Quiz bank questions

A client comes to an obstetric client for a routine prenatal checkup at 32 weeks. The nurse palpates the client's abdomen to determine fetal position so the fetal heart sounds can be assessed. It is determined that the fetal position is Left Occipital Anterior (LOA). Where should the nurse place the doppler to hear the FHR? 1. below the umbilicus, on the mother's left side 2. below the umbilicus, on the mother's right side 3. above the umbilicus, on the mother's right side 4. above the umbilicus, on the mother's left side

1. we want to listen to the FHR where the back is located if baby is LOA then the back of the head is against the front of the mom's left pelvis

A six month old infant has been admitted with a diagnosis of meningococcal meningitis. The primary healthcare provider has written multiple stat prescriptions. In what priority order should the nurse implement these prescriptions?

1. place client on droplet precautions 2. start IV of D 5 1/4 NS at 25mL/hr 3. Draw blood cultures q 8 hours x 3 4. Prepare client for lumbar puncture 5. administer ceftriaxone 250mg IV TID

Normal platelet count

150,000-400,000

What should the nurse include when providing teaching to a female client prescribed doxycycline for the treatment of acne? 1. take this medication with food to maximize absorption 2. use a non-hormone method of birth control while taking this medication 3. wear protective clothing when outside 4. drink plenty of fluids while taking this medication 5. iron and calcium supplements can be taken with this medication

2, 3 , 4 - take on an empty stomach - do not take irone supps, multivitamins, calcium supps, antacids, or laxatives within 2 hours before or after taking doxycycline

1. six year old with new onset diabetes 2. ten year old with pneumonia admitted two days ago 3. three month old admitted with severe dehydration 4. four year old admitted for developmental studies 5. twelve year old with post op wound infection taking po abx which of these patients can I delegate to an LPN/LVN

2, 4, and 5 because all of these patients are stable

Therapeutic serum Digoxin level

0.5-2 ng/mL

When caring for young adult clients, what developmental tasks would the nurse expect to see? 1. satisfying and supporting the next generation 2. reflecting on life accomplishments 3. developing meaningful and intimate relationships 4. giving and sharing with an individual without asking what will be given or shared in return 5. developing sense of fulfillment by volunteering in the community

3 and 4

The nursing supervisor is preparing a staff development program concerning the legal parameters of torts. Which example would the supervisor include as an intentional tort? SATA 1. administering a 0900 med at 1030 2. administering a med to an incorrect patient 3. performing an invasive procedure without an informed consent 4. telling a client that their med will be withheld if client does not behave 5. raising the side rails without a prescription when a client is at risk to fall

3 and 4 **1 and 2 are unintentional torts

A client has found out that she is pregnant and asks the nurse, "When is my baby due?" The client's last menstrual period began March 3. What date will the nurse calculate as the expected due date? 1. December 3 2. December 7 3. December 10 4. December 13

3. Nagele's rule: first day of LMP-3 months+ 7 days

Which arterial blood gas value would the nurse expect to see when monitoring a client in a hyperosmolar hyperglycemia state (HHS)? 1. pH 7.32 2. PaCO2 47 3. HCO3 22 4. PaO2 78

3. because the patient should not be in acidosis that is the main difference between HHS and DKA

What is the max amount of time blood can hang and be transfused

4 hours

A prescription for continuation of restraint use must be renewed every

4 hours!!

A postpartum client who is 2 hours post vaginal delivery remains on an oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? 1. ambulate in the room 2. perform crede' exercises 3. reassess the fundus in 30 minutes 4. massage the fundus

4. if the fundus is boggy and soft, massaging the fundus until firm will increase uterine tone and decrease bleeding -this is the only option that will fix the problem

Otitis Externa (Swimmer's Ear)

An infection of the outer ear, with severe painful movement of the pinna and tragus, redness and swelling of pinna and canal, scanty purulent discharge - we can use astringent drops after bathing to help avoid

Benztropine

Cogentin / Antiparkinson agent - anticholinergic

Serotonin syndrome symptoms

Delirium, tachycardia, hyperreflexia, shivering, agitation, sweating, muscle spasms, coarse tremors, fever

If the patient has a left total pneumonectomy will they need a chest drainage system?

NO this procedure is the excision of the entire lung, therefore a drainage system is not needed because the fluid and air must accumulate in the thoracic space to prevent mediastinal shift to the left

Following report, which newborn infant should the nursery nurse assess first? 1. positive Babinski's reflex 2. has circumoral cyanosis 3. negative Ortolani's sign 4. has telangiectatic nevi

2. this is bluish discoloration of and around the lips which is an indicator of cyanotic heart defect **a + Ortolani's sign is bad and means congenital hip dislocation we want a - **4. is also known as a stork bite which is normal

Tenesmus

The feeling that you need to pass stools, even though your bowels are already empty. It may involve straining, pain, and cramping.

ectoptic pregnancy

a pregnancy implanted anywhere outside the uterus; most common site is the uterine tube; must be surgically removed to prevent uterine rupture -significant cause of maternal death from hemorrhage if it ruptures

If the patient is receiving heparin what lab value do we watch?

aPTT

A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client?

achieve at least 80% of expected body weight

The NUMERIC scale is used for

adults and older children older than 5

What is a normal CVP reading?

is 2-6 mm Hg.

