RN Comprehensive Online Practice 2023 B
A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication? A. "Have you experienced muscle stiffness?" B. "Have you had any stomach pain or bloody stools?" C. "Have you experienced a dry cough?" D. "Have you noticed an increase in urine output?"
"Have you had any stomach pain or bloody stools?" The nurse should ask the client about the presence of stomach pain or bloody stools, which is an indication of gastrointestinal bleeding, an adverse effect of ibuprofen. Incorrect Long-term ibuprofen use does not cause increased muscle stiffness. However, the client might have joint stiffness as a manifestation of juvenile idiopathic arthritis. Long-term ibuprofen use does not affect the respiratory system or cause a dry cough. The nurse should recognize that long-term ibuprofen use can damage the kidneys and assess the client for decreased urine output.
A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what is causing the constipation. Which of the following responses should the nurse make? A. "Estrogen levels decrease during pregnancy, causing the stool to become hardened." B. "Decreased water absorption in the intestine during pregnancy causes constipation." C. "The intestine absorbs iron less efficiently during pregnancy, leading to constipation." D. "The enlarged uterus compresses the inte
"The enlarged uterus compresses the intestines and causes constipation." During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation. Incorrect Estrogen and progesterone levels increase during pregnancy, leading to decreased peristalsis and relaxation of the smooth muscles of the intestine, which can result in constipation. The intestine absorbs more water from the stool during pregnancy, leading to constipation. The small intestine absorbs iron more readily during pregnancy due to increased maternal needs, leading to constipation.
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden unexpected infant death (SUID). Which of the following guardian statements indicates an understanding of the teaching? A. "I will not allow anyone to smoke near my baby." B. "I will place bumper pads in my baby's crib." C. "My baby's head should be placed on a pillow for sleeping." D. "My baby should sleep in a side-lying position."
A. "I will not allow anyone to smoke near my baby." This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SUID. Incorrect: The guardians should not place bumper pads in the infant's crib because they increase the risk for suffocation. Therefore, this is a risk factor for SUID. The guardians should not place the infant's head on a pillow for sleeping because it increases the risk for suffocation. Therefore, this is a risk factor for SUID. The guardians should place the child in a supine position for sleeping to prevent SUID.
A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care? A. Notify the provider if a thrill is palpated at the fistula. B. Auscultate the affected extremity for a bruit. C. Discourage range-of-motion exercises in the affected extremity. D. Perform venipuncture in the affected extremity.
Auscultate the affected extremity for a bruit. The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present, which indicates patency. Incorrect The nurse should expect to palpate a thrill at the AV fistula, which indicates patency. The nurse should report the absence of a thrill to the provider. The nurse should encourage the client to perform range-of-motion exercises in the affected extremity to maintain muscle strength. The nurse should not perform a venipuncture in the client's affected extremity to prevent circulatory complications.
A nurse is assessing a client who has major depressive disorder and is taking amitriptylline. Which of the following findings should the nurse identify as an adverse effect of the medication? A. Diarrhea B. Frequent urination C. Excessive salivation D. Blurred vision
Blurred vision The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider. Incorrect Constipation is an adverse effect of amitriptyline. Urinary retention is an adverse effect of amitriptyline. Dry mouth is an adverse effect of amitriptyline.
A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? A. Weight Loss B. Urinary retention C. Hypertension D. Hypoglycemia
Hypertension The nurse should assess the client for hypertension, a complication of obstructive sleep apnea from hypoxia. Other complications include heart failure and cardiac dysrhythmias. Incorrect The nurse should identify weight gain as a risk factor for obstructive sleep apnea and provide recommendations for weight control to the client to reduce manifestations. The nurse should expect the client to develop enuresis, rather than urinary retention, as an expected finding of obstructive sleep apnea. The nurse should not expect hypoglycemia. The nurse should monitor the client for decreased oxygen levels.
A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess? A. Mood B. Speech C. Ideas of self-harm D. Memory loss
Ideas of self-harm The greatest risk to this client is injury from ideas of self-harm. Therefore, the priority assessment the nurse should make is to determine whether the client has had suicidal or homicidal ideas. Incorrect The nurse should determine the client's mood because it can provide valuable clues about affect and mental state. However, this is not the priority for the nurse to assess. The nurse should listen carefully to the rate, volume, and characteristics of the client's speech because these can provide valuable clues about current communication abilities. However, this is not the priority for the nurse to assess. The nurse should observe the client for any indications of memory loss because this can provide valuable clues about the client's current cognition. However, this is not the priority for the nurse to assess.
