PN-ATI EXIT
Type 2 diabetes and the flu
drink sugar-free liquids to prevent dehydration
Manifestations of PE
dyspnea; tachypnea; chest pain; tachycardia; anxiety; diaphoresis; decreased SaO2; pleural effusion; crackles and cough
Position for spinal cord injuries
high-fowlers
Risk for hypercalcemia
hyperparathyroidism; malignant disease; prolonged immobilization; vitamin d excess; thiazide diuretics; lithium; digoxin toxicity; overuse of calcium supplements
Risk factors of repiratory alkalosis
hyperventilation; hypoxemia; altitude sickeness; asphyxiation; asthma; pneumonia
Risk factors for hypocalcemia
hypoparathyroidism; hypomagnesemia; kidney failure; vitamin d insufficiency; inadequate intake; disease process (celiac, lactose intolerance, chrohn's, alcohol use disorder)
Orthopnea position .... lung expansion
increase
A nurse is caring for a school-age child who has sickle cell anemia and is in vaso occlusive crisis. which of the following actions should the nurse take?
increased oral fluid intake
Risk factors of metabolic alkalosis
ingestion of antacids; GI suction; hypokalemia; blood transfusion; prolonged vomiting; total parenteral nutrition
a nurse is caring for a client who has chronic kidney failure and a serum potassium level of 6.8 which of the following actions should the nurse take first
initiate continuous cardiac monitoring for the client
Where to test bath water
inner wrist
Nursing intervention for Addison's Disease
monitor and treat hypoglycemia
Nursing interventions for radiation treatment
monitor condition of skin; clients should wear soft, loose clothing, and avoid exposure to sun
Postop interventions for TURP
monitor for shock and hemorrhage; avoid heavy lifting; monitor for continuous bladder irrigation (expect bloody drainage); encourage fluid intake (at least 3,000mL/day); teach Kegel exercises
Nursing interventions for fluid volume excess
monitor respiratory rate, symmetry, and effort; monitor lung sounds, edema, ascites (excess fluid in the peritoneal cavity), and VS; maintain strict I&O; daily weights
Manifestations of hypokalemia (low potassium)
muscle weakness, cramping, nausea, vomiting, decreased bowel motility, dysrhythmias, irritability
Christian science dietary restictions
must abstain from alcohol
Characteristics that increase risk for falls
older age, cognitive/sensory impairment, impaired mobility, bowel and bladder dysfunction, side effects of medications, and history of falls
Equipment at client's bedside for seizure precautions
oxygen, oral airway, and suction equipment
ABG values [pH, PCO2, HCO3]
pH 7.35-7.45 PCO2 35-45 HCO3 21-28
A nurse is assessing a client was 2 hours postpartum for uterine atony which of the following actions should the nurse take?
palpate the clients fundus
Acceptable ways to ID patient
patient's name, DOB, assigned ID number, telephone number, or other person-specific identifier
Manifestations of hyperkalemia (high potassium)
peaked T waves, ventricular dysrhythmias, increased bowel motility
Medical Asepsis (Clean Technique)
perform hand hygiene frequently; use PPE as indicated; don't place items on the floor of client's room; don't shake linen; clean least soiled area first; place moist items in plastic bags; reinforce education with client and caregivers
Never put these in a newborn's crib
pillows, large floppy toys, or loose plastic sheets; they can suffocate
Prevention of SIDS
place babies on their backs to sleep, breastfeeding may provide some protection, and use of a pacifier when sleeping
a nurse is caring for a client who is experiencing a stroke four days ago and has dysphagia which of the following actions should the nurse plan to take to assist the client during meals?
place small bites of food in the unaffected side of the client's mouth
Do not give _ at bedtime
tetracycline; don't let them lie down b/c it might cause gastric reflux
nonmaleficence
the obligation not to harm others
fidelity
the obligation to be faithful to an agreement and responsibility; to keep promises
beneficence
the obligation to do good for others
A nurse is providing teaching to a client about the adverse effects of Sertraline which of the following adverse effects should the nurse report?
Excessive sweating
A nurse is discussing informed consent with a newly licensed nurse. Which of the following statements by the newly liscensed nurse indicates an understanding of the information
"A client can. withdraw consent at any time after signing the informed consent form."
veracity
the obligation to tell the truth
A nurse is reinfording discharge teachingIwith a cliant who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
"I should throw away my used tissues in a closed plastic bag.
A nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document?
"It communicates my wishes for end-of-life care."
A nurse is assisting with the care of a client who has schizophrenia and auditory hallueinations. Which of the following responses should the nurse make
"Let's talk about what the voices are saying to you."
A charge nurse on a medical-surgical is planning assessment for LPN who has been sent from the postpartum unit due to a staffing shortage for the shift. which of the following clients should the nurse delegate to the LPN?
A client who is post-operative following a bowel resection with an NG tube continuous suction
A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment for bladder cancer. Which of the following instructions should the nurse include in the teaching?
- cleanse the skin around the stoma with a moisturizing soap
A nurse is caring for a client who has increaed intracranial pressure following a traumatic brain injury. Which of the following actions should the nurse take?
-Administer stool softners to the client -Provide a quiet environment for the client -Maintain the head of the bed at 30 angle
A nurse is caring for a client who has a new prescription for warfarin. When reviewing the client's current medications. Which of the following medications should the nurse identify as contraindicated for use with warfarin?
-gingko -ibuprofen -aspirin
Total bilirubin
0.1-1
Onset of short-acting: Regular (Humulin R)
0.5-1 hour
INR levels
0.7-1.8
Therapeutic digoxin levels
0.8-2.0
A nurse is preparing to administer enoxaparin 1.5 mg per kilogram subcutaneously to a client who has a pulmonary embolism the client weighs 132 pounds the amount available is 100 mg/mL how many milliliters should the nurse administer
0.9 ml
A nurse is receiving change of shift report on a group of clients which of the following client should the nurse see first
A client who is postoperative following hip arthroplasty and reports calf pain
A home health nurse is prepaing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps.
1. clarify the reason for the referral 2. contact the family to determine availability and readiness to make an appointment 3. identify family needs and interventions 4. discuss plans for future visits 5. record information about the home visit
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?
Excessive sweating
A nurse manager is reviewing documentation with a newly licenced nruse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching?
Administered 8 u regular insulin sq
A nurse is reinforcing teaching with a client who has hypertension about decreasing sodium intake. Which of the following foods should the nurse recommend?
1 baked potato
A nurse is teaching a client about foods that are high in calcium due to the increase risk for developing osteoporosis. Which of the following foods should the nurse recommend as the best source of calcium?
1 cup of cooked kale
Average time for IM peak levels
1 hour
Onset of long-acting: Insulin glargine (Lantus)
1 hour
autonomy
the right to make one's own decision
Sodium recommendations
1,500mg/day or less
Average time for oral peak levels
1-2 hours
Onset of intermediate: NPH (Humulin N)
1-2 hours
A nurse is administering an in-service for group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in teaching?
Administering potassium via IV bolus
A nurse has identified tasks to delegate to a group of assistive personnel after receiving change of shift report. Identify the sequence the nurse should follow when delegating tasts to the AP.
1. Review the skill level 2. Communicate appropriate tasks 3. Monitor progress 4. Evaluate the AP performance
A nurse On the pediatric unit is assisting with the plan of care for a preschooler who will have a surgical procedure in the morning. The child has been crying despite his parents presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan because it offers which of the following benefits?
Allows the child to manipulate toy medical equipment
Magnesium levels
1.3-2.1
BUN levels
10-20
PT levels; therapeutic level?
11-12.5 seconds; therapeutic is 1.5 to 2 times the normal
Hot water heater setting for infant safety
120.2F (49C) or lower
Sodium levels
136-145
A nurse is preparing to administer cefpodoxime 10 mg/kg/day PO divided equally every12 hr to a child who weighs 66 lb. Available is cefpodoxime 20 mg/ml oral solution. How many mL should the nurse administer per dose?
15 mL
Platelet levels
150,000-400,000
A nurse is reinforcing dietary teaching with a client who's pre-pregnancy BMI was 30.5 the nurse should recognize that the client understands the teaching when she states she should expect to gain how many pounds during her pregnancy
16 pounds
A nurse on a medical surgical unit is performing medicaiton reconciliation for a newly admitted client. Which of the following actions should the nurse take?
Compare the client's list of home medications to the admission prescriptions written for the client
Therapeutic level for INR with anticoagulant therapy
2-3
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?
Apply continuous pressure to the lower part of the child's nose
A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following examples to the charge nurse include in the teaching?
Apply elbow immobilizer on an infant recovering from cleft lip cleft lip surgery
Phosphorus levels
3-4.5
A nurse is caring for a client who has a fractured leg and rates their pain at as 7 out of 10. which of the following medications should the nurse expect to administer?
Hydrocodone
Albumin levels
3.5-5
Potassium levels
3.5-5
Average time for IV peak levels
30 minutes
aPTT levels; therapeutic level?
30-40 seconds; therapeutic is 1.5 to 2 times the normal
A nurse is assisting with the admission of a client who has a urinary tract infection and a history of Myelomeningocele. After the admission history is complete, which of the following actions should the nurse recommend?
Attach a latex allergy alert identification band
HbA1c levels
4%-6%
A nurse is preparing to administer ranitidine 50 mg IV over 15 min to a client. Availale is rantidine 50 mg 0.9% sodium chloride solution.
400 ml/hr
WBC levels
5,000-10,000
A nurse is preparing to administer 0.9% sodium chloride 250 mL IV to infuse over 30 minutes to a client the nurse just set the IV pump to deliver how many milliliters per hour
500
Total protein
6-8
Number of wet and poopy diapers per day
6-8 wet and 3-4 poopy
Fasting glucose levels
70-105
A nurses assistant a client who has cancer to select high protein foods which of the following foods should the nurse recommend as the highest source of protein
8 ounce chopped hard boil egg
Calcium levels
9-10.5
Bath water temp for infants
97.9F (36.6C) to 99F (37.2C)
Chloride levels
98-106
A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization?
A 10 piece wooden puzzle
A nurse on the pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?
A Client in DKA and a blood glucose of 375
A nurse is assisting with discharge planning for a group of clients during a mass casualty incident which of the following client should the nurse recommend for discharge
A client who had diabetic ketoacidosis and has a blood glucose level of 120 mg/dL
A nurse is receiving change of shift report on 4 clients which of the following clients should the nurse plan to see first
A client who has a femur fracture and reports numbness of the toes
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
A client who has a hip fracture and a new onset of tachypnea
And charge nurse assigned a nurse to care for a group of clients which of the following client should the nurse ask the charge nurse to reassign to an RN
A client who has a new diagnosis of diabetes mellitus and needs to learn self administration of insulin
A nurse is reviewing assessment data for several clients. For which of the following clients should the nurse recommend nutrition?
A client who has a non healing leg ulcer
A nurse is assisting with the plan of care for a group of clients which of the following client should the most recommend for an interprofessional conference
A client who has a spinal cord injury
A nurse is caring for a client who have chronic pain. Which of the following clients should the nurse identify the candidates for occupational therapy?
