PNC Exam 2 prepu study guide
The nurse is working on a telemetry unit, caring for a client who develops dizziness and a second-degree heart block, Mobitz Type 1. What will be the initial nursing intervention?
Administer an IV bolus of atropine.
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
Echocardiogram
A male client is admitted to the unit for a total hip replacement. The surgeon orders a first-generation cephalosporin as a surgical prophylaxis because of what type of bacteria commonly associated with this type of procedure?
Gram-positive
When administering benazepril with spironolactone, the nurse should be aware that which electrolyte imbalance may occur?
Hyperkalemia
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Noncontrast computed tomogram
Morphine sulfate has which of the following effects on the body?
Reduces Preload
A 26-week gestation pregnant woman has completed a 1-hour glucose screening test. What action should the nurse take first if the glucose level is 150 mg/dL (8.3 mmol/L)?
Refer the client for a 3-hour glucose test.
What is used to decrease potassium level seen in acute renal failure? EBP
Sodium polystyrene sulfonate
A nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). The nurse takes what precautions? EBP
The nurse uses the same precautions as with any client.
Which statement best explains the importance of theoretic frameworks?
Theoretic frameworks advance nursing knowledge and practice.
A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action?
Turning the client from side to side, using the logroll technique
The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?
When hands are visibly soiled
A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply?
decreasing environmental stimulation
A client reports light-headedness, chest pain, and shortness of breath. They physician orders tests to ascertain what is causing the client's problems. Which test is used to identify cardiac rhythms?
electrocardiogram
A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find
irritability and poor sucking.
A nurse is working on a surgical floor. The nurse must logroll a client following a
laminectomy.
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?
medications listed on the client's medication administration record (MAR)
A black box warning alerts health care providers to risks in young adults 18 to 24 years of age when taking antidepressant medications. Which symptoms of concern should be included?
statements or resignation and futility and a desire to die
A client with a spinal cord injury has full head and neck control when the injury is at which level?
C5
Which is a focus of medical research rather than nursing research?
Drug metabolism
Which of the following is the treatment of choice for acoustic neuromas?
Surgery
Following an assessment of a client with posttraumatic stress disorder (PTSD), the nurse concludes that the client is at risk for suicide. What would be the immediate goals of management for this client?
The client will be physically safe.
The health care provider is selecting an antibiotic for a client with a known penicillin allergy. The provider knows that cephalosporins are a poor choice for this client because cephalosporins:
can cause allergic reactions in clients who are allergic to penicillins.
A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? EBP
"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours
A client with a diagnosis of hemophilia A has been admitted with bilateral knee pain. The nurse should anticipate performing what intervention during the client's treatment?
Administration of factor VIII and implementation of fall prevention measures
A home care nurse is to administer one aspirin a day to the client. The client has the over-the-counter medication in two forms. The first is available in the form of 325-mg scored tablets. The second is a Lo-dose aspirin of 81mg aspirin. What would the nurse's action be?
Consult the health care provider.
A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?
Gently aspirate the I.V. catheter to check for a blood return.
When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next?
Rinse their eyes with water, report the incident, and go to Employee Health.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?
Start IV fluids with a normal saline solution bolus followed by a maintenance dose.
Which cerebral lobe contains the auditory receptive areas? EBP
Temporal Lobe
The nurse is caring for a client who has just returned to the postpartum unit after a cesarean birth. Which action is a priority for the nurse to teach the client to perform over the next 24 hours to prevent complications?
deep breathing and coughing exercises every 2 hours
The health care provider prescribes an abdominal radiograph for a newborn to check for Hirschsprung disease. The nurse examines the newborn and finds which symptoms that are indicative of this disease? Select all that apply.
enterocolitis bilious vomiting abdominal distention absence of stool in the rectum
A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?
extravasation
A fracture is considered pathologic when it
occurs through an area of diseased bone.
A nurse is assessing a client with multiple myeloma. Due to this condition, what will this client be at risk for?
pathologic bone fractures.
During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?
maternal hypotension
Agnosia
the inability to recognize familiar objects.
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?
Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20.
A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor?
allowing volunteers to return neonates to the nursery
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?
International normalized ratio greater than 2
The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.
Quality improvement (QI) Client-centered care Teamwork and collaboration
Results from the 2013 OASIS data study revealed that data from the study can be used to identify individuals at greatest risk for readmission to the hospital. Using this data, what can the nurse determine will decrease the readmission rate of hospitalizations?
The shift of resources to the community
The nurse is instructing the parents of a child with head lice. Which statement should the nurse include?
Use shampoo with piperonyl butoxide.
The nurse is checking the client's chart for possible contraindications, before administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse should hold the meperidine when the nurse sees an order for what type of drug?
a monoamine oxidase (MAO) inhibitor
Which class of medication protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?
beta-adrenergic blockers
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
extreme anxiety
A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?
granulocytopenia
Parents of a 3½-year-old indicate they spend time with grandparents who live near a lake. The nurse will emphasize:
having the child wear a personal flotation device whenever near or on the water.
A nurse is monitoring a client receiving tranylcypromine sulfate. Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor?
hypertensive crisis
Accounting for age, illness, and risk factors, a transfusion is recommended when the hemoglobin is at which level?
<7 g/dL (<70 g/L)
The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? EBP
Aspiration of a brain abscess
The nurse is caring for a client who is HIV positive. What laboratory test is used to determine this client's ability to fight against viral infections?
CD4
A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion?
Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent.
The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace? All options must be used.
Verify the prescriptions for the settings for the brace. Have the client in a side-lying position. Assist the client to log roll and rise to a sitting position. Ask the client to stand with arms held away from the body.
The primary objective in the immediate postoperative period is
maintaining pulmonary ventilation.
