review #2

A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? A. Leave the client 5 min after beginning the transfusion. B. Infuse the transfusion at a rate of 200 mL/hr. C. Check the client's vital signs every hour during the transfusion. D. Flush the blood tubing with dextrose 5% in water.

C. Check the client's vital signs every hour during the transfusion.

The nurse is supervising care for a client who is receiving chemotherapy and has developed severe stomatitis. Which of the following instructions can the nurse provide to the unlicensed assistive personnel? Select all that apply.

- anything that doesn't require nursing judgment or teaching

A 27-year-old male client informed his health care provider that he was once diagnosed with leukemia 20 years ago. He has been in remission for many years. The nurse obtaining the history is aware that which type of leukemia is the most likely type?

-ALL

hemophilia pt has come to the emergency department for evaluation of a swollen right knee after a fall. Which action should the nurse perform first? A. administer the prescribed morphine B. obtain supplies to administer clotting factors C. prepare the client for x-ray of the knee D. elevate the right leg and apply ice

D. elevate the right leg and apply ice

The nurse is reviewing laboratory test results for a client with severe chronic obstructive pulmonary disease. The nurse should anticipate that the test results will indicate a. Anemia b. Neutropenia c. Polycythemia d. Thrombocytopenia

Polycythemia

A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests?

Schillings test

*ER RN Notes 1400 The client has asymmetry of the neck and reports unintentionally losing 11 lb (5 kg) over the past 3 months, as well as fatigue and night sweats. The client has also developed a nonproductive cough in the past 3 weeks, is having increasing difficulty swallowing, and states, "This lump on my neck has grown." The client lives alone and has worked in a chemical plant for the past 10 years. Chest x-ray 1715: A 9-cm (3.54-in) mediastinal mass is displacing the trachea. The lungs are

a,b,c

The nurse is caring for a client with hemophilia admitted for a facial laceration and im hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? Select all that apply. a. Administers coagulation factor replacement IV push b. Administers ibuprofen PO PRN for pain c. Applies ice packs to the affected joint hourly for 15 minutes d. Elevates the affected leg in the extended position e. Performs neurologic assessment every 30 minutes for 6 ho

a,c,d,e

The nurse is caring for a newly admitted client who is scheduled for surgical repair of acute aortic dissection. The nurse should recognize that it would be a priority to do which of the following? a. Administer IV beta blocker therapy b. Initiate IV antibiotics c. Insert an indwelling urinary catheter d. Verify informed consent

a. Administer IV beta blocker therapy

The nurse is providing an educational seminar on risk factors for cancer at a local community center. Which of the following teaching points should the nurse include in the seminar? Select all that apply. a. Adults over age 50 should have regular screenings due to a greater risk of cancer b. Alcohol consumption does not significantly increase the risk of cancer c. Increasing the intake of non-starchy vegetables and bran can lower the risk of cancer d. Poorly managed stress is known to increase

a. Adults over age 50 should have regular screenings due to a greater risk of cancer c. Increasing the intake of non-starchy vegetables and bran can lower the risk of cancer d. Poorly managed stress is known to increase the risk of cancer e. Tobacco use and secondhand smoke may be the most avoidable cancer risk factors

52-year-old client is being evaluated in the emergency department due to passing-out. His past medical history includes: HTN, DM, smoking. The nurse is preparing the client for discharge. Which discharge education should the nurse include? Select all that apply. a. Low fat diet b. Low calorie diet c. Cigarette smoking reduction d. Avoidance of all physical exercises

a. Low fat diet b. Low calorie diet (?) -not sure about this one lol

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.) a. Lubricate the lips with water-soluble ointment. b. Brush teeth with a soft toothbrush. c. Blow nose gently. d. Limit fruit consumption. e. Use a straight edge razor to shave.

a. Lubricate the lips with water-soluble ointment. b. Brush teeth with a soft toothbrush. c. Blow nose gently.

