in here anymore. I have other options." The nurse would evaluate the psychiatric nurse consult as helpful if the client makes which statements?

"I realize that I really do have more time to enjoy my friends and family."

An adolescent is to receive radioactive iodine for Graves' disease. Which statement by the client reflects the need for more teaching?

"The advantage of radioactive iodine is that I will not need future medication for my disease."

The emergency department nurse is assessing a client with reports of right-sided dull, abdominal and flank pain, nausea, and vomiting. The client's temperature is 101.2° F (38.4° C), pain is 10 out of 10, and rebound tenderness is exhibited. The health care provider orders: VS q 30 min, CBC, morphine 2 mg IM q 4 hours, regular diet, and enemas until clear. Which orders should the nurse question? Select all that apply.

-enemas until clear -regular diet

A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which of the following findings is the nurse most likely to observe in this client? Select all that apply.

-excessive thirst -excessive hunger -frequent, high-volume urination

The nurse used a secure access code to obtain a morphine 2 mg/ml vial from the computerized automated dispensing cabinet (ADC). Before exiting the system, the nurse is prompted to count the remaining vials. The nurse counts 10 remaining vials, but the system reads 9 remaining vials. What is the next action by the nurse?

Ask another nurse to assist with following the procedure to resolve the discrepancy.

A client at 39 weeks' gestation comes to the labor and delivery suite. The client states the membranes ruptured 12 hours ago. What priority assessment will the nurse perform?

Assess fetal heart rate (FHR).

The nurse reviewed laboratory values for a client with type 1 diabetes mellitus. The client's hemoglobin A1c (HbA1c) is 9 percent. What is the priority action for the nurse?

Assess the client's baseline knowledge about their treatment regimen

The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first?

Assess the client's orientation and vital signs.

The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction (Gardner-Wells Traction). What nursing actions are a priority when caring for the client? Select all that apply.

Assess the client's skin integrity. Maintain proper body alignment. Assess client's neurological function.

A client in the emergency department has symptoms of anxiety, a "racing heart," and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse?

Assess the client's vital signs and oxygen saturation.

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown. At 1030, the client has sharp mid-chest pain after having a bowel movement. What should the nurse do first?

Assess the client's vital signs.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client?

Check on the client every 30 minutes while the restraints are on.

The nurse is delegating activities to a recently graduated licensed practical/vocational nurse (LPN/VN) at a skilled nursing facility. Which activities are appropriate to delegate to the LPN/VN? Select all that apply.

Cleansing a leg wound and applying antibiotic ointment. Recording percentage of meal completion. Assisting an unlicensed assistive personnel (UAP) with a weight.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?

Close all of the doors on the unit.

During clindamycin therapy, a nurse monitors a client for pseudomembranous colitis. This serious adverse reaction to clindamycin results from superinfection with which organism?

Clostridium difficile

A child received a local anesthetic before a cardiac catheterization. Following the procedure, the child has a pressure dressing on the right extremity and an IV line in place. He is slightly drowsy. What should the nurse do first?

Compare the color in the right and left legs.

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first?

Determine what decontamination measures took place in the field before approaching the client.

After knee arthroplasty, the client has a sequential compression device (SCD). What should the nurse do?

Discontinue the SCD when the client is ambulatory.

A nurse is monitoring a client on the telemetry unit. The electrocardiogram tracing shows a PR interval of 0.22 seconds. What is the appropriate action of the nurse?

Document the findings and continue to monitor the client.

The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse's best action?

Document the findings in the newborn's chart.

The nurse is teaching a client who is taking dexamethasone for cerebral edema about early symptoms of Cushing's disease. The nurse should advise the client to report which of the following is a symptom of hyperadrenocorticism?

Easy bruising.

A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. What should the nurse do first?

Engage the child in quiet activities.

Which instruction should be included in the discharge teaching plan for a client after thyroidectomy for Graves' disease?

Have regular follow-up care.

The nurse is admitting a client from the healthcare provider's office. The orders read: Bedrest with bathroom privileges, IV 0.9% NSS run at 125mL/hr, MSO4 IV 5mg every 1 hour prn pain. What are the nurse's best action(s)? Select all that apply.

Hold pain medication. Call the healthcare provider and clarify order.