A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders? A. Borderline B. Antisocial C. Histrionic D. Paranoid
Borderline The nurse should identify that clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation. Incorrect Clients who have antisocial personality disorder tend to be manipulative, deceitful, and antagonistic. Criminal behavior and substance use are associated with this disorder. Clients who have histrionic personality disorder tend to be self-focused, melodramatic, attention-seeking, and impulsive. Typically, they do not believe they need mental health counseling. Clients who have paranoid personality disorder tend to be suspicious and distrustful of others. They display jealousy and expect hostility from others.
A charge nurse is observing a newly licensed nurse administer enteral feeding via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Instills 100 mL of air into the NG tube after checking for residual B. Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr C. Adds 20 mL of blue dye to each feeding to help detect aspiration D. Keeps the head of the bed elevated to 45° for 1 hr after feedings
Keeps the head of the bed elevated to 45° for 1 hr after feedings The nurse should keep the client's head elevated to 30° to 45° for 1 to 2 hr after feedings to decrease the risk for aspiration. Incorrect The nurse should inject 10 to 30 mL of air into the NG tube before checking for residual to clear the tube of any feeding. Instilling excessive air into the tube can cause abdominal distention and discomfort. The nurse should use 20 mL of tap water to flush the NG tube before and after each feeding. Using 0.9% sodium chloride irrigation can lead to hypernatremia. The nurse should avoid adding dye to the feeding to detect aspiration because using dye can increase the risk of complications.
A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? A. Lack of remorse B. Sensitivity to rejection C. Extreme mood swings D. Self-mutilating behavior
Lack of remorse A client who has antisocial personality disorder is more likely to show a lack of remorse. Incorrect A client who has narcissistic personality disorder is more likely to show sensitivity to rejection. A client who has bipolar disorder is more likely to exhibit extreme mood swings. A client who has a borderline personality disorder is more likely to exhibit self-mutilating behaviors.
A nurse is caring for a client at a provider's office. History and Physical 2 months ago: Client presented to clinic for routine visit. Client reported feeling tired at times but getting through the workday and walking after work. Reported chronic nonproductive cough. Smokes 1.5 packs of cigarettes per day. Today, 1030: Client reports fatigue over the past several days, spending more time in bed. Reports chronic productive cough with blood-tinged sputum this morning. Smokes 1 pack of cigarett
Pneumonia: tobacco use, WBC level, Temperature, oxygen saturation, ABG results COPD: tobacco use and oxygen saturation Heart Failure: tobacco use, BNP level and oxygen saturation The nurse should analyze cues of pneumonia that include tobacco use, elevated WBC count, a productive cough with blood-tinged sputum, elevated temperature, a decreased oxygen saturation level, and an ABG level indicating respiratory acidosis. The nurse should also analyze cues of COPD that include tobacco use and a decreased oxygen saturation. The nurse should also analyze cues of heart failure that include tobacco use, BNP level, and a decreased oxygen saturation.
A nurse is caring for a client who is pregnant. Nurses' Notes 1000: The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks. 1015: IV fluids initiated. Prochlorperazine administered via intermittent IV bolus. 1100: Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine. 1500: Client tolerating fluids well. Ate
Recommended: Alternate eating solid foods and liquids, eat every 2 to 3 hours, drink warm ginger ale when nauseated Contraindicated: Increase intake of high-fat foods When taking action and providing discharge teaching for a client who has hyperemesis gravidarum, the nurse should recommend the client should eat every 2 to 3 hr to avoid having an empty stomach, which can increase nausea. The client should separate liquids from solids every 2 to 3 hr to help minimize nausea. The client should eat foods high in protein that are low in fat. Warm ginger ale or ginger tea can also decrease nausea.
A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?
Sedentary lifestyle A sedentary lifestyle is a risk factor for osteoporosis. The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels.
A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Vital Signs 1100: Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min Blood pressure 128/68 mm Hg Oxygen saturation 97% on room air 1115: Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min Blood pressure 138/74 mm Hg Pulse oximetry 95% on room air 1130: Temperature 38.6° C (101.5° F) Heart rate 136/min Respiratory rate 16/min Blood pressure 154
Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm. - Mental status - Heart rate - Temperature - Blood pressure When analyzing cues, the nurse should identify that thyroid storm can be caused by trauma to the thyroid gland, such as surgery, and excessive release of thyroid hormone greatly increases the metabolic rate. Fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness, are characteristic of thyroid storm.