Can a UAP apply a condom catheter?

yes bc it is not an invasive procedure

What is the order to change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage?

- apply clean gloves - removed soiled dressings - discard soiled dressings and clean gloves in a red bag - don sterile gloves - clean surgical wound with moistened sterile 4x4s - clean around Penrose drain using a circular pattern inside to outside - place dry, sterile 4x4 over surgical wound and Penrose drain -apply abdominal dressing pad

A case manager is evaluating a client diagnosed with hemiplegia due to a CVA who will need assistive devices upon discharge. Which devices should the case manager include?

- dinner plate food guards - transfer belt - raised toilet seat - long handled shoe horn - wide grip eating utensils

A client who has been on bed rest for several day is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. 1. Assess the client's orientation 2. ambulate in the room 3. Assist the client to site on the side of the bed for 1-2 minutes 4. Apply a gait belt to the client's waist 5. Have the client stand by the side of the bed for a few seconds

1 3 4 5 2

The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains that an IUD is most appropriate for what individuals? SATA 1. a mother of a toddler who wants another child in three years 2. the client with a recent exacerbation of sickle cell anemia 3. a client with stage II breast cancer who has finished chemo 4. an adolescent who has recently become sexually active 5. the client with a double mastectomy 7 years ago

1 and 5 o not 2 because this client is already at risk for several complications including infection and clots o not 3 because chemo is making them immunosuppressed and the risk for infection is too high o not 4 because they are young and do not even have regular menstrual cycles a pill or patch would be better for them

Which of the below states are included in mandatory reporting laws? 1. financial abuse of an elder 2. negligence of a colleague 3. spousal abuse denied by the victim 4. gun shot victim 5. client diagnosed with gonorrhea 6. client diagnosed with west Nile virus

1, 4, 5, 6 NOT 2- THIS SHOULD BE DISCUSSED WITH SUPERVISOR NOT REPORTED NOT 3- BC A SPOUSE IS NOT CONSIDERED A VULNERABLE PERSON SO IT IS NOT REQUIRED BY LAW

the nurse is caring for a client with a colostomy who is experiencing excess flatulence. Which instructions should the nurse provide the client? SATA 1. limit intake of carbonated beverages 2. encourage fluid intake of 1000mL/24 hours 3. create a small hole in the colostomy stoma pouch 4. limit consumption of beans, onions, and broccoli 5. release the pouch clamp to release the gas in the colostomy pouch

1, 4, and 5 the client can control when to expel the flatulence in the stomach bag by releasing the pouch clamp on the colostomy pouch NOT 2 because the client should have a fluid intake of 2200-2700mL/24 hours

What is the priority nursing action for a pregnant client who has dilated to 6 cm while receiving an epidural? 1. continuous monitoring of maternal BP 2. frequent auscultation of the FHR 3. Admin an IV fluid bolus at least 500mL 4. Frequent monitoring of the maternal temp

1.

The nurse is providing prenatal education for a couple expecting their first child. The expectant mother asks about fetal movements. What is the best explanation by the nurse? 1. You should feel activity between weeks 16 to 20 2. The fetus is too small to feel any movements 3. Maybe around the end of the 1st trimester 4. It is different for each individual woman

1. we refer to fetal movement felt between weeks 16 to 20 as quickening -quickening is first sensed by the expectant mother

Wehn the surgical team arrives to take a client to the operating room, the client is sitting in a chair in the room. What is the best way for the nurse to get the client onto the transport little? 1. using a foot stool, assist client to step up and crawl onto the litter 2. have client return to bed and utilize slide board to transfer to litter 3. with feet placed apart, grasp client around waist and lift onto litter 4. put Hoyer pad under client, using lift to move client from chair to litter

2

Post thyroidectomy, the nurse assesses the client for complications by performing which assessment? 1. perform blood glucose monitoring q 6 hours 2. check for a + Chvostek's 3. Assess swallowing reflex 4. monitor neck dressings for change in fit and comfort 5. admin desmopressin per nasal spray for UO greater than 200mL/hr

2,3,4 -one of the possible complications of a thyroidectomy is to remove one or more parathyroid glands - the parathyroids' action is to regulate calcium

Regular insulin peaks in

2-3 hours so this is when they are at greatest risk for hypoglycemia

A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client? 1. Assess vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform ADLs

2.

A client with a history of cardiac disease has safely delivered a full term infant. When discussing discharge instructions, the nurse knows the teaching was successful when client makes what statement? 1. Now that the baby is born, I can eat more salt. 2. I must include lots of fiber to prevent constipation 3. I should return my previous dose of cardiac medication 4. I will need extra fluids to help with breast feeding needs

2.