A client who has painful hands due to degenerative joint disease
A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
A client who has preeclampsia and reports a persistent headache
A charge nurse on a medical unit is assisting with the emergency response plan followng an external disaster in the anticipation of multiple clients admissions which of the following current clients should the nurse recommend for discharge?
A client who is 1-day post-operative following a vertebroplasty
A nurse in an urgent care center is collecting data from a group of clients who all have in odor Of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse?
A client who is difficult to arouse and is unable to respond to questions
The healthcare facilities leadership team is implementing a new computerized charting system. Before the implementation date, which of the following actions should the charge nurse take first?
Collect the staff input about planning and implementing the change
A nurse in a long-term care facility is caring for a group of clients. One of the clients as walking in the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first?
A companyto his room
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse check first?
A dient admitted to the facility who has ascending Guillain-Barré syndrome
A community health nurse is contributing to the plan of care for for high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse recommend to care for first?
A four day old newborn who has elevated Bilirubin level and requires photo therapy
A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?
A healthcare surrogate makes Health Care decisions when the client is no longer able to
Which of the following breaks Patient confidentiality
A nurse tells the chaplain that her assigned client has a new diagnosis of cancer
A nurse is preparing for the admission of a client who has a seizure disorder which of the following supplies should the nurse place at the bedside for this client?
A tongue blade
A nurse is assisting with the plan of care for an order of the client who has dementia and is experiencing nocturnal confusion which of the following actions should the nurse take to decrease the clients risk for injury
Activate bed alarm
A nurse is assisting a client who requests to take a tub bath which of the following actions should the nurse take ?
Add bath oil after the client gets into the tub
A nurse is caring for a client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea. Which of the following actions should the nurse take first?
Administer an antiemetic
A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months the nurse notes of lithium level of 0.8 which of the following orders from the provider should the nurse expect?
Administer the medication
A nurse is caring for a client who has cancer of the throat and is receiving radiation therapy. Which of the following findings as an adverse effect of the radiation?
Altered taste sensation
A nurse delegates newly Licensed nurse to provide one on one observation for a client who requires suicide precautions. Which of the following actions by the newly licensed nurse indicates the need for further reinforcement of teaching?
Ambulates the client's roommate while the client sleeps
A nurse in an urgent care center is reviewing laboratory results for several clients who have benefit stations of influenza. Which of the following clients should the nurse report to the provider in mediately?
An infant who is wbc count is 24,000
A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying which of the following findings requires intervention by the nurse
And assistive personnel is encouraging intake of oral fluids
A nurse is caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma?
And irregularly shaped brown lesion with light blue areas on the neck
hip arthroplasty receiving heparin, adverse reaction?
Anorexia
A nurse is caring for a client who is at 38 weeks of gestation is an active labor and has ruptured membranes. Which of the following actions should the nurse take?
Apply a fetal heart rate monitor
A nurse is providing teaching to the parents of a newborn has been circumcised which of the following interventions should the nurse include in the teaching?
Apply petroleum jelly to the glans with diaper changes
A nurse is caring for a client who has a platelet count Of 50,000. After discontinuing the clients peripheral IV site, which of the following actions should the nurse take?
Apply pressure to the catheter removal site for 10 minutes
A nurse is preparing to administer eyedrops to a child which of the following actions should the nurse take ?
Apply pressure to the lacrimal punctum after administering drops
A nurse in an acute care clinic is talking with the client reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss nonpharmacological approaches that will relieve her pain. Which of the following interventions should the nurse suggest?
Apply warm compresses to sore joints
A nurse is caring for a client who has depressive disorder the client states everyone will be better off if I were not around which of the following responses should the nurse make
Are you thinking of hurting yourself?
A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following data should the nurse use as a common example of a suggestive finding?
Arm cast for a spiral fracture of the forearm
A nurse is caring for aclient who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life sustaining measures. Which of the following actions should the nurse take?
Arrange for an ethics committee meeting to address the family's concerns
A nurse is caring for an adolescent client who has been hospitalized for several weeks which of the following actions should the nurse take relative to the clients developmental stage?
Arrange for uninterrupted visits with the clients friends
A nurse is preparing to obtain a client signature on an informed consent form which of the following actions should the nurse take first?
As the client explain his understanding of the procedure
A nurse on a med-surg unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse interview?
Ask security to detain the client until the provider is notified
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
Ask the client directly what he is hearing
A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of care?
Ask the client to shift his weight every 20 minutes while sitting in a chair
A nurse is receiving a telephone prescription from a clients provider which of the following actions should the nurse take (select all that apply)
Ask the provider to spell out the name of the medication, request that the provider confirm the read back of the prescription, record the date and time of the telephone prescription
A nurse is assisting with developing a plan of care for a client who has GERD. The nurses should suggest monitoring the client for which of the following complications?
Aspiration
a nurse is caring for a client who has repeatedly refused meals. The nurse overhears an assistive Personnel telling the client if you don't eat I will put restraints on your wrist and feed you the nurse intervene and explain to the AP that this statment consitutes which of the following torts?
Assault
A patient in traction reports severe pain from a muscle spasm. What is the nurse's priority action?
Assess the patient's body alignment
A nurse is assisting with the plan of care for a client who is 72 hr postoperative following a above the knee amputation which of the following interventions should the nurse include
Assist the client to perform range of motion of the hips
a nurse is caring for a group of clients which of the following actions by the nurse demonstrates client advocacy?
Assisting a client to obtain a second opinion for a diagnosis
A nurse is observing a client who has schizophrenia and is in the day room when another client asks him if two items of clothing match. He replies a match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on. The nurse should identify these statements as which of the following speech alterations?
Associative looseness
A nurse is caring for a client who spent the past several minutes mumbling about being doomed to die and is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurses priority?
Attempt to reduce environmental stimuli
a charge nurse is preparing to lead negotiations among the nursing staff due to a conflict abot overtime requirements which of the following strategies should charge me to use to promote effective negotiation?
Attempt to understand both sides of the issue
A nurse is reinforcing teaching with a client who is in 16 weeks of gestation and has a prescription for fear is Sophie to treat I am deficiency anemia which of the following recommendations should the nurse week to improve the absorption of the medication
Avoid drinking milk with the iron supplement
A nurse is reviewing the guideines for dOcumenting client care, Which of the following actions should the nurse plan to take
Avoid quoting client comments when documenting.
A nurse is caring for a client who has a deep partial and full thickness burns and requires a topical anti-microbial drug. The nurse should reinforce with the client that the goal of this medication therapy is to reduce which of the following outcomes?
Bacterial growth
A nurse is preparing to peform a sterile wound irrigation and dressing change for a cliet. Which of the following actions by the nurse breaks in surgical aseptic technique?
Balancing the bottle on the sterile basin while pouring the liquid.
A nurse is reinforcing discharge teaching with a client who had a TIA. The nurse should instruct the client to monitor which of the following parameters at home?
Blood pressure
A nurse is assessing a client who is receiving morphine IV for pain which of the following findings should the nurse report to the first?
Blood pressure 80/40
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate the nurse should identify that which of the following is a manifestation of magnesium toxicity?
Blurred vision
A nurse in a prenatal clinic is collecting data from several clients. which of the following client reports should the nurse identify as an expected physiologic adaptation to pregnancy?
Breast tenderness
A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client?
Build trust with the client by sitting quietly with him
nurse is caring requesting assistance with smoking cassation. The nurse should anticipoce presoription for which of the following
Bupropion Naltrexone Methadone Disulfiram
A nurse is caring for a client who it 12 hours postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?
Burgundy colored urine
A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the following locations should the nruse palpate the client's fundus?
C
A nurse is caring for a client who is newly diagnoses with pancreatic cancer and has a questions about diesease. To research the disease the nruse should identify which of the following electronic databases?
CINAHL
A nurse is caring for a client who has gestational hypertension is experiencing toxic effects due to magnesium sulfate therapy. The nurse should anticipate administering which of the following medications?
Calcium gluconate
A nurse is beginning her shift and reviewing the medication administration records for her clients. She notes a dosage of medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?
Call the provider to clarify the dosage
A charge nurse in a long-term care facility notices the smell of alcohol on a nurses breath which of the following actions should the nurse take first
Call the supervisor to ask for another nurse
A nurse is collecting data from a toddler who has aids. The nurse should identify which of the following findings as an indication infection?
Candidiasis
A nurse is assisting with the green needle examination of a client who is in eight weeks of gestation the nurse notes the clients vagina and vulva are a purpleish color the nurse should document to find them as which of the following
Chadwick sign
A nurse response to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first?
Check airway patency
A nurse is implementing a bladder training program for a client who had a stroke which of the following intervention should the nurse take
Check for residual urine after voiding
A nurse is administering a continuous enteral feeding to a client. Which of the following actions should the nruse take?
Check gastric residuals every 4 hours
A nurse is using an IV pump for a newly admitted client which of the following actions should the nurse take?
Check the cords of the IV pump fraying
A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care?
Check the vascular access site for bleeding after dialysis
A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization which of the following findings in the clients record should the nurse recognize as a contra indication
Chemotherapy treatments
A nurse is reinforcing teaching with a client who has hypothyroidism and is taking levothyroxine. the nurse should instruct the client to report which of the following manifestations to the provider?
Chest pain
A nurse is reinforcing teaching with an assistive personnel about dietary restrictions for a client who is taking phenelzine to treat depression. The APs selection of which of the following foods for the clients lunch indicates an understanding of the instructions?
Chicken salad
A nurse in an infectious disease division of the local Health Department is caring for a client which of the following infections should the nurse identify should be reported to the health department?
Chlamydia
A nurse is reviewing the plan of care for a client who is receiving treatment for anorexia nervosa which of the following laboratory findings indicates that the clients nutrition plan is effective?
Cholesterol 190 mg/daL
A nurse is reinforcing teaching with a 36-year-old client who is 16 weeks of gestation and is scheduled for aminocentesis the nurse should include in the teaching the aminocentesis is performed to identify which of the following findings
Chromosomal abnormalities
A nurse is preparing to perform a wet to dry dressing change for a client who has an infected abdominal wound which of the following techniques should the nurse use when performing the dressing change
Clean the wound from center to outer edges
A nurse is reinforcing teaching with the parents of a newborn about me then which of the following instructions should the nurse include in the teaching
Cleanse the eyes from the inner canthus outward
A nurse in an acute care setting is preparing to administer medications to a client which of the following information should the nurse obtain to identify the client
Client's telephone number
A nurse is reviewing the medication administration record of a client who has benign prostatic hyperplasia. The client asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the following medication interacts adversely with saw palmetto?
Clopidogrel
A nurse is assessing a client who is receiving peritoneal dialysis for manifestations of peritonitis. Which of the following findings should the nurse identify as the first indication of peritonitis?
Cloudy effluent
A nurse is caring for a client during Her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse include on the list of calcium sources for this client?
Collard greens
A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record to the clients bedside and perform which of the following verification procedures?
Compare the medical record number and name on the medication administration record with the clients identification band
I'll charge nurse is observing a newly licensed nurse who is having difficulty finishing all client care activities by the end of his shift which of the following statements should the nurse make to help the newly licensed nurse improve his time management skills?