A nurse is caring for a school-age child who has dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective? A. Hematocrit 45% B. Urine specific gravity 1.035 C. Serum sodium 138 mEq/L D. BUN 19 mg/dL
Serum sodium 138 mEq/L A serum sodium level of 138 mEq/L is within the expected reference range of 136 mEq/L to 145 mEq/L and is an indication that the child is responding to the oral rehydration solution. Incorrect This laboratory value is above the expected reference range of 32% to 44% for a child and is an indication that dehydration is still present. This laboratory value is above the expected reference range of specific gravity 1.005 to 1.030 and is an indication that dehydration is still present. This laboratory value is above the expected reference range of 5 to 18 mg/dL for a child and is an indication that dehydration is still present.
A nurse is caring for a client who is pregnant in the acute care setting Nurses' Notes 1400 Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr. Denies any changes in vaginal discharge. External fetal monitor applied. 1430 Contraction pattern: contractions every 4 to 5 min, lasting 30 to 45 seconds, palpate mild in intensity Fetal heart rate: 150/min to 155/min, moderate variability, adequate accelerations present, no decelerations noted. Provider in
The nurse should first address the client's respiratory rate, followed by the client's level of consciousness When prioritizing hypotheses, the nurse should recognize that magnesium sulfate is a central nervous system depressant that can affect respirations, consciousness, and reflexes when toxic blood levels occur. Using the airway, breathing, circulation priority framework, the nurse should plan to first take action to support respirations, followed by action to increase the client's level of consciousness. The nurse should plan to discontinue the magnesium sulfate infusion and administer calcium gluconate as an antidote.
A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will administer aspirin to my child to treat pain or fever." B. "I will record an average of three readings from my child's peak expiratory flow meter." C. "I will place carpet in my child's bedroom to control allergens." D. "I will make sure my child receives a yearly influenza immunization."
"I will make sure my child receives a yearly influenza immunization." Children who have asthma should be immunized and protected from infections. Therefore, the nurse should educate the parent to ensure the child receives a yearly influenza immunization. Incorrect Children who have asthma are sensitive to aspirin, and because it is associated with the development of Reye syndrome, the nurse should teach the parent to avoid administration of aspirin. The parent should record the highest of the three readings, rather than the average, when recording their child's results from the peak expiratory flow meter. Carpet is an offending environmental irritant to a child who has asthma, which can trigger an attack. Therefore, the nurse should educate the parent about removing carpeting from the child's bedroom.
A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? A. "I would like to talk to you about the unit policies regarding break time." B. "If you continue to take a long lunch break, I will have to report this to the nurse manager." C. "Have you thought about how your extended lunch breaks affect the other members of our
"I would like to talk to you about the unit policies regarding break time." The charge nurse is dealing with the conflict in a cooperative, positive manner by using this statement to open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a personal affront.
A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? A. A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis B. A client who has alcohol use disorder and has decided to start attending Alcoholics Anonymous meetings C. A client who was admitted for dehydration and is receiving a continuous IV infusion D. A client who has a history of two p
A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support. Incorrect A client who is being proactive in the management of their alcohol use disorder does not require an interprofessional care conference. A client who has dehydration, which is an acute condition, does not require an interprofessional care conference at the time of admission. A client who has ruptured membranes at 38 weeks of gestation is not a complicated obstetrical client and does not require an interprofessional care conference.
A nurse is caring for a client. Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia.
Anticipated: Administer oxygen therapy to keep oxygen saturation above 95%, Keep the lights in the client's room dim, Monitor blood glucose every 4 hr, Contraindicated: keep the client, supine, maintain the client's hips in flexion, cluster nursing care When generating solutions, the nurse should identify that oxygen therapy, monitoring blood glucose, and keeping lights in the client's room dim are anticipated prescriptions. The client is exhibiting manifestations of increased intracranial pressure (ICP). Therefore, the nurse should titrate oxygen therapy to maintain the oxygen saturation level above 95% and avoid hypoxia. The nurse should frequently monitor the client's vital signs and blood glucose to avoid secondary brain injury. The nurse should also dim the lights in the client's room, because many clients who have increased ICP experience photophobia.
A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices? A. State the options loudly in a high-pitched voice. B. Expect extended time for verbal responses. C. Ask the client to point to items on a picture menu. D. Ask the client's partner to choose their meal.