A 70-year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00am. What should the nurse teach the client about sleep patterns in the elderly? 1. do not worry about a few hours of lost sleep 2. elders need as much sleep as younger adults 3. caffeine and some medications may interfere with sleep 4. elders sleep more than younger adults

3.

The nurse is providing post operative care to the craniotomy client. Hourly UO increased from 100mL last hour to 500mL this hour. What action by the nurse takes priority? 1. elevate HOB 90 degrees 2. Auscultate apical pulse 3. obtain BP 4. assess GCS

3. WE know the client is going into DI and so we should be worried about SHOCK!! BP should be assessed to assess if patient is going towards shock

A full term infant is being assessed 12 hours after birth. The infants respiratory rate is 50 and shallow, with periods of apnea. Which action by the nurse takes priority? 1. Apply oxygen by mask at 1 L 2. Prepare for emergency intubation 3. Continue monitoring q 15 minutes 4. Notify the primary healthcare provider stat

3. normal respirations in the healthy NB are generally shallow and expected to be between 30-50/minute with short periods of apnea up to 5 seconds -this infant is displaying normal RR

A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of MRSA. Which action by a new nurse when administering this medication would require intervention by the charge nurse? 1. dilutes medication in NS 100mL 2. delivers medication via an IV pump 3. calculates infusion rate at 30 minutes 4. monitors IV site every 30 minutes during infusion

3. the dose of this medication should be infused over 60 minutes to prevent hypotension and ototoxicity

On the 3rd day post op, a client develops a fever of 103.3 with sivering and nausea. The MD writes these prescriptions. Which should the nurse do first? 1. apply a cooling blanket for fever 2. give ceftriaxone 1g IVPB stat 3. draw blood cx 4. give promazine 50mg po PRN for nausea

3. think we want to get rid of the problem first so draw cultures then give cooling blanket

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is one bedrest. What is the most important assessment at this time? 1. protein in the urine 2. fetal heart tones 3. cervical dilation 4. H/H

4. we are worried about bleeding and that is an emergency -this early in the pregnancy think bleeding d/t abortion or ectopic pregnancy

The obstetrics nurse notes minimal variability with a late decel on the electric fetal monitor of a client that is 38 weeks' gestation. Which action will the nurse take first? 1. Notify the primary healthcare provider 2. Apply 10L O2 per NC 3. Prepare for an emergency C-section 4. Reposition the client to the left side

4. repositioning the client can help improve perfusion from the placenta to the fetus, especially if there is compression on the umbilical cord. THIS IS THE FIRST STEP **if we chose to call the MD first we would be delaying care when there is another thing we can do first

Beneficence

Doing good or causing good to be done; kindly action ex: sitting at the bedside and listening to an elderly client

Herpes zoster is contagious until

Lesions are dried and crusted

Positioning the dying client's bed facing the Mecca (east) is practiced in what faith

Muslim (Islam)

a client has herpes varicella zoster, what med do we prescribe

acyclovir - this is the virus that causes chicken pox in children and shingles in adults -an antiviral should be given

Shingles requires what precautions

airborne precautions -private room - negative pressure airflow -respirator mask

What should you assess prior to the primary healthcare provider performing an amniotomy?

fetal engagement - we want to make sure the fetus is engaged and at station 0 so that when the MD breaks mom's water we do not have to worry about a prolapsed cord

answering all questions posed by client in an honest manner is an example of

fidelity

When assessing a client's testes the nurse notes a lump the size of a piece of rice is this normal

noooo the most common symptom of testicular cancer are painless enlargement of one testis and the appearance of a palpable small hard lump on the from or side of the testicle

A client with 2nd and 3rd degree burns will have approx. 36% of their body burned for burns greater than 20-25% of the TBSA, the nurse should recognize what

that significant vascular damage occurs which causes increased permeability - the fluid leaks out of the vascular space and out into the tissues (3rd spacing edema). - the client can go into a severe FVD and shock

Are visitors allowed if standard and airborne precautions are followed and client is in isolation?

yes

Can calamine lotion be used for varicella?

yes you can apply it to the lesions several times a day

The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? 1. kidney stones 2. diarrhea 3. osteoporosis 4. tetany 5. FVD

1 and 3 too much calcium in the blood = too much calcium in the urine and increased risk of kidney stones -increased parathyroid hormone is pulling calcium from the bones, leaving them weak

Who would the nurse assess first following shift report? 1. client reporting SOB after receiving a bronchodilator respiratory treatment 2. newly admitted client diagnosed with esophageal cancer 3. client with emphysema who has a pulse ox reading of 89% 4. client on ventilator needing a NG feeding 5. client two hour post lobectomy

1 5 2 4 3

What should NSAIDs do for a patient with gout?

dramatically decrease pain after beginning medications -NSAIDs do no decrease uric acid levels

High pitched bowel sounds may be a sign of what?

early bowel obstruction

The FLACC scale is used for

pediatric clients age 2 months to 7 years and is appropriate when clients cannot communicate

What prescriptions are appropriate for the nursery nurse to initiate on a newborn prior to d/c home?