A client is diagnosed with diabetes mellitus. The physician orders 15 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles equipment, washes their hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?

Inject 35 units air into NPH vial; inject 15 units air into regular insulin vial, withdraw 15 units regular insulin; withdraw 35 units NPH.

A client has a tracheostomy. Which nursing action would prevent complications of suctioning?

Maintain sterility of the suction catheter.

A client with ascites had a paracentesis. Which post-procedure intervention should the nurse implement?

Monitor the client's temperature.

The nurse is administering furosemide to a client. What will the nurse include in the client's plan of care? Select all that apply.

Monitor urinary output hourly. Assess blood pressure prior to administration.

A client is ordered prednisone daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning?

Morning administration of prednisone mimics the body's natural corticosteroid secretion pattern.

An older adult had a myocardial infarction (MI) 4 days ago. At 0930, the client's blood pressure is 102/64 mm Hg. After reviewing the client's progress notes (see chart), what should the nurse do first?

Notify the health care provider (HCP).

A school-age child had a colostomy performed 4 weeks ago. The parents report to the nurse that for the past 3 weeks the child's stoma passed adequate amounts of formed stool, but in the past 2 days only thin, ribbon-like stool is passing. What action will the nurse take?

Notify the healthcare provider for stool softener prescription.

The nurse is reviewing the electrocardiogram of a client who has elevated ST segments visible in leads II, III, and aVf. Which choice is the nurse's best action?

Notify the healthcare provider.

The client has chronic pancreatitis. What should the nurse teach the client to do to monitor the effectiveness of pancreatic enzyme replacement?

Observe stools for steatorrhea.

The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. What should the nurse do first?

Obtain a culture specimen of the drainage.

The nurse is administering a tuberculin skin test. Place the steps for administering the tuberculin skin test in the correct order. All options must be used.

Obtain a tuberculin syringe, a half-inch, 26-gauge needle, and purified protein derivative. Draw up intermediate-strength purified protein derivative. Clean forearm area with alcohol. Inject 0.1 ml of the purified protein derivative. Create a wheal that is 6 to 10 mm in diameter. Remove the tuberculin syringe and dispose of the tuberculin syringe.

The client with acute lymphocytic leukemia (ALL) is at risk for infection. What action should the nurse take?

Place the client in a private room.

When administering an I.V. medication through a central line, the nurse notes that a client's central line gauze dressing was last changed 24 hours previously. What is the appropriate action by the nurse?

Proceed to administer the I.V. medication.

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next?

Proceed to suction the client's tracheostomy.

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. The client's level of consciousness is decreased, and they require nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?

Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport.

The client is wearing graduated compression stockings and begins to report leg pain in the right leg. Place the steps in order taken to accurately assess this client. All options much be used.

Remove the stockings. Assess the skin for redness and the leg for swelling. Assess for warmth discrepancies in both legs. Measure the calves of both legs. Notify the healthcare provider.

A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now "unable to concentrate at her card game" and "it seems harder and harder to finish my errands because I am so tired." What should the nurse suggest that the client do to manage the exhaustion?

Take frequent naps.

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. What should the nurse do first?

Take the client's blood pressure.

A client is experiencing an acute hemolytic reaction while receiving 1 unit of packed red blood cells. What actions should the nurse take first? Select all that apply.

Take the client's temperature. Assess for anxiety and mental status changes. Maintain the intravenous line with normal saline using new intravenous tubing.

A nurse is teaching a client with diabetes mellitus about self-management. Which statement would be correct about the administration of lispro insulin?

Take the insulin at around the same time each day at a meal.

A nurse realizes she is 1 hour and 30 minutes late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next?

The nurse should follow facility procedures for reporting an error.

A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?

The oxygen tubing is pinched.

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first?

a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours

Which client requires increased sensory stimulation to prevent sensory deprivation?

a 65-year-old client who has employment-induced presbycusis and advanced glaucoma

The nurse is caring for a client with peripheral artery disease (PAD) who has just returned from having a percutaneous transluminal balloon angioplasty. Which finding requires immediate attention from the nurse?

a change in the intensity of the pulse from the baseline

An infant with an upper respiratory tract infection has stridor. What actions should the nurse take to provide care for this child? Select all that apply.

administer oxygen notify the healthcare provider get emergency equipment to the bedside

A client comes to the emergency department after taking an overdose of amitriptyline hydrochloride. Immediate care for this client should include

administering activated charcoal every 4 hours for 24 hours.

Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

administering pain medication.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection?

an 86-year-old with burns from using a heating pad

Which factor, if described by the parents of a child with cystic fibrosis (CF), indicates that the parents understand the underlying problem of the disease?

an abnormality in the body's mucus-secreting glands

Which infants should the nurse recognize as being at higher likelihood for requiring phototherapy? Select all that apply.

an infant with AB+ blood born to a mother with B- blood an infant with a cephalohematoma an infant born to a mother with positive TORCH titers

A client with diabetic ketoacidosis (DKA) has asked the unlicensed nursing assistant for another pitcher of water. It is the third such request over the past 4 hours. The nurse would recognize this request as which manifestation?

an occurrence of the excess loss of fluid associated with osmotic diuresis

The nurse is preparing to administer the initial dose of digoxin PO to a client. What is the nurse's priority assessment before administering this medication?

apical heart rate

After receiving an I.M. injection, a client complains of burning pain at the injection site. Which nursing action would be most appropriate at this time?

applying a warm compress to dilate the blood vessels

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated?

applying an external fetal monitor and completing a physical assessment

A client is diagnosed with diabetic ketoacidosis. Which finding would the nurse anticipate?

arterial pH 7.33

A client with an intravenous (I.V.) site is experiencing pain. The nurse understands that pain with infusion is a sign of:

catheter position at the insertion site due to movement.

A client with acute osteomyelitis is to receive parenteral penicillin for 4 to 6 weeks. Before administering the first dose, the nurse asks the client about known drug allergies. An allergy to which antibiotic or antibiotic class necessitates cautious use of penicillin?

cephalosporins

A nurse has received a change-of-shift report on four clients. Which client should the nurse assess first?

client experiencing tracheal deviation following a subclavian catheter insertion

The nurse is teaching the client to self-administer insulin. Which approach to establishing learning goals will likely be most effective? When the goals are established by the:

client, nurse, pharmacist, and health care provider, so the client can participate in planning care with the entire team.

What is the best way for the nurse to position a chest tube for a client to prevent dislocation?

coiled flat on the bed and secured without putting tension on the tube

Which type of restraint is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair?

elbow restraints

The nurse is evaluating the test results of a client undergoing testing for depression. Which results of from a dexamethasone suppression test (DST) would the nurse interpret as indicative of depression?

elevated afternoon serum cortisol

A nurse regularly inspects a client's I.V. site to ensure patency and prevent extravasation during dopamine therapy. What is the treatment for dopamine extravasation?

elevating the affected limb, applying warm compresses, and administering phentolamine as ordered

A client with acute renal failure has the following laboratory results. Based on these findings, which of the following should the nurse administer?hemoglobin 9.2 g/dLblood urea nitrogen 22 mg/dLcreatinine 0.7 mg/dLpotassium 4.8 mEq/L

erythropoietin

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?

every 15 minutes

On initial assessment of a 7-year-old child with rheumatic fever, which finding would require contacting the primary care provider immediately?

heart rate of 150 bpm

The nurse is prioritizing care of a client in the immediate postpartum period. What is the nurse's priority assessment? Select all that apply.

height of fundus blood pressure urinary output

A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's spouse reports that the client acted confused and was extremely weak upon waking that morning. The client's blood pressure is 90/58 mm Hg, pulse is 116 beats/minute, and temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by I.V. infusion?

hydrocortisone

On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

hypocalcemia

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

increased urine osmolarity

A client is experiencing status asthmaticus. For which would the nurse anticipate an immediate order?

inhaled Beta-2 adrenergic agonist

The nurse is assessing a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). What findings does the nurse attribute to complications of this condition?

jugular vein distention and confusion

The nurse is caring for a client in a diabetic coma. The nurse is aware that this is caused by an excess of which substance in the blood?

ketones from rapid fat breakdown, causing acidosis

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

lactated Ringer's solution

The comatose victim of a car accident is to have a gastric lavage. Which position would be most appropriate for the client during this procedure?