Ask the client to point to items on a picture menu The nurse should recognize that using visual aids can help the client communicate their meal choices. The use of a visual aid, like a picture menu, can ensure the client understands the meal choices. Incorrect The nurse should recognize that clients who have sensorineural hearing loss have difficulty hearing high-frequency sounds. The nurse should speak in a lower tone of voice. The nurse should avoid speaking in a loud voice because it can make understanding what is being said more difficult. The nurse should recognize that clients who have a cognitive impairment may need additional time to comprehend and respond to meal choices. It is not an expected finding for clients who have sensorineural hearing loss to have difficulty with comprehension. The nurse should recognize that maintaining client autonomy is important. It is important for the nurse to assess the client's preferences for their preferred method of communication to allow
A nurse is assessing a newborn who is 3 days old History and Physical Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress. Apgar scores: 8 at 1 min and 9 at 5 min. Birth weight: 2.9 kg (6 lb 6 oz) The client who gave birth plans to breastfeed. Flow Sheet Day 2 of Life, 0900: Temperature 36.7° C (98.1° F) Heart rate 140/min Respiratory rate 48/min Weight 2.7 kg (6 lb); 6% weight loss Day 3 of Life, 0800: Temperature 36.4° C (97.5° F) Heart rate 140/min Res
Click to highlight the findings that require follow up. To deselect a finding, click on the finding again. - Temperature 36.4 C (97.5 F) - Weight 2.5 kg (5 lb 9 oz), 12% weight loss - Mild tremors noted when awake - Breastfeeding every 3 to 5 hr for 5 to 10 min. - Client reports nipple discomfort throughout the feeding When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.
A nurse in an emergency department (ED) is assessing a client. Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months ago Current medications: Haloperidol 5 mg PO TIDSumatriptan 50 mg PO every 2 hr PRN headache Vital Signs 1030: Heart rate 122/minRespiratory rate 28/minBlood pressure 182/85 mm HgTemperature 39.7° C (103.5° F)Oxygen saturati
Condition: Neuroleptic malignant syndrome Action: hold the client's antipsychotic medications and apply a cooling blanket Monitor: temperature and hydration status Upon recognizing and analyzing the client cues of decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges, the nurse's priority hypotheses should be that this client is most likely experiencing neuroleptic malignant syndrome, which is related to the client's haloperidol therapy. It is important to generate solutions and take actions that will decrease the client's temperature, blood pressure, heart rate, and respiratory status, which will improve the client's neurological status. The nurse should hold the client's antipsychotic medications and apply a cooling blanket to reduce the client's temperature. Neuroleptic malignant syndrome is a life-threatening condition. Therefore, the nurse should monitor the client's laboratory and arterial blood gas valu
A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take? A. Discuss the suspicion of physical abuse with the provider. B. Confront the parents with the suspicion of physical abuse. C. Ask the hospital security to detain and question the parents. D. Contact Child Protective Services.
Contact Child Protective Services. The nurse has a legal responsibility to report suspected physical abuse to Child Protective Services. Incorrect The nurse should allow the provider to perform an assessment of the child and come to their own conclusion about the situation. Confronting the parents about the suspicion of physical abuse is not the responsibility of the nurse and can cause the parents to become angry and defensive. Contacting facility security staff to detain and question the parents is unnecessary when the nurse has only a suspicion of physical abuse. Additionally, this action can cause the parents to become angry and defensive.
A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? A. Delegate non-nursing tasks to ancillary staff. B. Stock client rooms with extra supplies. C. Assign dedicated equipment to each client's room. D. Change continuous IV infusion tubing every 24 hr.
Delegate non-nursing tasks to ancillary staff. Delegating non-nursing tasks to ancillary staff is an effective method of providing high-quality, cost-effective care because this will allow additional time for nurses to focus on skilled tasks. Incorrect Stocking client rooms with extra supplies is an ineffective method of providing cost-effective care. Client care supplies are direct costs that fluctuate with the volume of service. Using this method, it is difficult to keep up with inventory and the facility might charge clients for supplies they do not use. Assigning dedicated equipment to each client's room is an ineffective method of providing cost-effective care. Clients who have infectious diseases, such as methicillin-resistant Staphylococcus aureus, should have dedicated equipment. Providing dedicated equipment for all clients would unnecessarily increase the direct costs for each client on the unit. Changing continuous IV infusion tubing no more than every 96 hr is an effectiv
A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy? A. Difficulty performing ADLs B. Inability to swallow clear liquids C. Elevated blood glucose levels D. Unsteady gait when ambulating
Difficulty performing ADLs The nurse should initiate a referral for occupational therapy to teach the client the skills necessary to become independent in performing ADLs such as bathing, dressing, or eating. Incorrect The nurse should initiate a referral to a speech-language pathologist for a client who has any swallowing difficulties. The nurse should initiate a referral to a dietitian for a client who has elevated blood glucose levels. A dietitian provides support and teaching to the client to ensure nutritional needs are met. The nurse should initiate a referral for physical therapy for a client who has an unsteady gait when ambulating. A physical therapist develops a plan to improve a client's strength and mobility and can identify assistive devices that might be necessary.