- hep B vaccines - erythromycin ointment - vitamin K -PKU screening

s/s that indicate the client with hyperthyroidism is experiencing thyroid crisis

- hyperkinesis -HTN -restlessness -confusion

A primary healthcare provider prescribed KCL 40 mEq in 100mL of NS to infuse over 30 minutes. What action should the nurse take??

call the healthcare provider because KCL cannot be infused any faster than 40 mEq per hour

Intense Perineal Pain postpartum

can be due to a perineal hematoma which is an EMERGENCY

what precautions are meningococcal meningitis

droplet precautions

Placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus -can be partially or wholly -leading cause of antepartum hemorrhage -usually leads to mom having a c sections

Injury to the frontal lobes can inhibit what?

motor control ability to speak words concentration memory judgement

If a patient is taking Spironolactone what should they avoid?

salt substitutes because they contain a lot of potassium and this is a potassium sparing drug

Foods high in purines

sardines, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads, scallops

Glycopyrrolate is used before ECT is performed for

to decrease stomach secretions which decreases the risk of aspiration

Where should electrodes be placed for a patient in Vfib?

below the right clavicle to the right of the sternum and just below the left nipple

What can be given to stimulate maturation of the baby's lungs in case preterm birth occurs?

betamethasone

in a triage situation, 2nd and 3rd degree burns over 60% of the body put the client in what triage category

black tag

Which menu selection by the client diagnosed with nephrotic syndrome indicate that teaching of proper diet was understood? 1. pancakes with whipped butter, syrup, bacon, apple juice 2. scrambled eggs, sliced turkey, biscuits, whole milk 3. grits, fresh fruit, toast, coffee 4. bagel with jelly, hash browns, tea

2. client needs low sodium and high proteins

Which client should the nurse assign to a room closest to the nurse's station? 1. A multigravida admitted with a new diagnosis of gestation diabetes 2. A primigravida admitted with a diagnosis of placenta previa 3. A primigravida admitted with a diagnosis of complete abortion 4. A pregestational diabetic admitted for glycemia control

2. clients with placenta previa is at a high risk for bleeding and must be monitored closely

Normal INR range

2-3

foods high in B12

-calf liver - feta cheese - shrimp -tuna

A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal infant bonding is occurring? STA a. holds by face to face b. talks about the baby's features c. touches baby frequently d. talks to baby e. allows baby to cry vigorously for 15 minutes

1, 2, 3 ,4

A client who is at 36 weeks gestations is admitted to the LD area for evaluation d/t worsening signs of pregnancy induced HTN. The BP upon arrival is 168/96. While being monitored, she reports a sudden onset of severe abdominal pain. Further nursing assessment reveals vaginal bleeding, abdominal rigidity, and a FHR of 90/min. What nursing action would be appropriate for this client? 1. continuously monitor the client's VS 2. Keep the mother informed of the fetus's condition 3. Careful monitoring of the FHR electronically 4. Accurate measurement of I&O 5. Prepare for emergency vaginal delivery 6. Monitor for restlessness and decreased LOC

1, 2, 3, 4, AND 6

A client diagnosed with mania and HTN is hospitalized d/t confusion and polyuria. Based on current data, what interventions should the nurse implement? EXHIBT SHOWS: - ataxia and mild hand tremors - stable VS - lithium carbonate 1000 mg po daily - lithium level of 2.1 1. hold the lithium carbonate dose 2. notify the MD of the lithium level 3. connect client to heart monitor 4. administer sodium polystyrene for hyperkalemia 5. pad the side rails of client's bed

1, 2, 3, 5 o client has lithium toxicity as the normal level is 0.5-1.2

The nurse is preparing d/c teaching for a client with PVD. Which teaching points should the nurse include about foot and leg care? 1. wear soft cotton socks 2. avoid hot whirlpools 3. rub feet dry 4. wash feet every other day 5. clear pathways in house

1, 2, 5

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up to date on immunizations? 1. diphtheria-tetanus- pertussis (DTaP) 2. inactivated polio 3. herpes zoster 4. meningococcal 5. haemophiles influenza type B (Hib)

1, 2, 5 they should also have: -MMR - varicella - pneumococcal - and rotavirus

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. remove the client from the room immediately 2. leave the client's room to obtain a fire extinguisher 3. instruct the UAP to pull the fire alarm 4. evacuate all clients from the unit

1. RACE rescue/remove alarm contain extinguish

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is NOT appropriate in this situation? STA 1. remove indwelling catheter 2. disconnect the ET tube from the vent 3. remove hospital ID band 4. cap all intravenous lines 5. wash body head to toe