The nurse suspects the client is experiencing acute disseminated intravascular coagulation (DIC). Which laboratory value is expected to be increased? Select all that apply. a. PT b. D-dimer c. Fibrinogen d. Activated PTT

a. PT b. D-dimer c. Fibrinogen d. Activated PTT *fibrinogen same as FDP

The client has been diagnosed with acute disseminated intravascular coagulation (DIC). Which of following descriptions indicates correct understanding of DIC? a. Widespread activation of clotting and fibrinolysis b. A genetically inherited clotting factor deficiency c. An immune response to heparin exposure d. Usually follows a viral infection

a. Widespread activation of clotting and fibrinolysis

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP? a. Blood pressure (BP) of 130/86 mm Hg b. Difficulty swallowing c. Dry, hacking cough d. Low back pain

b

A male client in the critical care unit for 4 days is being managed due to Septic Shock. The nurse wrote the following physical findings on progress notes: General: The client was admitted to the intensive care unit 18 hours ago for treatment of sepsis due to acute pyelonephritis. Neurological: The client is intubated and sedated. Pupils are 3 mm, equal, round, and reactive. Integumentary: The client's skin is pale; petechiae are noted on the upper and lower extremities. Two IV lines are present

b,c, e

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm? Select all that apply. a. Assess abdominal incision every 4 hours b. Check for bleeding at groin puncture sites c. Measure chest tube drainage d. Monitor fluid intake and urine output e. Palpate and monitor peripheral pulses

b,d,e

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? a. Assess and compare blood pressure in each arm b. Assess character and quality of peripheral pulses c. Assess for presence or absence of hair on lower extremities d. Assess for presence of bowel sounds

b. Assess character and quality of peripheral pulses

A client with peripheral arterial disease has just returned from femorotibial bypass surgery. What assessment finding should the nurse report to the health care provider immediately? a. Pedal pulse of +3 with brisk capillary refill of the affected extremity b. Severe, unrelieved aching pain of the affected extremity c. Tympanic temperature of 100.8 F d. Warmth, redness, and +1 edema of the affected extremity

b. Severe, unrelieved aching pain of the affected extremity

A client with peripheral arterial disease has just returned from femorotibial bypass surgery. What assessment finding should the nurse report to the health care provider immediately? Group of answer choices a. Pedal pulse of +3 with brisk capillary refill of the affected extremity b. Severe, unrelieved aching pain of the affected extremity c. Tympanic temperature of 100.8 F d. Warmth, redness, and +1 edema of the affected extremity

b. Severe, unrelieved aching pain of the affected extremity

A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? a. Leave the client 5 min after beginning the transfusion. b. Infuse the transfusion at a rate of 200 mL/hr. c. Check the client's vital signs every hour during the transfusion. d. Flush the blood tubing with dextrose 5% in water.

c. Check the client's vital signs every hour during the transfusion.

A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern? a. Diminished breath sounds in bilateral lung bases b. Hypoactive bowel sounds in all 4 quadrants c. Urinary output of 90 mL in the past 4 hours d. Warm extremities with 1+ bilateral pedal pulses

c. Urinary output of 90 mL in the past 4 hours

A 52-year-old client is being evaluated in the emergency department due to passing-out. His past medical history includes: HTN, DM, smoking. The nurse is assessing a client with aortic stenosis. Which of the following findings would be consistent with the condition? a. bounding peripheral pulses b. distended neck veins c. syncope on exertion d. loud S2 heart sound

c. syncope on exertion

The nurse is talking with a client with newly diagnosed peripheral artery disease. Which of the following statements by the client would require immediate follow-up? a. "I am glad that the hair on my legs will return with treatment." b. "I take my atorvastatin in the morning with my other medications." c. "I avoid walking when my feet hurt so I do not make the pain worse." d. "I elevate my legs in the recliner and use a heating pad if my feet are cold."

d. "I elevate my legs in the recliner and use a heating pad if my feet are cold."

A 24 -year-old male client was seen in the emergency department due to pain in the right hip. The hip was noticed to be swollen and tender to touch. He revealed both parents had a history of malignancy. Which of the following is a most likely cause if cancer is being suspected? a. Acute Myelocytic Leukemia b. Acute Lymphocytic Leukemia c. Chronic Myelocytic leukemia d. Chronic Lymphocytic Leukemia

d. Chronic Lymphocytic Leukemia

A 52-year-old client is being evaluated in the emergency department due to passing-out. His past medical history includes: HTN, DM, smoking. What caused the syncopal episode for this client? a. Pulmonary edema b. Reduced diastolic blood volume c. Regurgitation of blood through aortic valves d. Reduced stroke volume

d. Reduced stroke volume

The nurse is caring for assigned clients. The nurse should first check the client with.. a. liver cirrhosis who has a decreased RBC count and is reporting pruritus b. pneumonia who has an elevated WBC count and coarse crackles bilaterally c. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations d. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration

d. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration

The nurse suspects the client is experiencing acute disseminated intravascular coagulation (DIC). Which laboratory value is expected to be decreased? Select all that apply a. PT b. D-dimer c. Fibrinogen d. Activated PTT e. Platelets

e. Platelets