A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? A. Encourage oral fluids B. Apply topical calamine lotion C. Administer acetaminophen as an antipyretic D. Initiate transmission-based precautions
Initiate transmission-based precautions. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to initiate transmission-based precautions for the child. The child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection. Incorrect Encouraging oral fluids is nonurgent because it is an expected finding for a child who possibly has varicella to have dehydration caused by a fever. Therefore, there is another action that is the nurse's priority. Applying topical calamine lotion is nonurgent because it is an expected finding for a child who possibly has varicella to have pruritus. Therefore, there is another action that is the nurse's priority. Administering acetaminophen as an antipyretic is nonurgent because it is an expected finding for a child who possibly has varicella to have a fever. Therefore, there is another action that is the nurse's priority.
A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect? A. Pink, frothy sputum B. Bradycardia C. Pale, dry skin D. Wheezing
Pink, frothy sputum A client who has manifestations of pulmonary edema can have pink, frothy sputum due to fluid leaking across the pulmonary capillaries and into the lung tissue. Incorrect A client who has manifestations of pulmonary edema will have tachycardia due to insufficient oxygen exchange and perfusion caused by fluid in the lung tissue. A client who has manifestations of pulmonary edema will have clammy, cyanotic skin due to insufficient oxygen exchange and perfusion caused by fluid in the lung tissue. A client who has manifestations of pulmonary edema can have crackles due to fluid in the lung tissue. Crackles can progress as the condition worsens.
A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills? A. Compare the nurse's time management skills to the skills of coworkers. B. Review client satisfaction reports about the nurse's performance. C. Ask another staff nurse to evaluate the nurse's time management skills. D. Maintain regular notes about the nurse's time management skills.
Maintain regular notes about the nurse's time management skills. Maintaining notes over a period of time provides a comprehensive view of the nurse's abilities, so the manager can identify trends in the nurse's overall performance. Incorrect The nurse manager should compare the nurse's performance to standards from the nurse's job description to avoid potential bias. Client satisfaction reports concerning clients' facility stay are completed and evaluated to ensure that the client received quality care and reflect the performance of all members of the interdisciplinary team. It is not the responsibility of other staff nurses to provide the nurse manager with evaluative data about a coworker's time management skills. The nurse manager should gather data from other individuals who supervise the nurse, such as a charge nurse or unit supervisor, and have the nurse complete a self-evaluation.
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? - Drainage system located above the client's chest level - Continuous bubbling in the water-seal chamber - Occlusive dressing on the insertion site - Drainage of 125 mL/hr
Occlusive dressing on the insertion site An occlusive dressing on the insertion site prevents air from leaking and is an expected finding. Incorrect The chest drainage system should be kept below the client's chest level to facilitate drainage and prevent fluid from backing up into the client's lungs. Continuous bubbling in water-seal chamber indicates an air leak. Chest tube drainage should be less than 70 mL/hr.
A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit? A. Shortness of breath B. Visual disturbances C. Decreased BUN levels D. Orthostatic hypotension
Orthostatic hypotension Clients who have a fluid volume deficit can experience orthostatic hypotension, which is a result of the body's inability to maintain adequate blood pressure following position changes. Incorrect The nurse should identify shortness of breath as an indication of fluid volume excess because extra fluid interferes with oxygen exchange at the alveolar level. The nurse should identify that visual disturbances, such as blurred vision, indicate fluid overload rather than fluid volume deficit. ncreased BUN levels should indicate to the nurse that the client has a fluid volume deficit.
A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?
Performing a rapid needs assessment Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage.