1, 3, and 5 the client expired of injuries within 24 hours of being admitted to the hospital which requires investigation by a coroner. It must be determined if death resulted from fall injuries or whether and action, or lack thereof, by medical personnel contributed to the client's death -as a part of the coroner's assessment the nurse must leave all invasive lines and tubes in place for investigation purposes -the body should not be washed as this can remove evidence and the ID band should never be removed

A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? STA 1. turn the client to the L side 2. Administer oxygen 3. start an IV line 4. prep the mother for C-section 5. Notify the MD

1,2, 5 late decels are associated with fetal hypoxia and acidosis

A client diagnosed rheumatoid arthritis has been prescribed celecoxib. What should the nurse include in the client's education regarding this medication? 1. Do not take celecoxib with ibuprofen 2. GI complaints and HA are among the most common SE 3. Drink a lot of water to offset the dehydration that may occur 4. Notify the healthcare provider immediately if black stools are noted 5. This medication provides relief of pain and swelling so you can perform ADLs

1,2,4,5 NOT 3 bc this med actually can cause the client to develop fluid retention, they need to decrease Na intake

All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse? 1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour. 2. One hour postpartum client with a continuous trickle of vaginal bleeding. 3. 2 hours postpartum client reporting intense perineal pain. 4. Client at 36 weeks gestation with a blood pressure of 148/92.

1. this client is at lowest risk for complications as she is having infrequent contractions and is not high risk for preterm delivery -she is receiving oral terbutaline which is a tocolytic agent that is used to inhibit uterine contractions and suppress preterm labor

Which findings would indicate to the nurse that client with Addison's disease has received too much glucocorticoid replacement? 1. dry skin and hair 2. hypotension 3. rapid weight gain 4. decreased blood glucose level 5. increased cholesterol

3 and 5 excessive drug therapy with glucocorticoids will cause rapid weight gain, round face, and fluid retention -cholesterol and triglycerides in the blood also are increased by glucocorticoids

Which assignment would be most appropriate for the nurse to delegate to a UAP? 1. obtaining a sterile urine specimen from an indwelling catheter 2. inserting an in and out catheter on a client postpartum 3. taking vital signs on a client 12 hours postpartum 4. removing an indwelling catheter on a client 5. perform perineal care on a client with an episiotomy

3 and 5 the other answer choices involve invasive procedures, the UAP is NOT allowed to perform invasive procedures!!

Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? 1. Two people must witness a consent signature 2. A RN must witness a consent signature 3. Signing as a witness implies that the client willingly signed the consent 4. A witness must be over the age of 21

3. signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion *NOT 1. BC ONLY ONE SIGNATURE IS REQUIRES AS A WITNESS *NOT 2. BC THE RN DOES NOT HAVE TO BE THE WITNESS *NOT 3. BC WITNESS HAS TO BE OVER THE AGE OF 18

A client who has right sided weakness and weighs 280 pounds needs to be transferred from the bed to the chair. Which instruction by the nurse to the UAP is most appropriate? 1. stand at the client's right side 2. you are physically fit and at lesser risk for injury 3. using proper body mechanics will prevent you from injuring yourself 4. use the mechanical lift and with another UAP transfer the client to the chair

4.

A nurse is at highest risk for blood-borne exposure during which situation? 1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking foreceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves.

4.

At a summer pool party, an adult client is found unconscious in the water. Someone calls 911, and a nurse present at the party immediately initiates what priority action? 1. Initiate chest compressions. 2. Assess client for any injuries. 3. Wrap client in warm blankets. 4. Check for any respirations.

4.

A client enters the PACU with a three way indwelling catheter that has a continuous irrigation of NS infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. chart the drainage color and amount 2. increase the flow rate of the irrigation solution until the urine is a light pink 3. notify the MD of the dark red drainage 4. pull traction on the indwelling tube and tape the indwelling tubing to the client's leg

2. continuous bladder irrigation is used following surgery to ensure that the bladder remain clear of clots

What instructions should the nurse include when teaching a mother, whose newborn has hyperbilirubinemia, regarding phototherapy and its effects? STA 1. Breastfeeding should be d/c until phototherapy is completed 2. Feed newborn at least every 2-4 hours 3. Make sure the newborn's eyes are closed when applying eye patches 4. Keep the baby quiet and swaddled 5. Report immediately if the urine becomes dark in color

2. providing adequate breast milk or formula by feed q 2-4 hours is key to preventing and treating jaundice because it promotes elimination of bilirubin in the stools and urine 3.

The nurse is evaluating an elderly bedridden client for possible fecal impaction. What sign/symptom should the nurse report as MOST indicative for fecal impaction? 1. rigid, board like abdomen 2. absence of any bowel sounds 3. diarrhea with severe cramping 4. constipation with liquid seepage

4.