Complete the task for one client before moving onto the next client
A nurse is collecting data from a client who is at 20 of the following findings should the nurse monitor as a common adverse effect of iron weeks of gestation and has been taking ferrous sulfate. For which the following findings should the nurse report to the provider?
Constipation
a nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis the nurse should monitor the client for which of the following complications?
Contractions
A nurse is caring for a client who is today's postoperative the client has a prescription for acetaminophen 300 mg with codeine 30 mg one tablet every 3 to 4 hours PRN for pain the nurse in advertently administers two tablets to the client in which of the following location should the nurse document the eror
Controlled substance inventory record
A nurse is caring for a client who has a new diagnosis of acute systemic lupus erythematosus And is to begin medication therapy. Which of the following types of medications should the nurse expect to administer?
Corticosteroids
A nurse is caring for a client who has an abdominal surgical incision and notices an evisceration which of the following actions should the nurse take ?
Cover the one with a transparent dressing
A nurse is reviewing the medical record of a client who has requesting a prescription for sildenafil citrate. Which of the following data in the clients record should the nurse identify as a contradiction for the use of this medication?
Current use of nitro to treat heart failure
Long term use of glucocorticoid medications can cause ...
Cushing's disease
A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus which of the following instruction should the nurse include in the teaching
Cut your toenails straight across
A nurse is assisting with the admission of a client to the medical unit and ask him if he has advanced directives. The client states I have a document with me the name of someone who can make healthcare decisions for me I am not able to. Should identify that the client is referring to which of the following documents?
DPA
A nurse is caring for a client who was admitted for observation following that he injury which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure
Decreased BP
A nurse is reinforcing teaching about albuterol with a client who has asthma which of the following affects of medication shut the nurse include in the teaching
Decreased bronchospasms
A nurse in an intensive care unit is assessing a client who has heart failure and is been receiving metoprolol for 3 days. which of the following findings indicates that treatment has been effective?
Decreased edema
A nurse is collecting data from a client who has aids and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider?
Decreased hemoglobin
A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia which of the following findings indicate that the medication is here in a therapeutic affect
Deep tendon reflexes 2+
A nurse is caring for a client who is receiving instrument internal to feeding and he has diarrhea which of the following actions should the nurse take
Deliver a smaller amount of formula more frequently
A nurse is teaching a wellness class about depression for a group of an older client which of the following information should the nurse include in the teaching
Depression can be misdiagnosed as a neurocognitive disorder in older clients
A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?
Determine if the stockings are binding
A nurse in the emergency department is interviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first?
Determine the client's current anxiety level
A nurse in an emergency department is caring for a client who has a closed head injury which of the following actions should the nurse take?
Determine the clients Glasgow Coma Scale score
A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction. Which of the following manifestations should the nurse identify as indications Of a myocardial infarction?
Diaphoresis, dizziness, anxiety, impending doom, nausea, and vomiting
A nurse is caring for a client who is taking acarbose to treat type two diabetes. Which of the following should the nurse monitor for adverse effects?
Diarrhea
A nurse is caring for a client who is taking acetaminophen overdose which of the following findings should the nurse expect
Diarrhea
A nurse is assessing a client who is receiving daily aspirin. The nurse should identify that which of the following findings might indicate allergic reaction to this medication?
Difficulty swallowing
A nurse is reinforcing teaching with the parents of an infant who has a cleft palette. The parents asked the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months to prevent which of the following outcomes?
Difficulty with language acquisition
A nurse is caring for a client who has schizophrenia and is experiencing delusions which of the following actions should the nurse take?
Direct long conversations about the delusions towards reality-based topic
A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?
Exaggerate lip movements
A nurse is collecting data from a client who has a urinary tract infection and is taking Ciprofloacin The client reports pain in her calf muscle which of the following statements should the nurse make
Discontinue the medication I will ask your provider for another antibiotic
A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning which of the following actions should the nurse take
Discontinue use and take the IV pump
A nurse is reinforcing discharge teaching with a client who has a new prescription for metoprolol. Which of the following instructions should the nurse include?
Do not stop taking his medication abruptly, count your radial pulse daily, change positions slowly
A nurse is reviewing guidelines for documenting client care. Which of the following should the nurse plan to take
Document info telephoned in my a nurse who left the United for the day
A nurse is caring for a client who has bipolar disorder and it's experiencing acute Mania. The nurse obtain a verbal prescription for mechanical restraints. Which of the following actions should the nurse take?
Document the clients condition and Behavior every 15 minute
A nurse is collecting data from a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from a parent? The following questions should the nurse ask?
Does anyone smoke around four in the same house as your child?
A nurse is caring for a client who has MRSA infection. A dietary assistant asks the nurse what precautions are necessary for entering the clients room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant?
Don gloves when entering the room and use hand sanitizer when exiting
Teaching diabetes mellitus and taking insulin lispro and insulin gargine
Draw up insulin lisp and insulin glar in separate syringes
A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine which of the following instruction should the nurse include in the teaching
Drawl up the insulin list Bro and insulin glargine in separate syringes
A nurse is reinforcing teaching with the parent of a preschooler who has atopic dermatitis which of the following instruction should the nurse include in the teaching
Dress the child in soft Cotton clothing
A nurse is contributing to the plan of care for a client who has urinary incontinence which of the following intervention should the nurse suggest to help prevent skin breakdown
Dry the skin thoroughly after cleansing the perennial area
A nurse is collecting data from a client who is it risk for a pulmonary embolism following surgery which of the following findings should the nurse monitor
Dyspnea
a nurse is assessing a client who is post-operative and has a history of pulmonary embolism which of the following should the nurse report to the provider?
Dyspnea
A nurse is providing dischargeteachign to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching?
Eat 1 g/kg of protein per day
A nurse is collecting data from a client who is receiving IV therapy the nurse suspects fluid infilteration which of the following findings should the nurse expect at the insertion site
Edema
A nurse is contributing to the plan of care for a client who had a stroke and is to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend to take prior to initiating each feeding?
Elevate the head of the bed
A nurse is caring for a client who has been giving methylergonovine intramuscularly for postpartum hemorrhage which of the following should the nurse monitor for adverse reactions
Elevated blood pressure
A nurse is preparing educational material. Which of the following techniques should the nurse use in creating the material?
Emphasize important information using bold lettering
A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy which of the following instruction should the nurse include in the teaching
Empty clients asked me pouch before removing skin barrier
A nurse is caring for a client who is 4 hours postpartum. The client reports an urge to void but is unable to void. Which of the following actions should the nurse take?
Encourage the client to attempt to void while using a sitz bath
A nurse is feeding a client who had a stroke resulting in left side of weakness which of the following actions should the nurse take
Encourage the client to drink a small amount of liquids to clear his mouth of food
A nurse is planning care for a client who has bipolar disorder and is experiencing Mania. Which of the following interventions should the nurse include in the plan?
Encourage the client to frequent rest periods
A nurse is caring for a client who is 2 days postoperative following an above the knee amputation which of the following actions should the nurse tske to promote progression toward independence and mobility for the client
Encourage the clieny to use overbed trapeze
a nurse is caring for a one day old Newborn who has jaundice and is receiving phototherapy which of the following actions should the nurse take?
Ensure that the newborn wears a diaper
A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect?
Enuresis
America's hair for a client who is postoperative following joint replacement and he has a new prescription for enoxaparin. for which of the following actions should the nurse monitor
Epistaxis
A nurse is collecting data from a client who is taking varenicline for smoking cessation . Which of the following findings is nurses priority?
Erratic Behavior
A nurse is reviewing the laboratory data of a client who reports manifestations that suggests systemic lupus erthematosus. The nurse should expect an increase in which of the following parameters for a client who has SLE?
Erythrocyte sedimentation rate
A nurse is reinforcing teaching with the parents of a school aged child who has oppositional defiant disorder which of the following reccomendations should the nurse include in the teaching
Establish consequences for disruptive behavior
A nurse manager is a system with the negotiation between to charge nurses were having a conflict overstaffed not completing assignments which of the following actions should the nurse manager take
Establish ground rules before beginning discussion between the charge nurses
A nurse is discussing the fire safety with newly hired nurses. Which of the following identify as the priority if a fire occurs in the health care facility?
Evacuate clients from the unit
A nurse is caring for an older adult client who has an in the canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as a source for this sound?
Excessive wax In the ear canal
A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare a child for the procedure?
Explain in simple terms how the procedure will affect the child
A community health nurse is a system in the development of a brochure about hypertension which of the following actions should the nurse take
Explain the medical terminology using basic one syllable words
A new resident provider asks the nurse for an access code to review a clients online record. The resident is not scheduled to attend the Facility's orientation computer class until next week. Which of the following actions should the nurse take?
Explained that it is against policy to share access codes and refer the resident to his supervisor
A nurse is talking with a group of clients at a senior center about the risk factors for osteoporosis. Which of the following statements should the nurse include?
Extended periods of immobility increase your risk for osteoporosis
A nurse is collecting data from a middle adult client who reports experiencing sexual dysfunction the nurse should identify that which of the following medications the client states can cause sexual dysfunction
FLUOXETINE
A nurse is caring for a client who is experiencing a diazepam overdose which of the following medications should the nurse administer?
Flumazenil
A nurse is collecting data from a child who is one hour postoperative following a tonsillectomy which of the following findings is the nurses priority
Frequent swallowing
Anurse is collecting data from a client who has diabetic ketoacdosis. Which of the following findings should expect
Frutiy breath
Digoxin toxicity s/s
GI effects - anorexia, nausea, vomiting, abdominal pain; CNS effects - fatigue, weakness, diplopia, blurred vision, yellow-green or white halos around objects
Risk factors for hyponatremia
GI loss; adrenal insufficiency; water intoxation; excessive diaphoresis; medications (diuretics, anti-convulsants, SSRIs, lithium)
A nurse is contributing to the development of an in-service training about the differences in mental health bellefs across various cultural groups. Which of the following culture-bound syndromes should the nurse include when discussing Navajo Indian cultural beliefs?
Ghost sickness
a nurse is caring for a client who has a new prescription of Warfarin which of the following medications are contraindicated?
Ginkgo ibuprofen aspirin
A nurse is caring for a client who has a peanut allergy the client states I feel like my throat is closing which of the following actions should the nurse take
Give epinephrine intramuscularly
A nurse participating in the community health fair is providing information to a client who has a blood pressure of 150/90 during a blood pressure screening. Which of the following actions should the nurse take?
Give the client a written record of his blood pressure to bring to his provider
A nurse is caring for four clients which of the following situations require a signed consent form
Giving a Haemophilus influenza B vaccine to a infant
A nurse is caring for a client who is taking warfarin. Which of the following laboratory values should the nurse recognize as an effective response to the medication?
INR 3.0
A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers which of the following foods should the nurse include
Grapes
Newborn vital signs
HR 100-160 R 40-60 BP 60-80 systolic; 40-50 diastolic
APGAR categories
HR, respiratory effort, muscle tone, reflex irritability, color
A nurse is preparing to assist the provider with a paracentesis for a client who has ascites which of the following actions the nurse plan to take?
Have the client void prior to the procedure
A nurse is providing teaching about the digoxin administration to the parents of a toddler who has heart failure which of the following statements should the nurse include in the teaching?
Have your child drink a small glass of water after swallowing the medication
A nurse is contribution to the plan of care for a client who had prolonged exposure to the cold weather And has a core body temperature of 32.5 c (90.5 f)which of the following data is the priority for the nurse to monitor
Heart rhythm
A nurse is caring for a client who has dehydration. Which of the following laboratory values should the nurse expect for this client?
Hematocrit 55%
A nurse is reviewing the medical record for a client who is at 30 weeks of gestation and has anemia which of the following laboratory values should the nurse expect
Hgb 9.9 g/dL
A nurse is preparing to administer an otic antibiotic to an adult client. Which of the following actions should the nurse plan to take?
Hold the dropper 1 cm ( .5 inches) above th ear canal during administration.
A nurse is reinforcing teaching with a client about how to use an albuterol MDI. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order?
Hold the mouthpiece 1 to 2 inches in front of your mouth, tilt your head back slightly and open your mouth wide, depress the canister while taking a slow deep breath, and hold your breath for 10 seconds
A nurse is preparing a sterile field for a procedure the prvider will perform at the client's bedside. Which of the following actions should the nurse take?
Hold the sterile drape above the waist and away from the body.
A nurse is assisting with the care of a client who has Addison's disease and comes to the emergency department reporting nausea, vomiting, diarrhea, and of abdominal pain. To prevent addisonian crisis, the nurse should expect that the provider will prescribe which of the following medications?
HydroCortisone
A nurse is reviewing the laboratory report for a client who has CDK. The nurse finds the following laboratory test results: potassium 6.8, calcium 7.4, hemoglobin 10.2, and phosphate 4.8. Which of the following findings is the priority for the nurse to report to the provider?
Hyperkalemia
A nurse is caring for a client who has end-stage kidney disease. Clients adult child asks the nurse about becoming a living Kidney donor for their parents. Which of the following conditions would be a contraindication?
Hypertension
A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child's medical history should the nurse identify as a contraindication to the procedure?
Hypertension
A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives which of the following findings is a contra indication for this client
Hypertension
A nurse is collecting data on a client who has alcohol use disorder and is experiencing withdrawal which of the following manifestations should the nurse expect ?
Hypertension
A nurse is caring for a client who is taking furosemide which of the following affects should the nurse monitor
Hypokalemia
A nurse is preparing to administer Vancomycin IV to an adult client. The client asks the nurse at the medication can be given two hours earlier. Which of the following statements should the nurse make?
I can start the medication 30 minutes earlier
A nurse is teaching a prenatal class about infection prevention at a community center. which of the following statements by a client understanding teaching?
I can visit my nephew who has chickenpox 5 days after the sores of crusted
A nurse is caring for a client who states I feel we have a good relationship and you will keep my information confidential I want you to know I am planning to commit suicide today which of the following responses should the nurse make
I can't keep a conversation like this to myself
A nurse is reinforcing teaching with a client about advance directives and a healthcare proxy which of the following client statements and the kids and understanding of the teaching
I do not need to name a relative as my designee in my health care proxy
a nurse working in a health department is conducting a health screening for a group of farmworkers which of the following client statements indicates a possible Health risk?
I eat vegetables directly from the field where I work
A nurse is collecting data from a client who has taken MEDROXYPROGESTERONE acetate for the past six months which of the following statements by the client should the nurse report to the provider immediately?
I have breast tenderness
A nurse in a substance use disorder program is interacting with the client. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission?
I have read that problems with substance can have a variety of predisposing factors
A nurse in an inpatient medical health facility is reinforcing teaching with a client who signed a consent form for electro convulsive therapy which of the following statements about a client indicates an understanding of the procedure
I might have short term memory loss after the procedure
A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception which of the following statements by the client indicates an understanding of the teaching?
I need to keep the cap in place for at least six hours after intercourse
A nurse in the providers office is talking with an older adult client reports having trouble sleeping. Which of the following statements should the nurse identify as a possible causes for the patients sleeping difficulties?
I often have a cup of coffee with my dessert before going to bed
A female client who has we currency Cystitis asked the nurse about preventing future episodes. Which of the following statements should the nurse provide for the reinforcement of teaching?
I prefer tub baths to showering
a nurse is teaching a client who has alcohol use disorder about disulfiram. which of the following client statements indicates an understanding of the teaching
I should avoid products containing alcohol like mouthwash while taking this medication
A nurse is reinforcing teaching with a client who has primary open angle glaucoma and a new prescription for timilol Eyedrops which of the following statements by the client indicates an understanding of the teaching
I should check my heart rate while taking this medicine
A nurse is reinforcing teaching with a group of adolescent male clients about testicular examination which of the following statements by a client indicates an understanding of the teaching
I should expect one testicle to be larger than the other
A nurse is reinforcing teaching with a client who has a new diagnosis of COPD which of the following statements by the client indicates an understanding of the teaching
I should practice pursed lip breathing exercises
A nurse is reinforcing teaching with a client who has Gerd and a prescription for ranitidine which of the following statements by the client indicates an understanding of the teaching
I should take this medication in the morning and at bedtime
A nurse is reinforcing teaching with a female client who has tuberculosis and a new prescription for rifampin which of the following statements by the client indicates an understanding of the teaching?
I should use supplemental birth control while I am taking this medication
A nurse is providing teaching to a client who is on glucocorticoids therapy which of the following statements by the client indicates an understanding of the teaching?
I take a calcium and vitamin D supplement daily
A nurse is providing discharge teaching to a client who has Type 1 diabetes mellitus about preventing diabetes ketoacidosis when ill. Which of the following statements by the client indicates an understanding of the teaching?
I will call my doctor if I am sick
A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical mastectomy. Which of the following statments by the client indicates an understanding of the teaching?
I will complete my arm exercises four times a day
A nurse in a providers office is reinforcing teaching about skin care with a client who has a new diagnosis of lupus which of the following statements about a client indicates an understanding of the teaching
I will dry my skin by patting it with a towel
A nurse is teaching a group of newly licensed nurses about client advocacy which of the following statements by the newly licensed nurse indicates an understanding of teaching question teaching?
I will intervene if there's a conflict between a client and his provider
a nurse is teaching a client who has heart failure about engaging in an exercise programwhich of the following statements by the client indicates an understanding of the teaching?
I will make sure I can still talk while exercising
A nurse is reinforcing teaching with a parent of a newborn about home safety percolation which of the following statements by the parent indicates an understanding of the teaching
I will make sure that I can fit one finger between the mattress and the side of my newborns crib
A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir which of the following statements by the client indicates an understanding of the teaching?
I will mix the medication with water
A nurse is providing discharge teaching to a client who is post-operative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching?
I will need to keep my hand elevated above my heart for several days
A nurse is reinforcing teaching with a client who has a spinal cord injury and will need to perform intermittent urinary self catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure?
I will perform intermittent self catheterization every 2 to 3 hours
A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches which of the following statements by the client indicates an understanding
I will place the pitch on a hairless area of skin
A nurse is reinforcing teaching with a parent of a 4 month old infant during a home visit which of the following statements by the parent indicates an understanding of the teaching
I will use a cool mist vaporizer in my babys room
A nurse in a mental health facility is reinforcing teaching with a client about panic attacks which of the following statements by the client indicates an understanding of the instructions?
I will use abdominal breathing at the first sign of a panic attack
A nurse is teaching a client who is receiving radiation therapy about skin protection which of the following client statements indicates an understanding of the teaching?
I will use my hand instead of a washcloth to wash the irradiated area of skin
A nurse is reinforcing teaching with the parent of a child who has type one diabetes how to manage the child's disorder during illness, such as cold. Which of the following statements by the parent indicates an understanding of the teaching?
I'll check his blood glucose more often
A nurse is assessing a client who is 1-day post-operative following the placement of an ileostomy which of the following findings should the nurse report to the provider?
If someone has a purplish blue hue
A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further instruction is required?
If the patient seems confused, I will raise all four side rails so that he doesn't hurt himself
During a client care staff meeting, A charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing client information?
In the unit medication room
A nurse is reinforcing teaching with a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include?
Increase her caloric intake with meals
a nurse is caring for a client who has respiratory depression from an opioid Administration after administering naloxone to the client which of the following findings should the nurse expect?
Increase pain
A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunizations should the nurse recommend?
Influenza
A nurse manager is developing the protocol for discipline which of the following actions should the nurse manager take when implementing this new protocol?
Inform staff about the purpose of the units new processes
A nurse is assisting with the admission of a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurses priority?
Initiate airborne precautions
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the clients nutritional requirements?
Keep a calorie count for foods and beverages
A nurse is assisting with the admission of a client who has vera Cella zoster which of the following intervention should the nurse plan to implement
Initiate contact precautions for the client
A nurse is caring for a client who has schizophrenia which of the following behaviors of the client should the nurse identify as a negative symptom
Initiates speech rarely
A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?
Insert a large bore NG TUBE
A nurse is planning care for a client who has cancer and is about to receive low-dose brachytherapy via vaginal implant. Which of the following interventions should the nurse include plan of care?
Insertion of an indwelling urinary catheter
A home health nurse is preparing to set up a continuous passive motion machine for a client who is postoperative following total knee replacement which of the following actions should the nurse plan to take first
Inspect the cpm machine electrical cord for damage
The charge nurse is coordinating the evacuation of clients from the facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process?
Instruct clients who are able to ambulate to leave
A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system which of the following actions should the nurse take?
Instruct the client to hold the drainage bag a waist height when ambulating
A nurse is reinforcing teaching about hand hygiene with a newly licensed news which of the following information should the nurse include in the teaching
Interlace the fingers while rubbing hands together
A nurse is caring for a client who has a prescription for worsen which of the following laboratory test should the nurse monitor
International normalized ratio
A nurse is assessing a newborn 2 hours following birth. Which of the following findings should the nurse expect?
Irregular respiration
a nurse is teaching a guardian of an adolescent who has a mild persistent asthma and a new prescription for maintenance prednisone which of the following statements by the guardian indicates an understanding of the teaching?
Is medication increase my son risk for infection
A nurse is caring for a client who takes more friend to treat chronic a fib and has early manifestations of Alzheimer's disease. The clients partner asked the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make?
It is likely that ginkgo biloba will interfere with the effectiveness of his other medications
A nurse is caring for a client who is obese. the client is crying and states everyone is staring at me because of my weight which of the following responses should the nurse make?
It sounds like you're saying that you feel uncomfortable around others
A nurse is reinforcing teaching with the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the instructions?
It will help our child if we structure our daily routine
A nurse at a long-term care facility hears an AP talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions?
It's almost time for your appointment. Let me do your hair for you and brush your teeth
A nurse is caring for a client who is so hours. For the following surgical creation of a tracheostomy which of the following is she should the nurse take to help promote the clients recovery
Keep suction equipment at the bedside
A nurse is reinforcing teaching with the school-age child has just had a fiberglass cast application follow a lower extremity fracture. Which of the following instructions should the nurse reinforced with the child and his parents about care during the first 48 hours?
Keep the cast above the level of your heart
A nurse is caring for a client following a thyroidectomy. For which of the following complications should the nurse assess the client?
Laryngeal stridor
A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client?
Lateral
A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease the son states I am so tired all the time but mom needs me which of the following responses should the nurse make
Let me give you some imformation about respite care for your mother
A provider tells a client who reports practicing Hinduism that at 12 weeks gestation she needs more protein in her diet and suggest eating more meat. After the provider leaves examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make?
Let's discuss other foods that are also high in protein that you could substitute for meat
Nurse is collecting data from a 66-year-old client during a routine physical examination at her first clinic visit and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies I am not sure but it's been at least five years since I've had any immunizations. Which of the following responses should the nurse make?
Let's go ahead with giving you this immunization
A nurse in a providers office is caring for a client who states my doctor is always in a big hurry it makes me nervous and I forget what I wanted to ask her which of the following responses should the nurse make
Let's make a list of what you'd like to ask the doctor before she comes in to see you
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands the family centered care?
Let's set up a meeting with the doctor to discuss your options for home care
A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following reaponsea should the nurse make
Let's talk about what the voices are saying to you.
A nurse is providing nutritional teaching about appropriate food choices to a client who has a new diagnosis of uric acid calculi. Which of the following foods should the nurse include in the teaching?
Lima beans
A nurse is assisting with the community health education course for a family members who have an Alzheimer's disease which of the following information should the nurse include ?
Limit number of choices for the client
A nurse is reviewing a medical record of a client who has a prescription for a combination of oral contraceptive. The nurse should identify that which of the following findings is a contraindication to receiving this medication?
Liver disease
A nurse in a rehabilitation facility is observing an AP help a client transfer from the bed to a wheelchair. Which of the following actions indicate to the nurse that the AP understands how to perform this task?
Lock the brakes on the bed and the wheelchair before moving the client
A nurse is caring for a newborn who has hyperbilirubinemia and is receiving photo therapy which of the following findings should the nurse report to the provider
Loose stools
A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak which of the following intervention should the nurse recommend
Place disposable thermometers in the clients room
A nurse is collecting data from a client who has macular degenration which of the following findings should the nurse expect
Loss of central vision
A nurse is collecting data from a client who has tuberculosis and a prescription for EthAmbutol. The nurse should inform the client that he is likely to develop which of the following alterations as an adverse effect of this medication?
Loss of red\green color discrimination
A community health nurse is reviewing the reports for a group of clients. The nurse should identify that which of the following disorders is on the cdc's national notifiable conditions with?
Lyme disease
Immediate treatment for MI [MONA]
M - morphine O - oxygen N - nitroglycerin A - aspirin
Diseases for contact precautions [Mrs. Wee]
M - multidrug resistant organism R - respiratory infections S - skin infections W -wound infections E - c.diff E - eye infection; conjuctivitis
A nurse is collecting data from a client who has heart failure the nurse notices the client has crackles in the bases of the lungs shortness of breath and a respiratory rate of 24 bpm which of the following actions should the nurse take
Maintain the client and high Fowlers position
A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make?
Maintain the head of the bed at 30°
a nurse is caring for a client who is active labor and notes that the fetal heart rate Baseline has been 100/min for the past 15 min the nurse should conclude which of the following conditions is possible causes of fetal bradycardia?
Maternal hypoglycemia
A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client that she will undergo which of the following screening test at 16 weeks of gestation?
Maternal serum alpha-fetoprotein
A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?
Measure the client's urine output every hour
A nurse realizes that it's wrong medication has been administered to a client which of the following should the nurse take?
Measure the client's vital signs
A nurse is contributing to the plan of care for a client who has ascites Due to cirrhosis which of the following interventions should the nurse recommend to include in the plan
Measure the clients abdominal girth daily
A nurse is caring for an infant who is experiencing dehydration. Which of the following data related to hydration status is the nurses priority to collect?
Measure the clients weight daily
A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nruse perform as part of this screening?
Measure the truncal rotation
A nurse in a long-term care facility is delegating care for a group of clients for the upcoming shift which of the following tasks the nurse delegate to an assistive personnel (select all that apply)
Measure vital signs for a client who requires contact precaution, record urine output for a client who has a super pubic catheter, trees for a client who is receiving radiation therapy to radiology
A nurse is caring for a client who has chronic phantom limb pain following and above the knee amputation. Which of the following medication prescriptions should the nurse verify with the provider?
Meperidine
A nurse is going to medical surgical unit is caring for a client who developed deep, rapid respirations. Arterial blood gas Analysis: pH 7.25, PaCO2 morning 40, HCO3 18. Which of following should a nurse identify and report to the provider?
Metabolic acidosis
A home health nurse is conducting a home inspection for a client who is it was for falls which of the following instruction should the nurse provide for the client
Move the clients bed to the main floor on the house
A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for management which of the following statements by the partner indicates an understanding of the teaching
Music will distract my husbands awareness of the pain
A nurse is talking with the parent of a four month old infant about growth and development. Which of the following statements indicates that the parent needs further instruction?
My baby loves to play with pillows in her crib
A nurse is reinforcing teaching about breastfeeding with the mother of a full term newborn who is 5 days old which of the following statements by the mother indicates an understanding of the teaching
My baby should breast-feed 5 to 10 minutes on each breast.
A nurse is teaching a group of clients at a community health care about genetic risk for diseases which of the following statements by a client indicates an understanding of the teaching?
My family has genetic risk for breast cancer so I am considering a total mastectomy
A nurse is reinforcing teaching with a female client about contraception which of the following statements by the client indicates an understanding of the teaching
My partner will use condoms with spermicides
A nurse is assisting with the plan of care for a client who is post operative following a hip arthroplasty. In the clients medical record, the nurse notes a history of COPD. Which of the following oxygen delivery method should the nurse recommend to use this client?
Nasal cannula
A nurse in an urgent care center is collecting data from an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report to the provider as an indication of impending airway obstruction?
Nasal flaring
A nurse in a pacu is caring for a client who is post-operative following a total knee arthroplasty using general anesthesia. Which of the following findings should the nurse report to the provider immediately?
Nasal flaring is present with inspiratory stridor
A nurse is collecting data from a client who has a history of angina and reports having adult chest pressure they radiates to the left side of his neck which of the following is the priority medication the nurse should anticipate the provider prescribes
Nitroglycerin
A nurse is caring for a adolescent client who is bulimia nevosa which of the following actions should the nurse take first
Observe the client during and after meals
A nurse is reinforcing discharge teaching to a client who does not speak the same language as the nurse. The clients neighbor, who speaks to the clients native language and the nurses, arrives to drive the client home. Which of the following actions should the nurse take?
Obtain the services of an interpreter
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize her femur fracture. Which of the following actions should the nurse recommend for the clients plan of care?
Offer the client a diet high in fluid and fiber
A nurse in a nurgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
Olguria
A nurse is reinforcing teaching with the parent of a client who has severe reactive airway disease about Glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it Orally. Which of the following information should the nurse provide to the parent?
Oral glucocorticoids are more likely to slow linear growth in children
A director of nursing and rehabilitation facility is planning to measure the quality of care provided. Which of the following artists should the nurse plan to use after client's discharge to gather information about quality of care?
Outcome audit
A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
Palpate the distal pulse to the cast
I nurse is assisting with the care of a client who had a precipitous delivery. The nurse should identify the collection which of the following data as a priority during the fourth stage of labor?
Palpating the clients fundus
A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination which of the following should the nurse perform?
Palpation
A nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in assisting in disaster preparedness?
Participate in community drills and mock events
A nurse is assisting with the care of a client who is receiving mechanical ventilation for respiratory failure which of the following actions should the nurse take
Performed passive range of motion every two hours
A nurse is caring for a client who has a pseudomembranous colitis do to CDIff. Which of the following interventions is the nurses priority?
Performing hand hygiene before and after contact with the client
A nurse is reinforcing teaching with a client who has a new prescription for a Doxycycline. The nurse should reinforce to the client the need to monitor for which of the following adverse effects of this medication?
Photosensitivity
A nurse answers the room of a school age child and find some on the floor experiencing a tonic clonic seizures which of the following actions should the nurse take
Place a pillow under the child's head
A nurse is contributing to the plan of care for a client who has believe we are never say which of the following intervention should the nurse recommend
Schedule the client for a dental examination
A nurse is reinforcing teaching with the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include?
Place the should harness in the slots that are level with the new born shoulder.
A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior which of the following actions should the nurse take after applying physical restraints to the client
Plan to remove the restraints as soon as the client is calm
37 weeks and HELLP syndrome
Platelet 77,000
A nurse is preparing a sterile field to perform a dressing change for a clients leg wound which of the following actions should the nurse take?
Play sterile objects at least 2.5 cm from the edge of the sterile field
A nurse is preparing to administer a NG tube feeding to a school-age child. Which of the following actions should the nurse plan to take?
Position the child at 10 to 20° angle after feeding
A nurse at a long-term care facility notes that a client who has dementia is having problems with orientation. Which of the following actions should the nurse take to improve the clients level of orientation?
Post a large calendar on the bulletin board
A nurse is reviewing the medical record of a client who has hepatic cirrhosis which of the following lab values should the nurse report to the provider
Potassium 3.1 mEq per liter
A nurse is caring for a client who has heart failure. For which of the following laboratory values should the nurse withhold the clients morning dose of digoxin and contact the provider?
Potassium 3.2
A nurse is reviewing the medical record of a client who has COPD which of the following laboratory findings indicates a need to request a dietary referral for the client ?
Pre-albumin 13 mg /dL
a nurse is reviewing the medical record of a client which of the following findings should the nurse report to the provider
Prealbumin
A nurse is assigned to care for several clients who are post operative. The nurse should identify the client taking which of the following medications is at risk for delayed wound healing?
Prednisone to treat persistent arthritis exacerbations
A nurse is completing an admission assessment for a client who has narcissistic personality disorder which of the following should the nurse expect?
Preoccupied with aging
A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. which of the following responses should the nurse include as the best predictor of future violence?
Previous violent Behavior
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse plan to take to reduce the infants pain during the procedure?
Promote skin to skin contact with the infant's Guardian during the procedure
A nurse on a mental health unit observes a client yelling at another client which of the following actions should tge nurse take first
State expectations for the clients behavior
A nurse is planning a community health program about Parkinson's disease. Which of the following is are the tertiary prevention?
Provide daily exercise classes to improve ambulation for a client who has Parkinson's disease
A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication?
Pulse ox of 85%
Bleeding precautions [RANDI]
R - razor (electric) A - aspirin (NO!) N - needles (small gauge) D - decrease needle sticks I - injury (protect from)
Response for fire [RACE]
R - rescue A - alarm C - contain E - extinguish
A nurse is reinforcing teaching with the Parent of a child who has a new prescription of iamotrigine For a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider?
Rash
A nurse is collecting data from a school age child who has celiac disease. Which of the following findings should the nurse expect?
Steatorrhea
A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?
Reading the newspaper
A nurse is collecting data from a client who has sickle cell anemia and is experiencing a vaso-occlusive which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information There are three tabs that contain separate categories data.) Exhibit
Recommend a transfusion of packed Rbcs
A nurse is planning to delegate the post operative care of a client following an appendectomy. Which of the following actions should the nurse assigned to an assistive personnel?
Record urinary output after emptying the indwelling urinary catheter
A nurse in a provider's office is assessing a client for melanoma. Which of the following findings should the nurse report to the provider?
Red blue papule on the upper back
A nurse is reinforcing discharge teaching with a client who has had a transient ischemic attack. Which of the following instructions should the nurse include?
Reduce dietary sodium
A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following findings should indicate to the nurse that the AAA is expanding?
Report of sudden severe back pain
A nurse is assisting with his food selections for a client who follows kosher dietary tradition which of the following food choices should the nurse include on the client's food tray?
Scrambled eggs and toast with milk
A nurse delegates a task to an AP and the AP refuses tk comolete the assigned task which of the following actions should the nurse take
Report the AP TO THE RISK MANAGER
A newly licensed nurse in an urgent care center is caring for a client who has bruises that the nurse suspects are due to child abuse. Which of the following actions should the nurse take?
Report the suspected abuse to local authorities
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. The nurse notes bright red urinary drainage after notifying the surgeon which of the following actions should the nurse take?
Request a prescription to obtain the clients bun level.
A nurse is assigned an assistive personnel to perform a Gastroatomy Feeling for a client who has been receiving feedings at homeWhich of the following actions should the nurse take to monitor the APs performance of the task
Request the AP to provide a return demonstration of the task
A nurse is caring for a client who receives cyclosporine instead of cycloserine the nurse to monitor the client for which of the following Adverse effects
Respiratory depression
The partner tells the nurse that she is able to manage the client;s physical care but she doesnt want to leave him home alone whhile she travels for work. Which of the following referrals should the nurse make?
Respite care
A nurse is providing dietary teaching to a client who has chronic kidney disease which of the following instruction should the nurse include?
Restrict foods containing phosphorus
A nurse is collecting data from a client who has an acute visual disturbance and describes it as a curtain pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?
Retinal detachment
A nurse is participating in a performance improvement program which of the following actions should the nurse take to evaluate the effectiveness of the program
Review the facilitys policy and procedure manual
A nurse is caring for a client who is postoperative following a liver biopsy. In which of the following position should the nruse place the client following the procedure?
Right lateral
A nurse is discussing risk factors for child abuse with members of the parenting group the nurse should identify which of the following findings as a characteristic of perpetrators of child abuse
Rigid expectations of behavior
A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?
Rise slowly when getting out of bed
Following a kosher diet which of the following on the menu is OK
Roasted salmon
A nurse is reinforcing teaching about self a ministration of NPH insulin with a client who has type two diabetes. Which of the following instructions should the nurse include?
Rotate injection sites within the same area
Diseases for droplet precautions [SPIDERMAN]
S - scarlet fever; sepsis P - pneumonia; pertussis I - influenza D - diphtheria E - epiglottitis R - rubella M - mumps; meningitis AN - adenovirus
A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. These manifestations indicate which of the following adverse effects of haloperidol?
Screen the client for tardive dyskinesia
A nurse is preparing to insert an indwelling catheter for a client. Which of the following actions should the nurse plan to take?
Secure the urinary catheter to the clients thigh
A nurse is caring for a client who is postoperative following a sub total thyroidectomy the nurse should place the client in which of the following positions
Semi Fowler's
A charge nurse in a long-term care facility notes that several staff members are linked in completing an annual mandatory educational session about extremity restraint safely. Which of the following actions should the nurse plan take?
Send an email to each nonadherent employee that includes a link to upcoming educational sessions
A nurse is caring for a client who is today's postoperative which of the following findings should the nurse identify as an indication of postoperative infection
Serous drainage in the clothes section collection device
A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant which of the following should the nurse report to the provider?
Serum creatinine 1.6
A charge nurse in a skilled nursing facility notes several recent conflicts among staff on different shifts. Which of the following strategies should charge nurse plan to use to resolve these conflicts?
Set up a series of meetings for all staff members to discuss issues
A nurse is reinforcing teaching with the client who is going to have an EEG in the morning. Which of the following information should the nurse provide to the client?
Shampoo your hair before the procedure, and don't put any styling products on it afterward
A nurse is caring for a client who is febrile. To reduce his clients fever the nurse applies a cooling blanket which of the following findings indicates the client is having an adverse effect to the cooling?
Shivering
A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include?
Sit with your back supported, keep your knees at hip level, and use an ergonomically designed computer keyboard
A nurse is caring for a client who reports insomnia. Which of the following findings is the priority for the nurse to report to provider?
Snores loudly at night with morning headaches
A nurse is reviewing laboratory findings for a client who is receiving Total parenteral Nutrition which of the following findings should the nurse notify the provider?
Sodium 125
A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage the clients behavior?
Speak to the client with clear calm caring statements
A nurse is caring for a client who is ALS which of the following recommendations is priority?
Speech language pathologist
A nurse manager in a long-term care facility is discussing evidence-based practice with a group of staff nurses which of the following activities should the nurse manager identify as an example of evidence-based practice
Staffing the unit based on client acuity and needs
A nurse is assessing a client's coccyx area for pressure ulcer the nurse knows that The Superficial subcutaneous fat is visible and present which of the following pressure ulcer stages should the nurse document?
Stage 3
A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of the following resources shoudl the nurse consult?
State Nurse Practice Act
A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?
Stop reinforcing the teaching and check with the surgeon about informed consent
A nurse is reinforcing teaching with a client who has a new prescription for sertraline. The client asked the nurse if we should continue to take St. John's wort for depression. Which of the following instructions should the nurse to give the client?
Stop taking the herbal supplement while taking the medication
A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction?
Stop the infusion
A nurse is re-enforcing discharge teaching with a client who is stable angina pectoris which of the following statements by the client indicates an understanding of what to do when chest pain occurs
Stop what I am doing and lie down
A nurse is caring for an infant who has respiratory syncytial virus which of the following interventions should the nurse take?
Suction nares prior to feeding
A nurse is caring for a client who is in stage kidney disease the client has decided to stop dialysis treatment which of the following actions should the nurse take
Support the clients Decision and stop the treatment
A nurse is reinforcing teaching about passive range of motion exercises with the family of a client who has had a stroke which of the following instructions should the nurse include in the teaching
Support the extremity above and below each joint during the exercises
A nurse is assessing a client who has opioid use disorder. Which of the following findings should the nurse expect during opiate withdrawal?
Tachycardia
A nurse is caring for a client who has Graves' disease which of the following findings should indicate to the nurse that the client is developing a thyroid storm?
Tachycardia
A nurse is caring in the clients respirations and notes they are of average death rate is 24 bpm and the rhythm is regular which of the following alterations in the clients breathing pattern should the nurse continue to monitor
Tachypnea
A nurse is providing teaching about clutch safety to a client. Which of the following client actions indicates an understanding of the teaching?
The client keeps axilla free of pressure
A nurse on a pediatric mental health unit is caring for a school age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in the conversation?
Tell me about your favorite videogame
A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make ?
Tell me what concerns you most about being hospitalized
A charge nurse working in a long-term care facility overhears to assistive personnel in the nurses station discussing a client who was just admitted which of the following actions should the charge nurse take
Tell the APs to stop the conversation
A nurse on a pediatric unit is preparing to insert an IV catheter for a 7 year olds who is dehydrated. Which of the following actions should the nurse take?
Tell the child there will be discomfort during the catheter insertion
A nurse is collecting data from a client who is receiving clozapine to treat schizophrenia. The nurse should identify that an increase in which of the following parameters is an early indication of agranulocytosis?
Temperature
A nurse is caring for a client who reports diarrhea for the past 48 hours which of the following finding's indicates the client is experiencing dehydration
Temperature 37.2 (99.1)
A nurse is providing teaching to the parents of a newborn about newborn genetic screening which of the following statements include in the teaching?
Test should performed after your child is 24 hours old
A nurse is observing an assistive personnel take a clients and tympanic temperature which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure
The AP pulls the pinna up and back
A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?
The client exhibits impulsive behavior
A nurse is caring for a client who has major depressive disorder and is taking antidepressants the nurse should identify which of the following findings is the priority to report to the provider
The client has a sudden increase in energy
A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hours ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make?
The client has had an exposure to tuberculosis
A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow which of the following information should the nurse report to the occupational therapist?
The client has two small children at home
A nurse is collecting data from a client who has anorexia nervosa which of the following findings should the nurse identify as a positive outcome to treatment ?
The client resumes menstruation
A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the clients insomnia?
The client watches television in her bed during the day
A nurse is reinforcing teaching with a client who is to habe their plaster cast applied to his right arm Which of the Following information should the nurse include in the teaching
The client's extremity Should be elevated after the cast is applied
A nurse is caring for a client who is receiving a transfusion of 250ml of RBC the nurse should identify that which of the following findings indicates the client has responded positively to the transfusion?
The clients hemoglobin level increases following the transfusion
A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. Which of the following responses should the nurse make?
The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common
A nurse is assisting to plan teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse recommend to include
The importance of colonoscopy screening starting at age 50 years old
Results of enzyme linked immunosorbent assay testing for an 18 month old infant who has pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors?
The infants mother is likely HIV positive
A nurse is caring for a client who has antisocial personality disorder who request to smoke outside of a scheduled smoke break which of the following is an appropriate response by the nurse ?
The smoking times on the unit or after each meal
A client is requesting information from a nurse about a nitrazine test. Which of the followng statements should the nurse make?
The test will determine if there is leaking amniotic fluid
A nurse is reinforcing teaching with a newly licensed nurse about performing a 12 lead ECG which of the following statements about a newly licensed nurse indicates an understanding of the teaching
The test will show conduction patterns and different paths of cardiac electrical activity
A nurse is reinforcing teaching with the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include?
The tubes should stay in place until they fall out on their own
A nurse is collecting data from a client who is jn bucks traction which of the following findings indicates the functioning correctly
The weights apply a pulling force continiously
A nurse is teaching a newly-licensed nurse about incident report. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
They assist with unit quality improvement
A cause of metabolic acidosis
diarrhea [acidosis - from the ass]; fever; hypoxia; starvation; seizure; kidney failure; diabetic ketoacidosis; dehydration
A nurse is caring for a 3 yr old at a well child visit the parent reports they are concerned that their son has begun playing with an imaginary friend. Which of the following responses should the nurse make
This is a common behavior for children this age
A nurse is caring for a client who is why her newborn is receiving phytonadione injection which of the following statements shiuld the nurse make
This medication prevents your baby from developing bleeding problems
A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff which of the following responses should the nurse make?
This must be frightening to you let's talk more about it
A nurse is caring for an adolescent client who gave birth to a stillborn preterm fetus. The client is crying and says to the nurse why did this happen to me? Which of the following responses should the nurse make?
This must be so difficult for you
A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?
This type of seizure can be mistaken for daydreaming
A nurse is transcribing a clients prescription for erythromycin 500 mg four times per day which of the following information shared the news clarify with the provider
Time
A nurse is preparing to give change of shift report on a client who is today's postoperative following total knee arthroscopy which of the following information about the client should the nurse include in the report
Time of last pain medication
A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity?
Tinnitus
A nurse is assessing a client to determine the need for physical restraint the nurse should identify which of the following as a reason to apply physical restraints?
To maintain patency of an IV line
A nurse is assisting to prepare for the transfer of a client from the post anesthesia care unit following a sub total thyroidectomy. Which of the following equipment should the nurse have available at the patient's bedside?
Tracheostomy tray
A nurse is reinforcing teaching with a client about treatment options for profound sensorineural hearing loss. The client should include which of the following information about the function of cochlear implants?
Transmits impulses directly to the auditory nerve endings
A nurse is collecting data from a client who has hypothyroidism and take levothyroxine. Which of the following findings indicates that the client is experiencing acute levothyroxine overdose?
Tremor
A nurse is assessing a client who is pregnant and has a new diagnosis of hyperemesis gravidarum. Which of the following finding should the nurse report?
Urine output 20ml per hour
A nurse is reinforcing teaching with a parent who is preschooler has night terrors which of the following instructions should the nurse include
Use a night light near the child's bed
The nurse is reinforcing teaching with a client who is receiving chemotherapy and develop stomatitis which of the following instruction should the nurse include in the teaching
Use a soft bristle toothbrush
Digoxin antidote
digibind
A nurse is reviewing the medication administration record of a client which of the following prescription should the nurse clarify?
digoxin .250 po daily
A nurse is talking with a parent of a preschooler. The parent reports that her child grows upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent?
Use a stable relaxing routine such as a bath and bedtime story before bed
A charge nurse is observing a newly licensed nurse performing dressing change on a peripheral IV site. For which of the following actions by the new nurse should the charge nurse intervene
Use a sterile gloves to remove the old dressing
A nurse in an emergency department is caring for a child who reports being sexually abused by family member which of the following actions the nurse take?
Use leading statements obtain information from the child
A nurse is preparing to administer 10 units of insulin glargine and four units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse take?
Use separate syringes for administering insulin glargine and NPH insulin
A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety which of the following actions should the nurse take?
Use short sentences when communicating with the client
A nurse at a family planning clinic is preparing to give a presentation to clients about to use a diaphragm. Which of the following information should the nurse plan to include in the session?
Use spermicidal jelly whenever you use your diaphragm
A nurse in an adult daycare facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss which of the following strategies should the nurse include in the plan
Use symbols in the communal room signage
A nurse is planning care for a client who is six hours postoperative following a right knee arthroplasty which of the following interventions should the nurse include in the clients plan of care?
Use the continuous passive motion machine intermittently
A nurse is caring for a client who speaks a different language from the nurse. Which of the following actions should the nurse take?
Use the facility based interpreter of the same sex as a client
A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?
Use three pronged grounded plugs.
A nurse is providing discharge instructions about newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include?
Used car seat when traveling by airplane
A nurse begins to be the newly admitted client who reports that she has my hair anything to eat today the The nurse interrupts the bath and obtains a healthy meal for the client this action by the nurse is an example of which of the following
Veracity
A nurse is administering a client's morning oral medications which of the following actions should the nurse take
Verify the medication three times with the medication administration record
A nurse is reinforcing teaching with a parent of a preschooler who has varicella about expected Clinical manifestations. Which of the following manifestations should the nurse include (select all that apply)
Vessels that form crust, pruritis
A nurse is reviewing the medical record of a client who has schizophrenia and is taking Clozapine. which of the following findings should the nurse identify as a contraindication to administration of Clozapine?
WBC count 2900
A staff nurse is observing a newly licensed nurse suction a clients tracheostomy. Which of the following actions by the newly-licensed nurse requires intervention by the staff nurse?
Waits for 2 minutes between suctions
A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for the client?
Walking with a staff member
Stomach pain in lower left quadret
diverticular disease, pelvic pain, groin pain
Ours in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse can I vote in the upcoming presidential election? Which of the following responses should the nurse make?
We can work together to find out how you can get a mail in ballot
A nurse is discussing the plan of care of a client who is four hours postoperative and has a urostomy with an assistive personnel which of the following statements should the nurse include in the discussion
We need to check the clients urine output every hour
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of therapeutic relationship. Which of the following statements should the nurse make during this phase?
We should establish our roles in the initial session
A nurse is Reinforcing teaching with the Client family about home oxygen use via nasal cannula which of the following statements by a family member indicates an understanding of the teaching
We will frequently check the top of his ears for sores
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
Weak femoral pulses
A nurse in a long-term care facility is caring for a client who has methicillin resistant Staphylococcus aureus (Mrsa)which of the following actions should the nurse take
Wear a gown when assisting the client with personal hygiene
A nurse is reinforcing teaching with a client who has a UTI which of the following instruction should the nurse include in the teaching
Wear cotton underwear
A nurse is caring for a client who has glomerulonephritis the nurse should Identify that which of the following findings is the priority?
Weight gain of 3 kg
A nurse is providing discharge teaching to a client who has a new prescription for phenelzine the nurse should instruct the client to eat which of the following Foods while taking this medication?
Whole grain bread
A nurse is caring for a client who has a prescription for nph insulin 10 units and regular insulin 15 units subcutaneously after injecting 10 units of air into the nph vial which of the following actions should the nurse take next
Withdraw 10 units of NPH insulin
A nurse is collecting data from a newborn who was born 18 hours ago which of the following findings should the nurse report to the provider
Yellow sclerae
A nurse is reinforcing teaching with a client who has a prescription for an antibiotic therapy the client tells the nurse that he always experiences diarrhea when he takes antibiotics which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea
Yogurt
A nurse is reinforcing teaching with a client who has diabetes Molite us about a 24 hour creatinine clearance test which of the following statements should the nurse include in the teaching?
You can begin collection of urine after discarding your first morning void
A nurse is reinforcing teaching with a client who has type two diabetes. The client states I eat pasta every day. I can't imagine giving it up. Which of the following responses should the nurse make?
You don't have to give up pasta; just adjust the amount you eat
A nurse is teaching a client who is pregnant and has a new prescription for an iron supplement. Which of the following statements should the nurse include?
You might become constipated while taking this medication
A nurse is caring for a one month old infant who has a manifestation of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks what are the indications that my baby needs an IV? Which of the following response should the nurse make?
Your baby needs an IV because she is not producing tears
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
Your desire to be an organ donor must be documented in writing
A nurse is reinforcing teaching with a client who is scheduled for LASIK surgery which of the following information should the nurse include?
Your procedure will only take 10 to 15 minutes per eye
A nurse is reinforcing teaching with the client who has come to the family planning clinic requesting an IUD. Which of the following information should the nurse reinforced with the client?
Your risk for ectopic pregnancy increases with an IUD
a nurse manager is a vision protocol for the use of belt restraint which of the following guidelines should the nruse manager include?
document the client's condition every 15 minutes
A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following clients requires follow-up?
a client who is taking Warfarin and has an INR 1.8
A nurse is caring for a client who is receiving intermittent enteral tube feeding. Which of the following client is at risk for aspiration?
a history of gastroesophageal reflux disease
a nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder which of the following interventions should the nurse include
allow the clients and of time to perform procedures ritual
Manifestations of carbon dioxide toxicity
alteration in LOC; tachypnea; increased BP; tachycardia with dysrhythmias
Breastfeeding teaching
alternate breasts; feed every 2-3 hours (8-12 times in 24 hrs); place baby on back after feeding; breast milk can be stored at room temp for 4-6 hrs, refrigereated in sterile bottles for use withing 8 days, or frozen in steril containters for 3-6 months; thaw milk in refrigerated, under running lukewarm water, or placed in container of lukewarm water (microwaving can destroy immune factors and can lead to hot spots that can burn newborn); discard used portions of breast milk; avoid alcohol and limit caffeine
a nurse is reading a tuberculin test for a client who is receiving a purified protein derivative test 72 hours ago which of the following findings indicates a positive test?
an induration measuring 10 mm
Stomach pain in lower right quadret
appendicitis, constipation, pelvic pain, groin pain (inguinal hernia)
Do not delegate to AP
assessment, teaching, medication, evaluation, and unstable patients
When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:
assist the woman to empty her bladder.
Surgical Asepsis (Sterile Technique)
avoid coughing, sneezing, and talking directly over field; only dry sterile items touch the field (1 inch border is nonsterile); keep all objects above the waist; wash hands and don sterile gloves to perform procedure
Interventions for ICP
avoid extreme flexion, extension, or rotation of heat; elevate HOB at least 30 degrees; monitor fluid and electrolyte values (may restrict fluid to prevent increased cerebral edema); maintain seizure precautions; avoid coughing, sneezing, straining, and suctioning;
Maximum IM injection dose for small infants
doesn't exceed 0.5mL
Maximum IM injection dose for small children
doesn't exceed 1mL
hindu post mortem
dont touch the patient's body
Tasks that can be delegated to AP
bathing; grooming; dressing; toileting; ambulating; feeding (without swallow precautions); positioning; bed making; specimen collection; I&O; VS (on stable patient)
Motor skills of 7 month old
bears full weight on feet; moves objects from hand to hand
Diet management for Diverticulitis
begin with clear liquids, then advance to low-fiber diet; low residue
Contraction of hep B
blood or bodily fluids of an infected person
Risk factors for hypokalemia
body fluid loss (vomiting, diarrhea); kidney disease; dietary deficiency; excessive diaphoresis; medications (corticosteroids, diuretics, absue of laxatives); alkalosis
S/S of physical abuse
bruises, welts in various stages of healing; burns; fractures; lacerations; lack of emotional response; withdrawal; aggression
S/S of sexual abuse
bruises; lacerations; bleeding of genitalia, anus, or mouth; STI; difficulty walking or standing; UTI; withdrawn; personality changes; regressive behaviro
Medications for smoking cessation
bupropion (Zyban); nicotine gum (Nicorette); nicotine patch (Nicotrol); nicotine nasal spray (Nicotrol NS); vareniciline (Chantix)
Magnesium sulfate antidote
calcium gluconate
a nurse is caring for a client who has major depressive disorder the client tells the nurse no one cares about me completely alone which of the following response to the nurse make?
can you give me an example of how others are making you feel this way
Position of cane walking
cane opposite affected leg [COAL]
Circumcision education
change diaper at least every 4 hours and clean with warm water; following clamp procedures, apply petroleum jelly each diaper changes fro at least 24 hours after to keep diaper from adhering to penis; apply diaper loosely; don't give tub bath; warm water should be trickled; avoid premoistened towelettes;
Motor skills of 10 month old
changes from a prone to a sitting position; grasp rattle by its handle and picks up finger foods
Medications for detoxification
chlordiazepoxie (Librium); diazepam (Valium); lorazepam (Ativan); oxazepam
Mixing insulin
clear (regular) before cloudy (HPN)
a nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome which of the following recommendations to the nurse include question
consume foods high in bran fiber
Contraction of hep A
contaminated water or food
Contraction of hep E
contaminated water supplies or in travelers returning from abroad
A nurse is caring for a client who is post-operative and has a chest tube drainage system. Which of the following findings should the nurse notify to the provider?
continuous bubbling in the Water Seal chamber
Addison's disease need to add ...
cortisol
S/S of LSHF
cyanosis, tachycardia, orthopnea, pulmonary congestion (cough, crackles, wheezes, blood-tinged sputum, tachypnea) restlessness, paroxysmal nocturnal dyspnea
Newborn's first BM
dark green and viscous
Motor skills of 1 month old
demonstrates head lag; strong palmar grasp reflux
a nurse is providing teaching to an older adult about methods to promote nighttime sleep which of the following instructions should the nurse include
eat a light snack before bedtime
S/S of RSHF
edema, weight gain, ascites, distended jugular veins, fatigue, anorexia
A nurse is reviewing home recommendations with a client who is post-operative following knee surgery which of the following are committing should the nurse make?
ensure that all area rugs are rubber backed
Nursing Interventions for Delirium
establish client's baseline LOC by interviewing family; monitor VS and perform neuro chekcs; monitor for acute onset and fluctuating LOC; maintain comfort measures; monitor ability to function in the immediate environment; determine physiologic reason delirum is occuring
How often to remove restraints and check on client
every 2 hours
Time to feed newborns
every 2-3 hours
Contraction of hep C
exposure to tainted blood; can transfer from mother to child during birth; tattooing, body piercing, and cocaine snorting are associated
a nurse is assessing an older client who has left-sided stroke which of the following findings should the nurse expect
expressive aphasia
S/S of emotional neglect and abuse
failure to thrive; eating disorder; withdrawal; extreme behaviors; delayed development; attemtps suicide; sleep disterbances
Contributing factors to type 2 diabetes
family history, obesity, race/ethnicity, hypertension, history of gestational diabetes, and sedentary lifestyle
a nurse is assessing a client who has an active labor which of the following findings should the nurse report to the provider
fetal heart rate Baseline 170
S/S of meningitis
fever, headache, irritability, altered LOC, nuchal rigidity, increased ICP
Foods rich in iron
fish, organ meats, green leafy veggies, enriched breads/cereal/macaroni, whole grain products, dried fruit like raisins and apricots, and egg yolk
A nurse is preparing to assist with the lumbar puncture of an infant the nurse should plan to place an infant which of the following positions
flexed side lying
a nurse is preparing discharge information for a client who has Type 2 diabetes mellitus which of the following resources should the nurse provide to the client?
food exchange list for meal planning from the American Diabetes Association
Judaism dietary restrictions
food is required to be kosher; meat and dairy can't be on same plate; pork and shellfish prohibited; fasting required on yom kippur; lactose intolerance is common among Jews of European origin
Islam dietary restrictions
food must be lawfaul; pork, alcohol, and some shellfish are prohibited; ramadan is a period of fasting during the ninth lunar month
Stomach pain in upper right quadret
gallstones, stomach ulcers, pancreatitis
a nurse is planning care for a group of clients which of the following methods should the nurse used to manage time effectively?
gather supplies prior to completing a dressing change
Toxic level of Digoxin
greater than 2.4
Preventing food poisoning
hand hygiene; ensure meat and fish are cooked to the correct temp; check expiration dates; refrigerate perishable items
Description of semi-fowlers
head of bed elevated at 30 degrees
Description of fowlers
head of bed elevated to 45 degrees
Description of high-fowlers
head of bed elevated to 90 degrees
A nurse is assessing a client who is currently taking furosemide. which of the following reports by the client indicates a manifestion of an adverse effect of the medication?
hearing loss
Diet for COPD
high-calorie
Diet management for Diverticulosis
high-fiber diet
a nurse is teaching a newly-licensed nurse about postpartum Hemorrhage which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
inversion of the uterus is the leading cause of postpartum hemorrhage
Positioning for hip arthroplasy
keep abductor pillow in place while in bed; don't flex hip more than 90 degrees
Cord care
keep cord dry; keep the top of the diaper folded underneath it; cord falls off around 10-14 days after birth; give sponge baths and avoid submerging newborn until cord falls off
Risk factors for hyperkalemia
kidney failure; adrenal insufficiency; acidosis; excessive potassium intake; medications (potassium-sparing diuretics and ace inhibitors)
Foods rich in folic acid
leafy green veggies, eggs, liver
Foods rich in thiamine
lean meats, whole grain cereals, leguems
LDL levels
less than 130
Onset of rapid-acting: Lispro (Humalog)
less than 15 minutes
Total serum cholesterol levels
less than 200
Alcohol withdrawal antidote
librium (chlordiazepoxide)
Motor skills of 2 month old
lifts head off matress; holds hands
Stool during breastfeeding
loose, pale, and/or yellow
Lab values for renal failure
low magnesium and high creatine
Description of prone
lying on abdomen, legs extended, and head turned to side
Description of supine
lying on back, head, and shoulders
Description of sims
lying on left side with most of the body weight borne by the anterior aspect of the ilium, humerus, and clavicle (client is unconscious or receiving enema)
Description of lithotomy
lying on the back with hips and knees flexed at righ angles and feet in stirrups
A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurses priority to prevent wound infection?
maintain consistent hand-washing by the staff
Positioning for knee arthroplasty
maintain continue passive motion machine to promote joint mobility
Serum creatinine levels
males 0.6-1.2; females 0.5-1.1
HDL levels
males 35-65; females 35-85
Creatine clearance
males 90-139; females 80-125
Diseases that require airborne precautions
measles, TB, herpes zoster and varicella
Foods rich in niacin
meat, beans, peas, peanuts, enriches grains
Scope of practice for LPN
meets the health needs of clients, care for client whose condition is considered to be stable and/or chronic with an expected outcome, performs reinforcement teaching, contributes to care plan (doesn't make them), administers IVPB medications, and monitors IV fluids
Foods rich in riboflavin
milk, organ meats, enriched grains, green leafy veggies
Nursing interventions for fluid volume deficit
monitor VS, skin turgor (for older adults, check skin over sternum or forehead), and lab data; maintain strict I&O; daily weights; initiate fall precautions
Nursing intervention for Cushing's Disease
monitor and treat hyperglycemia
A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemisphere stroke. Which of the following interventions should the nurse include in the plan?
place the client left arm on a pillow while she is sitting
If patient isn't voiding, don't give ...
potassium
NEVER give _ in IV push
potassium
Contraction of hep D
produces when hep B is present; can be prevented with hep B vaccine
Heparin antidote
protamine sulfate
a nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion which of the following should the nurse plan to take?
protect the IV bag from exposure to light
A nurse is preparing to teach the parents of a child who has cystic fibrosis which of the following instruction should the nurse plan to take?
provide diet high in protein and calories
Motor skills of 9 month old
pulls to a standing position; pincer grasp is more precises
Motor skills of 3month old
raises head and shoulders off mattress; voluntary grasp present
Only type of insulin that's given IV
regular insulin
A nurse overhears to assistive Personnel discussing to care for a client while in the elevator. Which of the following actions the nurse take?
report the incident to the aps charge nurse
Risk factors of respiratory acidosis
respiratory depression; pneumothorax; airway obstruction; inadequate ventilation
Latex allergy manifestation
rhinorrhea (thin, watery discharge from the nose)
Five rights of delegation
right person, task, circumstances, direction and communication, and supervision and evaluation
Motor skills of 6 month old
rolls from back to front; holds bottle
Motor skills of 4 month old
rolls from back to side; places objects in mouth
Motor skills of 5 month old
rolls from front to back; strong palmar grasp
Foods to avoid when taking aldactone
salt substitutes and foods with high levels of potassium
Non-stress test interventions (pregnancy)
seat client in a reclining chair or place in semi-fowler's or left lateral position; monitor response of fetal HR to fetal movement
Anurse is caring for a client who has depression and reports St John's Wort along with citalopram the nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?
serotonin syndrom
Psoriasis and vaccines
shouldn't receive any live vaccines while taking medication
Motor skills of 12 month old
sits down from a standing position without assistance; tries to build a two-block tower without success
Motor skills of 8 month old
sits unsupported; begins using pincer grasp
Vaccinations contraindicated in pregnant women
smallpox, measles, mumps, rubella, varicella
Catholicism dietary restrictions
some may abstain from eating meat on Ash Wednesday and on Fridays during Lent
Don't give Metformin when ...
someone is having procedures with contrast dye; can cause acute renal failures
Precautions for Staphylococcal Infection
standard/contact precautions; gloves, PPE including gown/mask if in contact with site of infections
Precautions for Vancomycin-Resistant Enteroccoccus (VRE)
standard/contact precautions; hand hygiene and gloves; gown if in contact with contaminated materials
Stomach pain in upper left quadret
stomach ulcer, duodenal ulcer, biliary colic, pancreatitis
Stomach pain in upper middle quadret
stomach ulcer, heartburn/indigestion, pancreatitis gallstones, epigastric hernia
Calculating delivery date
subtract 3 months and add 7 days to the first day of the last menstraul period
A nurse is providing teaching to a client who is 14 weeks of gestation about finding to report to the provider which of the following findings should the nurse include in the teaching?
swelling of the face
S/S of fluid volume excess
tachycardia; bounding pulse; hypertension; confusion; headache; crackles; weight gain; ascites; dependent edema; distended neck veins; pale skin
S/S of fluid volume deficit
tachycardia; thready pulse; hypotension; orthostatic hypotension; fatigue; syncope; dizziness; confusion; increased R; thirst; weight loss; nausea; vomiting; oliguria (decreased production of urine); diminished cap refill; dry, scaly skin; dry mucous membranes with cracks; poor skin turgor
A nurse assessing a client intermittent infusion device the client states why do you have to do that if you are not giving me medicine which of the following statements should the nurse make?
this clears blood from the tubing and catheter
A nurse is teaching a client who has chronic urinary tract infection which of the following instruction should the nurse include?
try to void a 4 hr
Don't give what food with MAOIs
tyramine (chocolate, alcohol, and fermented foods like cheese)
Duration of precautions for varicella
until lesions crust over
Hinduism dietary restrictions
vegetarian diet is encouraged; most abstain from beef and pork; right hand is used for eating and left hand for toileting and hygiene; several days a year are set aside for fasting
Buddhism dietary restrictions
vegetarian diet practiced by many; avoids alcohol
Coumadin antidote
vitamin k
Motor skills of 11 month old
walks while holding onto something; places objects into a container
Risk factors for hypernatremia
water deficit; GI loss; hypertonic tube feedings; diabetes insipidus; burns; heatstroke
What signs that indicates effectiveness of levothyroxine?
weigh loss
a nurse is admitting a client who has schizophrenia and experiences occasional auditory hallucinations which of the following question should the nurse ask?
what helps you ignore what you were hearing
A nurse is caring for a client who will undergo a procedure the client says he does not want the provider to discuss the result of his partner. For which of the following is an appropriate response by the nurse?
you have the right to decide who receives information