lateral

A client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem?

myocarditis

A client receiving thyroid replacement therapy develops influenza and forgets to take the prescribed thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing what life-threatening complication?

myxedema coma

The nurse is assessing a client with an A-V fistula. Which finding should the nurse report to the healthcare provider?

skin discoloration distal to the fistula

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

tetany

The nurse is prioritizing care for several clients. Which client should the nurse assess first?

the client with stridor who just received the first dose of an antibiotic

The single parent of a young teenager is being treated for complicated bronchitis at a small rural hospital. The parent does not live in the area and has a poor command of English. The facility is experiencing delays in accessing a translator. In considering whether to allow the teenager to translate medical information for his parent, the nurse should consider that:

these circumstances may allow the child to translate.

A client's caregivers state that they childproofed their home for their 2-year-old. During a home visit, the nurse discovers some situations that show the caregivers don't fully understand the developmental abilities of their toddler. Which situation displays misunderstanding by the caregivers?

toy chest in front of a second-story, locked window

What is a priority nursing assessment for an infant receiving phototherapy?

urine output

When caring for a client with diabetes insipidus, the nurse expects to administer

vasopressin.

A nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will order daily supplements of calcium and

vitamin D.

When evaluating teaching a client how to administer insulin, which action indicates that additional teaching is necessary?

waits 30 minutes to eat breakfast after injecting rapid-acting insulin

Which finding is the best indication that the goals for total parenteral nutrition (TPN) are being achieved for the client?

weight gain of 0.5 lb/day (0.2 kg/day)

Which findings should a nurse expect to assess in client with Hashimoto's thyroiditis?

weight gain, decreased appetite, and constipation

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?

Elevate the head of the bed 30 to 45 degrees.

A neonate receives an IV infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply.

-when the infusion is started -at the beginning of each shift -when the neonate returns from X-ray

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands the condition and how to control it?

"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."

X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."

A client with diabetes is explaining to the nurse how he cares for the feet at home. Which statement indicates the client needs further instruction on how to care for the feet properly?

"I inspect my feet once a week for cuts and redness."

The nurse is assessing a client with hepatitis A and notices that the aspartate transaminase (AST) and alanine transaminase (ALT) lab values have increased. Which statement by the client indicates the need for further instruction by the nurse?

"I take acetaminophen for arthritis pain."

A client has been diagnosed with hypothyroidism. Which statement by the client would demonstrate appropriate teaching by the nurse?

"I will increase fiber and fluids in my diet."

A client recently diagnosed with hyperparathyroidism demands to see what the healthcare provider has written in the chart. What is the nurse's best response?

"I'll get the chart and set up a time for you to review it with your healthcare provider."

A physician has referred a client newly diagnosed with diabetes mellitus to the diabetes nurse-educator. When the nurse brings up the subject, the client states, "I'd rather work with you than with a stranger." What is the nurse's best response?

"I'll set up a meeting for today. Then you and I can meet to talk about how things went."

The nurse teaches a client with type 2 diabetes mellitus about diabetic retinopathy. Which statement if made by the client would indicate to the nurse that teaching was effective?

"Tight control of blood sugar and blood pressure can prevent damage to my eye."

The nurse is caring for a client in the medical unit. The nurse receives a health care provider's order for hydrocortisone 100 mg intravenously at a rate of 10 mL/hour for a client in acute adrenal crisis. The nurse understands that this treatment is common in clients with which disease process?

Addison's disease

A client diagnosed with Cushing's syndrome is admitted to the hospital and scheduled for a dexamethasone suppression test. What should the nurse do during this test?

Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning.

A client presents with acute onset chest pain rated as 7/10 radiating to left arm and mid-scapular region, blood pressure of 155/95 mm Hg, heart rate of 98 beats/min, respiratory rate of 22 breaths/min, and an oxygen saturation of 94%. What is the nurse's priority intervention?

Administer sublingual nitroglycerin.

A nurse obtained a client's fasting blood sugar (FBS) at 0700, which was 144 mg/dL (8 mmol/L). The client has an order for regular insulin 8 units every morning. What should the nurse do next?

Administer the insulin as ordered.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take?

Contact the previous nurse requesting that the nurse correct the error.

A client with venous thrombus reports having pain in the legs. What should the nurse do first?

Elevate the foot of the bed.

A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which should be the primary focus of nursing care for this client?

Decrease cardiac demands by promoting rest.

The nurse is caring for a client with a double lumen tunneled central catheter with ordered bloodwork and intermittent I.V. medications. What is the correct action by the nurse?

Dedicate the largest lumen for blood draws.

Which position would be appropriate for a client with severe ascites?

Fowler's

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane (NPH) insulin to be taken before breakfast. At about 4:30 p.m. (1630), the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

The isophane (NPH) insulin is peaking.

A client is taking phenelzine 15 mg PO three times a day. The nurse is about to administer the next dose when the client tells the nurse about having a throbbing headache. Which action should the nurse do first?

Obtain the client's vital signs.

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which action should the nurse take to best ensure the safety of the client while complying with policy?

Provide a bed that is low to the floor.

A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

A client in a long-term care facility has signed a form stating that the client does not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia.

What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor?

The nurse must file an incident or adverse event report.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager?

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight.

A pregnant client is diagnosed with partial placenta previa. The nurse should prepare the client for which intervention?

activity limited to bed rest

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)?

arterial oxygen level of 46 mm Hg (6.1 kPa)

A client undergoing a bilateral adrenalectomy has postoperative prescriptions for hydromorphone hydrochloride 2 mg to be administered subcutaneously every 4 hours as needed for pain. Why should the nurse administer hydromorphone in small doses?

as potent as morphine in larger doses.

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently?

assess vital signs.

A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should be alert for which signs and symptoms?

coma, anxiety, confusion, headache, and cool, moist skin

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital?

conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use.

Which assessment would be most important for the nurse to make initially in a school-age child being seen in the clinic who has a sore throat, muscle tenderness, arms feeling weak, and generally is not feeling well?

difficulty swallowing

Which action is the best precaution against transmission of infection?

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection

A nurse is caring for a client with suspected diabetes insipidus. Which test does the nurse anticipate the physician will order to confirm the diagnosis?

fluid deprivation test

What important considerations would the nurse make when teaching and caring for a client newly diagnosed with diabetes mellitus?

involving the client in the development of the teaching plan and encouraging questions and active participation

A client with hypothyroidism has started to take thyroid hormone replacement therapy and asks the nurse about the reason for feeling sad and depressed. What should the nurse tell the client? "The feelings of sadness and depression are caused by:

low thyroid hormone levels and will improve with replacement therapy."

Which statement indicates that the client with diabetes insipidus understands how to manage care? The client will:

maintain normal fluid and electrolyte balance.

When planning care for a client with a small-bowel obstruction, which should the nurse consider to be the primary goal?

maintaining fluid balance

For a client with Graves' disease, which nursing intervention promotes comfort?

maintaining room temperature in the low-normal range

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?

measles

Which action is most effective when a nurse is assessing the client suspected of developing diabetes insipidus?

measuring urine output hourly

When obtaining the nursing history of a client who has type 1 diabetes mellitus, the nurse should assess the client for which early symptom of diabetic nephropathy?

microalbuminuria

A nurse obtains a fingerstick glucose level of 45 mg/dl (2.47 mmol/L) on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene?

obtain a repeat fingerstick glucose level.

The nurse is assessing a client with bipolar disorder during a follow-up appointment after initiating treatment with lithium carbonate. Which symptom would cause the nurse to suspect lithium toxicity?

persistent GI upset

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and

phosphorus

The primary goal in the plan of care for the client after cataract removal surgery is to:

promote safety at home.

A nurse is caring for a client newly diagnosed with primary hypertension. Which activity best reflects the implementation phase of the nursing process?

providing education about documenting blood pressure readings

A nurse should expect a client with hypothyroidism to report

puffiness of the face and hands.

A 60-year-old female is diagnosed with hypothyroidism. What additional information should the nurse obtain when conducting a focused assessment?

weight gain.

Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect?

with each meal and snack

When teaching a client about taking oral glucocorticoids, how should the nurse instruct the client to take the medication?

with meals or with an antacid

The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider?

worsening headache