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says " I have changed my mind. I do not want to go through with the surgery". What should the nurse do first? 1. convince the client to proceed with the plans for surgery 2. notify the surgery department to cancel the surgery 3. notify the primary healthcare provider of client's decision 4. suggest that the client talk over the decision with the family members

3.

A female client considers using spermicidal agents because she wants both birth control and protection from STIs. What information should the nurse provide the client about spermicidal agents? 1. effectively reduces vaginal fungal infections such as candida albicans 2. eliminates bacterial and viral STIs 3. most effective when used in conjunction with barrier methods, such as a diaphragm 4. causes few side effects

3.

How closely monitored is access to a facility's health information system? 1. No monitoring; the system is password protected. 2. Monitored intermittently. 3. Monitored closely and constantly for inappropriate use. 4. Monitored daily and sporadically.

3.

Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurse? 1. tell the family members that information about clients cannot be provided 2. ask for the victims' permission before talking with the family members 3. instruct the family to wait for public announcements about victims 4. inform them if their family members have been admitted

4. the national emergency situation allows waivers for the HIPPA provisions. D/T emergency situation, the nurse may inform the family members about the status of their loved ones

the nurse notices the primary healthcare provider removes gloves after performing an invasive procedure on a client. The healthcare provider then enters another client's room without washing hands. What is the initial action by the nurse? 1. ignore it since the primary healthcare provider knows best 2. contact the nursing supervisor 3. notify the chief of medical staff 4. remind the primary healthcare provider of the importance

4. the nurse is the advocate for the patient and can advocate by telling the provider to wash their hands

The labor nurse is assessing a client admitted in preterm labor. Which client finding would require a social service consult? 1. very quiet and avoids eye contact 2. reports thar she is not married 3. has injuries in various stages healing 4. reports frequent arguments with her partner

3. injuries in various stages of healing indicate a pattern of abuse -abuse not only harms mom but also increases the risk of fetal harm or death and preterm delivery

The client has just returned from Electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurser to place the client in until full consciousness is regained? 1. supine 2. fowler's 3. lateral 4. high fowler's

3. lateral

Post cataract removal, a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.

4

What race is at a higher risk for developing type 2 diabetes mellitus?

African Americans, Hispanics, American Indians, Asian Americans

Asterixis

aka Liver Flap, a flapping tremor of the hands. When the client extends the arms & hands in front of the body, the hands rapidly flex & exten -indicates hepatic failure is worsening

Education regarding buccal admin of medications

- this route allows the medication to get into the blood stream faster than the oral route - stinging may occur after placing the medication in the cheek -if swallowed, the medication may be inactivated by gastric secretions

What should the nurse document after a client has died?

- time of death - who pronounced the death - disposition of personal articles - destination of body - time body left facility

following total hip replacement, how is hip dislocation prevented?

- using an abduction pillow while sleeping - using a toilet extender - showering rather than taking a bath DO NOT: - cross legs - bend over at the hips

A client is having a total laryngectomy performed. What is important to know post procedure?

- vocal cords are removed and trachea is closed so that no air goes into mouth or throat - CLIENT WILL NOT BE ABLE TO TALK - breathe through a tracheostomy in their neck for the rest of their life - the capacity to smell is diminished or lost since the client can no longer move air through the nasopharynx

Prolonged steroid use symptoms

- weight gain - decreased wound healing - HTN - increased facial hair - moon face

Which symptoms would the nurse be likely to observe in the client who overdosed on diazepam?

-bradypnea -bradycardia -somnolence (extreme, prolonged drowsiness)

What assessment findings would be concern to the nurse who is caring for a client with an arterial line to the radial artery?

-capillary refill: left hand-2 seconds, right hand- 4 seconds -blue tinged color to finger tips of right hand - left radial pulse- 88/min' right radial pulse- 82/min - blanching to the right hand

Normal creatinine levels

0.6-1.2 mg/dL

A nurse has never had varicella has been exposed to a client diagnosed with herpes zoster. Which actions should the nurse take? 1. notify the infection control nurse 2. continue to care for client as varicella and herpes zoster are not related 3. go to the lab to have a Tzanck smear performed 4. obtain herpes zoster vaccine for protection from this exposure 5. receive the varicella -zoster immune globulin within 96 hours of exposure

1 and 5

What discharge instruction should the nurse implement for a client diagnosed with insomnia? 1. eliminate chocolate in the evening 2. drink a glass of red wine 1 hour prior to bedtime 3. perform progressive relaxation techniques at bedtime 4. take acetaminophen/diphenhydramine 2 tabs at bedtime 5. leisurely walk 3 hours prior to bedtime 6. increase the airflow on the CPAP machine

1,3,5

The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? 1. Cumulative index for nursing and allied health literature (CINHAL) 2. Cochrane library 3. health and wellness resource center 4. MEDLINE

1.

The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? STA 1. weigh QD 2. IV of normal saline at 125mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1mg by mouth T.I.W. 5. Dehydroepiandrosterone (DHEA) 5mg by mouth every other day

1. QD is listed on the JCAHO do not use list of abbreviations it should be prescribed as daily instead of QD 4. T.I.W. stands for three times a week however it is unapproved abbreviation instead use three times a week

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

1. a client with a surgical wound is at risk for hemorrhage and is at greater risk than birth from a vaginal delivery -the surgical opening of the abdomen and the uterus makes the patient at higher risk

What can lead to right sided heart failure?

pulmonary HTN- high blood pressure in the lungs -when pulmonary pressure exceeds the systemic pressure the result is back flow to the right side of the heart instead of pumping out to the lungs which results in R sided HF

position of patient post liver biopsy

right lateral decubitus

Negative air flow has not been proven to prevent

surgical site infections -it is used more for an airborne infection isolation room

The nurse is teaching the type II diabetic about monitoring average blood glucose levels over time. The nurse evaluates teaching has been effective when the client verbalizes the need to return to the clinic for what test? 1. glucose tolerance test 2. glycosylated hemoglobin 3. glucose-6-phosphate dehydrogenase 4. fasting blood glucose

2. which is also know as A1C

Side effects of a patient who has received too much levothyroxine

**think that if we are giving levo then we are replacing hormones so we risk throwing them into HYPERTHYROIDISM!!!** - angina - heat intolerance -tremors

How do we use a three-point gait with crutches

move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward

The CRIES scale is used with

neonates and infants

If client has an ammonia level of 80 what neurological functioning do we expect to see?

neuro deterioration- lethargic with slurred speech and decreased orientation normal ammonia level 10-60

Can babies less than 6 months receive the flu shot?

nooo

How do we reduce heartburn after taking Alendronate for osteoporosis?

- drink plenty of water with the medication -sitting upright after taking medication

Expected symptoms in clients with bulimia nervosa

- feelings of self worth unduly influenced by weight - recurrent episodes of binge eating - recurrent inappropriate compensatory behavior to prevent weight gain -excessive weight gain

What things can result in left sided heart failure

- long term HTN - the inability of the mitral valve to close properly - narrowing of the aorta

A client has a calcium level of 3.2 what symptoms should we expect?

- muscle rigidity and cramping - positive Chvostek's sign - seizures - laryngospasms **think NOT SEDATED SO THEY ARE RIGID**

Kosher diet reminders

- no pork products including bacon, ham, and sausage - fish is allowed if it has fins and scales -pasta, potatoes, salads, and tea are allowed

S/S that mom may be hemorrhaging post partum and should report to MD immediately

- oliguria - perineal pad saturation in 10 minutes (perineal pad saturation in less than 15 min is considered excessive) -boggy uterus - constant trickling of bright red blood from vagina

What electrolyte is most significantly lost from the upper GI tract

potassium

If patient has ever had rheumatic fever they must be what before any procedure or surgery

pre medicated with abx

What are some nutritious diet options for a patient with COPD who needs to avoid losing weight?

- scrambled eggs -cheese omelet - sliced banana - orange juice **we want high protein and fiber** avoid milk and dairy products like whole milk and yogurt as this can cause an increase in mucus production

Catopril (Capoten) cannot be taken when you are

pregnant

Hypokalemia can lead to what dysrhythmias

premature ventricular contractions

Most common symptoms of UC

10-20 bloody diarrhea stools a day

The nurse is discussing foot care with a client recently diagnosed with diabetes. Which statement by the client indicates an understanding of foot care? 1. I will soak my feet for 30 minutes a day 2. I will avoid using a heating pad on my feet 3. I can use scissors to remove the corns on my toes 4. I enjoy walking without my shoes around the house

2 d/t decreased sensation in the feet the client is a t risk of blistering and burning their feet

A hospitalized client reports needing scented candles to air sleep. The nurse informs client lit candles are not permitted in the facility. What appropriate alternatives could the nurse suggest to the client to assist with the sleep process? STA 1. use an electric potpourri burner 2. place dry potpourri in nightstand 3. bring in live flowers to keep in room 4. spray scented air freshener frequently 5. dab scented oil on corner of the sheets

2 and 5

The nurse enters the client's room to admin morning meds and notes that the client is praying aloud. What would be the nurse's best action? 1. interrupt the client to admin meds 2. wait quietly until the prayer is finished 3. join the client for prayer 4. ask the client if you can provide a directed prayer

2.

The nurse is caring for a primipara client at 27 weeks gestation. Which client learning need should the nurse identify as priority at this stage of pregnancy? 1. Appropriate nutrition 2. Signs of preterm labor 3. Fetal teratogens 4. Newborn care

2. client is entering 3rd trimester when the risk for preterm labor and delivery are highest -women who know the signs can be recognized and reported much faster

A client has been admitted to the L&D unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. DTR +3 2. UO of 80mL over 4 hours 3. RR of 24 breaths/min 4. severe headache with blurred vision

2. we should have 30mL/hr this client should have 120mL in 4 hours

The nurse is caring for a client c heat exhaustion. Which finding suggests a problem? 1. temperature of 101 2. hot, dry skin 3. profuse sweating 4. headache

2. if the skin is dry then the body is not sweating and we want sweating to help the body cool itself

A child has been vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has? 1. hypocalcemia 2. hypermagnesemia 3. hypokalemia 4. metabolic alkalosis 5. respiratory acidosis

3 and 4 -clients who vomit are losing acid, therefore they will be metabolic alkalosis - potassium is lost through the upper GI tract

Which diet choice contains the least amount of tyramine? 1. smoked turkey and dressing, sweat peas and carrots and milk 2. baked chicken over pasta with parmesan sauce, baked potato and tea 3. fired catfish, French fries, coleslaw, and apple juice 4. liver smothered in gravy and inions, rice, squash, and water

3.

A pregnant client's initial blood work shows negative rubella titer. The nurse is aware that indicates what important course of action? 1. Client needs to be isolated until delivery 2. Client is immune to rubella currently 3. Client should be given rubella vaccine after delivery 4. Client has never been exposed to rubell

3. a negative titer indicates the client has no rubella antibodies -since rubella vaccine is a live vaccine must be given after delivery

A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider? 1. early decelerations 2. FHR 160/min 3. BP 90/62 4. Temperature of 99.6 F

3. hypotension is an adverse effect of epidural analgesia due to vasodilation -maternal hypotension reduces blood supply to the placenta, decreasing fetal oxygen supply

A low income family with children live in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be MOST important for the home health nurse? 1. immunization status 2. school- related problems 3. lead poisoning 4. signs of child abuse

3. lead may be found in the soil around rusted cars and can cause lead exposure. Old paint contains lead and young teething children could chew on chipped paint objects.

What best indicates a + Mantoux Tuberculin Skin test? 1. formation of a vesicle that is 4mm in diameter 2. A sharply demarcated region of erythema of 10 mm 3. A central area of induration of 15mm surrounded by erythema 4. A circle of blanched skin surrounding the injection site

3. measure ONLY THE INDURATION -erythema or swelling is not to be measured or called positive

After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority? 1. Position the client on her left side 2. Increase the IV fluid rate 3. Place the client in the knee-chest position 4. Administer oxygen per tight face mask

3. it is likely this is occurring due to a prolapsed umbilical cord after AROM, priority intervention is to relieve pressure on the cord from being trapped between the presenting part and the pelvis we can do this by placing manual pressure on the presenting part with your fingers or placing her in knee to chest position

A client is admitted to the hospital at 36 weeks gestation with a diagnosis of placental abruption. Following an initial assessment, what action by the nurse is most important? Exhibit show: HR 120 and regular, RR 26 and non-labored, BP 90/50, FHR 110 1. apply the fetal monitor 2. complete an abdominal prep 3. insert large bore IV 4. have client sign the consent form

3. the client's BP is dangerously low we need a large bore IV with lots of fluids

A client with the diagnosis of TB should be in what kind of room?

private room on airborne precautions - do not let the questions trip you up by saying protective isolation

Foods high in tyramine

Avoid party foods aged cheese, blue cheese, cured meat, summer sausage, pepperoni, salami, smoked/processed meats, pickled foods, sauces, soybeans, pop peas, dried fruit, meat tenderizers, yeast, alcoholic foods

If giving lovenox and the patient needs an antidote what do we use

protamine sulfate bc lovenox is a low dose heparin

A patient with Chron's is at risk for infection due to what

fistula formation with an abscess

Gutherie Test (aka PKU test)

hyperphenylalanine levels -tests to determine the Prescence of phenylalanine in the blood - a + test indicates a metabolic disorder - to conduct the test, blood is taken from baby's heel - take it as close to discharge as possible

Symptoms of alkalosis are often due to associated potassium loss and may include

irritability, weakness, and cramping -excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis

An Asian patient is being d/c after a colonoscopy. During the d/d instructions the client stares directly at the floor, despite being able to speak English. Based on the body language how would the nurse classify the behavior?

the client is being attentive - in the Asian culture making eye contact with the nurse would be considered rude and offensive as the nurse is considered the superior to the client in this situation

The nurse is performing CPR on an adult client with facial and neck trauma. Following the admin of rescue breaths, where is the best location for the nurse to assess for a pulse in the client?

the femoral artery it is large and close to the trunk of the body

How do Native Americans traditionally view pain?

they are more likely to be quiet and less expressive of pain -they tend to tolerate higher pain levels

Donzepil

used to treat confusion in clients with Alzheimer's and dementia

The client needs an irone dextran IM injection, what is the best site for admin?

ventrogluteal site using Z track method

What is an appropriate short term goal for a patient with dissociative identity disorder?

verbal recognition of the existence of multiple personalities

How do you calculate BMI?

weight (lbs) / height (in)^2 x 703

intentional tort

when a person intends to perform an action that causes harm to another