A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG) Laboratory Results 0630 Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5 mEq/L) Chloride 116 mEq/L (98 to 106 mEq/L) BUN 24 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9 mg/dL (9 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC count 9,500/mm3 (5,000 to 10,000/mm3) I & O 0700 4 hr input 400 mL 4 hr output
The client is at greatest risk for developing dysrhythmias, as evidenced by electrolyte imbalance. The nurse should analyze cues to determine the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's report of muscle cramping. Potassium and magnesium depletion are common manifestations in clients who are postoperative following CABG. Due to medication or hemodilation, it is important for the nurse to closely monitor electrolytes.
A nurse is caring for a client who is on the spinal cord injury (SCI) unit Nurses' Notes Day 3, 1700 Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, pa
The client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. The nurse should analyze cues from the client's manifestations and determine that the client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who has a cervical SCI is at risk for respiratory complications because spinal innervation to the respiratory muscles is disrupted. Adventitious breath sounds in the lower lobes bilaterally and a decrease in oxygen saturation to less than 92% can indicate pneumonia. The client's sudden increase in blood pressure, bradycardia, flushing of the skin above the area of the injury, headache, and blurred vision are manifestations of autonomic dysreflexia, which can be a life-threatening condition.
A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3 (7.35 to 7.45), PaO2 56 mm Hg (80 to 100 mmHg), PaCO2 54 mmHg (35 to 45 mmHg), HCO3 26 mEq/L (21 to 28 mEq/L), and SaO2 87%. Which of the following is the correct interpretation of these values? A. Uncompensated metabolic acidosis B. Uncompensated respiratory acidosis C. Compensated respiratory acidosis D. Compensated metabolic acidosis
Uncompensated respiratory acidosis A pH of 7.3 is below the expected reference range and indicates the client has acidosis. A PaCO2 of 54 mm Hg is above the expected reference range, which indicates the acidosis has a respiratory origin when combined with the low pH. The HCO3- of 26 mEq/L is within the expected reference range, indicating that the acidosis is not metabolic in origin and the body has not yet corrected the imbalance through compensation.
A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? A. Muscle spasms of the affected extremity B. A pain rating of 6 on a scale from 0 to 10 C. Upper chest petechiae D. Ecchymosis over the fractured area
Upper chest petechiae The greatest risk to this client is organ damage from fat embolism syndrome, a life-threatening complication of fractures. In fat embolism syndrome, a fat embolus enters the blood stream and can obstruct blood vessels of a major organ, such as the lung, kidney, or brain. Manifestations include petechiae on the upper torso, dyspnea, hypoxia, headache, lethargy, and confusion. Therefore, the nurse should identify this as the priority finding. Incorrect The nurse should reposition the client or check the weights to relieve the client's muscle spasms. However, another finding is the priority. The nurse should provide analgesia to relieve the client's moderate pain level. However, another finding is the priority. The nurse should identify ecchymosis over the fractured area as an expected finding due to localized trauma and provide comfort measures. However, another finding is the priority.
A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect? A. Hgb 15 g/dL (12 to 18 g/dL) B. Urine specific gravity 1.052 (1.005 to 1.03) C. Urine osmolality 300 mOsm/kg (50 to 1200 mOsm/kg) D. Hct 44% (37% to 52%)
Urine specific gravity 1.052 (1.005 to 1.03) The nurse should recognize the client's urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.03. An increased urine specific gravity indicates dehydration from vomiting.
A nurse is caring for a client who is postoperative following an appendectomy. Nurses' Notes 1800: Client alert and oriented to person, place, time, and situation.Skin warm and dry.Lungs clear on auscultation Bowel sounds hypoactive in all four quadrants. Urine clear yellow Incisional dressing clean and dry. Client reports pain as 6 on a scale of 0 to 10.1815: Morphine administered as prescribed.2000: Client reports abdominal pain as 10 on a scale of 0 to 10. Client reports nausea, no vomiting.
Which of the following 4 client findings should the nurse report to the provider? - Oxygen saturation - Heart rate - Pain level - Nausea When recognizing cues, the nurse should identify that the findings of pain, nausea, heart rate, and oxygen saturation are unexpected findings for a client who is postoperative following an appendectomy. These findings should be reported to the provider.
A nurse is caring for a client in the emergency department (ED). Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for p
Which of the following interventions should the nurse implement? Select all that apply. - Assess the client's mouth every 8 hr - Assess peripheral circulation hourly - Use humidification with oxygen therapy - Administer IV fluids When taking actions, the nurse should administer IV fluids, use humidification with oxygen therapy, and assess the client's mouth every 8 hr and peripheral circulation hourly. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling
