some crazy stuff. From sarah

an older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. it has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150 mL of dark brown emesis. in which order should the nurse implement these interventions? (arrange with the highest priority intervention on top, and lowest priority intervention on bottom.) 1. send emesis sample to the lab. 2. complete focused assessment. 3. offer PRN pain medication. 4. elevate the head of the bed.

4. elevate the head of the bed. 3. offer PRN pain medication. 2. complete focused assessment. 1. send emesis sample to the lab.

which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client's arm? a. explain that temporary burning at the IV site may occur. b. monitor capillary refill distal to the infusion site. c. apply a topical anesthetic at the infusion site for burning. d. assess IV site frequently for signs of extravasation.

d. assess IV site frequently for signs of extravasation.

an infant is unresponsive and gasping for breath. prior to starting CPR, which site should the nurse palpate for a pulse? a. carotid. b. aortic. c. mitral. d. brachial.

d. brachial.

the UAP reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. which action should the nurse implement? a. estimate the blood pressure by assessing the pulse volume of the client's radial pulses. b. advise the UAP to document the last blood pressure obtained on the client's graphic sheet. c. document why the blood pressure cannot be accurately measured at the present time. d. demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

d. demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

a client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness. the client has been taking spironolactone 50 mg tablets PO every day. the nurse receives report from the lab that the client has a serum potassium level of 6.2 mEq/L. which intervention is most important for the nurse to implement? a. assess strength of deep tendon reflexes. b. observe color and amount of urine. c. compare muscle strength bilaterally. d. determine apical pulse rate and rhythm.

d. determine apical pulse rate and rhythm.

the nurse is precepting a new graduate nurse and explains the placement of a face mask on the client. what statements by the new grad nurse indicate understanding or no understanding of the use of the face mask in the care of this client?

no understanding: 1. i should place the mask first over the nose and then cover the mouth. 2. i should put gauze under the elastic straps over the ears. 3. the client should take a 1-2 minute break from the face mask each hour. 4. the mask should cover only the mouth and leave the nose open for expiration. understanding: 1. i can adjust the oxygen level on the flowmeter to keep the client's oxygen saturation greater than 94%. 2. i should clean the face mask once per shift.

select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer? a. BUN 17 mg/dL b. used for prophylaxis. c. peripheral IV in large vein. d. dosage in safe range. e. no known allergies. f. potassium 4.4 mEq/L.

a. BUN 17 mg/dL c. peripheral IV in large vein. d. dosage in safe range. e. no known allergies.

the nurse recognizes that __________, __________, and __________ are findings consistent with elder mistreatment. a. malnutrition. b. diminished breath sounds. c. poor hygiene. d. dark room lighting. e. bilateral leg edema. f. short term memory loss.

a. malnutrition. c. poor hygiene. d. dark room lighting.

the nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. which action should the nurse include? a. wear protective goggles while performing the procedure. b. instruct the client to cough as the suction tip is removed. c. apply a water-soluble lubricant to the catheter. d. instill 3 mL of normal saline before suctioning.

a. wear protective goggles while performing the procedure.

following the fluid bolus, the client is more awake and able to answer questions. what questions are appropriate for the secondary survey? select all that apply. a. what was your last meal? b. do you take any medications? c. do you live with anyone? d. what happened before you fell? e. is it possible that you are pregnant? f. are you fully insured?

a. what was your last meal? b. do you take any medications? d. what happened before you fell? AMPLE: Allergies. Medication. Past medical history. Last ate (time). Events leading up to incident.

an older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. what intervention(s) should the nurse include in this client's plan of care? select all that apply. a. instruct client and family to reconsider end-of-life choices. b. encourage the family to visit frequently. c. teach client how to use guided imagery. d. record the client's desire to live. e. encourage family to bring the client old photographs.

b. encourage the family to visit frequently. c. teach client how to use guided imagery. e. encourage family to bring the client old photographs.

to start the client on O2 as ordered, what item(s) should the nurse collect from the supply room? select all that apply. a. tape. b. humidifier bottle. c. flowmeter. d. nasal cannula. e. lamb's wool. f. sterile water. g. suction cannister.

b. humidifier bottle. d. nasal cannula. c. flowmeter. e. lamb's wool. f. sterile water.

a client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. the hcp prescribes a sepsis protocol. which intervention is most important for the nurse to include in the plan of care? a. monitor blood glucose level. b. maintain strict intake and output. c. keep head of bed raised 45 degrees. d. assess warmth of extremities.

b. maintain strict intake and output.

the nurse is monitoring a client with cushing's disease in the post-anesthesia care unit (PACU) after a hypophysectomy. which intervention is most important for the nurse to include in the client's plan of care? a. keep head of bed at 30 degrees. b. provide frequent mouth care. c. monitor intake and output. d. maintain nasal packing.

b. provide frequent mouth care.

the nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. which instruction should the nurse provide to the adult male client? a. for the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens. b. urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours. c. urinate immediately into a urinal, and the lab will collect the specimen every 6 hours, for the next 24 hours. d. cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle.

b. urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours.

after receiving a change of shift report for clients on a medical-surgical unit, which task should the nurse assign to the practical nurse (PN)? a. complete comprehensive assessments. b. use bladder ultrasound to detect urinary retention. c. initiate teaching for client care after discharge. d. begin initial sterile wound care for surgical clients.

b. use bladder ultrasound to detect urinary retention.

what interventions should the nurse initiate if elder mistreatment is suspected? select all that apply. a. question the client in front of the suspected abuser. b. confront the abuse about concerning actions. c. take photographs to document the abuse or neglect. d. throw away soiled clothing. e. report findings to adult protective services. f. perform a thorough physical assessment. g. complete a comprehensive history. h. develop a safety plan.

c. take photographs to document the abuse or neglect. e. report findings to adult protective services. f. perform a thorough physical assessment. h. develop a safety plan.

which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? select all that apply. a. the client may be developing sepsis. b. the client may need food. c. the client may be improving clinically. d. the client may require more morphine. e. the client may be experiencing sedative effects of morphine. f. the client may have increasing symptoms of head injury. g. the client may be dehydrated. h. the client may have been sleeping.

e. the client may be experiencing sedative effects of morphine. f. the client may have increasing symptoms of head injury. h. the client may have been sleeping.

which of the following findings would indicate the client has recovered from the adverse drug reaction? shaking is lessened. client is no longer flushed. no longer itching. anxiety has decreased. skin warm and dry. heart rate 62 bpm. blood pressure 130/72. no chest pain noted. respirations are even and unlabored. drowsy.

shaking is lessened. client is no longer flushed. no longer itching. heart rate 62 bpm. blood pressure 130/72. respirations are even and unlabored.

an older adult male reporting abdominal pain is admitted to the hospital from a long term care facility. it has been seven days since his last bowel movement, and his abdomen is distended, and he just vomited 150 mL of dark brown emesis. in what order should the nurse implement these interventions? 1. elevate the HOB. 2. complete focus assessment. 3. offer PRN pain medication. 4. send emesis sample to the lab.

1. elevate the HOB. 3. offer PRN pain medication. 2. complete focus assessment. 4. send emesis sample to the lab.

for each body system, what potential nursing interventions would be appropriate for the care of the client. immunological: a. IV fluids. b. administer antihistamine. c. administer steroid. d. assess rash. cardiovascular: e. echocardiogram. f. monitor vital signs continuously. g. defibrillator at bedside. h. provide warmth. respiratory: i. pain medication. j. chest x-ray. k. provide a calm environment. l. assess lung sounds.

a. IV fluids. b. administer antihistamine. c. administer steroid. d. assess rash. e. echocardiogram. f. monitor vital signs continuously. h. provide warmth. i. pain medication. k. provide a calm environment. l. assess lung sounds.

the nurse is reviewing the assessment findings. what client findings are of immediate concern to the nurse? respiratory: a. O2 Sat 82% RA. b. RR 14 breaths/minute. cardiovascular: c. HR 106 beats/minute. d. BP 83/41

a. O2 Sat 82% RA. d. BP 83/41

a client with atrial fibrillation is scheduled for an elective cardioversion. the nurse inserts two IV catheters and connects the monitoring lead wires to the client in preparation for the procedure. which action is most important for the nurse to implement prior to deploying the current for the cardioversion? a. activate the synchronization mode. b. verify the prothrombin time (PT). c. select a monitor lead with a tall R wave. d. administer prescribed sedative.

a. activate the synchronization mode.

after receiving report, the nurse can most safely plan to assess which client last? a. an adult client with no postoperative drainage in the jackson-pratt drain with the bulb compressed. b. an older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. c. an older adult client with a distended abdomen and no drainage from the nasogastric tube. d. an adult client with a rectal tube draining clear, pale red liquid drainage.

a. an adult client with no postoperative drainage in the jackson-pratt drain with the bulb compressed.

the client is at immediate risk for developing ___________, ______________, and ______________. a. anaphylaxis. b. cardiac arrest. c. arrhythmias. d. peripheral edema. e. necrosis. f. renal failure.

a. anaphylaxis. b. cardiac arrest. c. arrhythmias.

the nurse is caring for a client with heart failure. which of these prescribed medications places the client at risk for cardiogenic shock? a. digoxin. b. captopril. c. nadolol. d. hydrochlorothiazide.

a. digoxin.

the nurse identifies several nursing problems for an older adult with gastroenteritis who is experiencing fever, chills, anorexia, and diarrhea. the client has a history of a stroke with left-sided hemiplegia and is dependent on care provided by the spouse. which problem should the nurse determine has the highest priority? a. fluid volume deficit. b. impaired bed mobility. c. bowel incontinence. d. caregiver role strain.

a. fluid volume deficit.

the nurse is teaching a primigravida about preeclampsia. what finding(s) are indicators of preeclampsia and should be reported to the hcp? select all that apply. a. headache. b. swollen hands. c. chills and fever. d. blurred vision. e. lack of appetite. f. urinary frequency.

a. headache. b. swollen hands. d. blurred vision.

the charge nurse observes a new nurse preparing to insert an IV catheter. the new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. which action should the charge nurse take? a. instruct the nurse to use a transparent dressing over the site. b. plan to observe the secured IV site after the insertion procedure. c. confirm that the nurse has gathered the necessary supplies. d. remind the nurse to tape the gauze dressing securely in place.

a. instruct the nurse to use a transparent dressing over the site.

the nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). which client complaint is life-threatening and should be reported to the hcp immediately? a. intensifying headache. b. difficulty with balance. c. right ear hearing loss. d. facial numbness.

a. intensifying headache.

the nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. which information reported by the client indicates understanding? a. keep diabetic medication on schedule as prescribed. b. limit maximum daily fat intake to 15% of total calories. c. restrict alcoholic beverages to no more than 1-2 per week. d. check blood sugar levels every 4-6 hours.

a. keep diabetic medication on schedule as prescribed.

a client who is hypotensive is receiving dopamine, an adrenergic agonist IV at the rate of 8 mcg/kg/min. which intervention should the nurse implement while administering this medication? a. measure urinary output every hour. b. initiate seizure precautions. c. monitor serum potassium frequently. d. assess pupillary response to light hourly.

a. measure urinary output every hour.

the primary caregiver of an older adult client calls the nurse at the outpatient clinic due to the sudden onset of changes in the client's behavior. the caregiver reports to the nurse that the client normally is oriented and able to answer questions but now is confused and agitated. what action(s) should the nurse take? select all that apply. a. provide instruction on taking the client's temperature. b. review the client's current food and medication allergies. c. determine if the client has recently experienced a fall. d. ask if the client is experiencing any pain with urination. e. encourage increased intake of high protein foods.

a. provide instruction on taking the client's temperature. b. review the client's current food and medication allergies. c. determine if the client has recently experienced a fall. d. ask if the client is experiencing any pain with urination.

the nurse is preparing a 50 mL dose of 50% dextrose IV for a client with insulin shock. how should the nurse administer the medication? a. push the undiluted dextrose slowly through the currently infusing IV. b. dilute the dextrose in one liter of 0.9% normal saline solution. c. mix the dextrose in a 50 mL piggyback for a total volume of 100 mL. d. ask the pharmacist to add the dextrose to the total parenteral nutrition (TPN) solution.

a. push the undiluted dextrose slowly through the currently infusing IV.

the nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. the client reports having sex with multiple partners. which response should the nurse provide? a. remain non-judgemental and assure the client of confidentiality. b. clarify that all STIs are transmitted through sexual intercourse. c. inform the client that complications will not result from reinfection. d. provide counseling that most contraceptives protect against infection.

a. remain non-judgemental and assure the client of confidentiality.

the nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm3. after notifying the hcp, which action should the nurse take next? a. review serum protein levels. b. assess neurological status. c. begin abdominal girth measurements. d. initiate antibiotic therapy.

a. review serum protein levels.

the laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. the client reports feeling fatigued and is unable to concentrate during the morning assessments. based on these findings, which action should the nurse implement? a. schedule frequent rest periods. b. administer PRN oxygen. c. provide high-protein snacks. d. monitor glucose levels every 4 hours.

a. schedule frequent rest periods.

a client on the cardiac telemetry unit unexpectedly begins manifesting ventricular fibrillation and the advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. later in the day, a family member questions why the code was called, telling the nurse that the client has a living will. how should the nurse response? a. seek clarification of the type of advance directive the client has. b. check the client's arm for a "Do Not Resuscitate" (DNR) bracelet. c. schedule a client and family conference to review the plan of care. d. explain that living wills can not be followed by emergency personnel.

a. seek clarification of the type of advance directive the client has.

the nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. which action should the nurse implement immediately? a. test the fluid on the dressing for glucose. b. document the findings in the electronic medical record. c. change the dressing using a compression bandage. d. mark the drainage area with a pen and continue to monitor.

a. test the fluid on the dressing for glucose.

the nurse is preparing to administer a narcotic analgesic to a client with a fractured femur who also has obstructive sleep apnea (OSA). which intervention is most important for the nurse to implement? a. elevate the head of the bed to a 45-degree angle. b. apply the client's positive airway pressure device. c. lift and lock the side rails in place. d. remove dentures or other oral appliance.

b. apply the client's positive airway pressure device.

the client provides 3 positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire. which interpretation should the nurse provide the client? a. one positive response indicates the client should seek help with alcohol addiction. b. at least two positive responses are strongly suggestive of alcohol dependence. c. all responses to the CAGE questionnaire must be positive to suggest alcohol dependence. d. the CAGE questionnaire is a tool used to identify general substance abuse.

b. at least two positive responses are strongly suggestive of alcohol dependence.

a client with a history of gout presents to the clinic with an inflamed left knee. the client reports the knee is extremely painful to touch for the second time in 6 months. the hcp prescribes colchicine and ibuprofen. which instruction should the nurse include in the discharge teaching? a. encourage active range of motion to limit stiffness. b. avoid acetylsalicylic acid-containing medications. c. eat high protein foods to achieve ideal body weight. d. use an electric heating pad when pain is at its worst.

b. avoid acetylsalicylic acid-containing medications.

oxygen at 5L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. when planning care for this child, which principle of oxygen administration should the nurse consider? a. increase oxygen rate during sleep to compensate for slower respiratory rate. b. avoid administration of oxygen at high levels for extended periods. c. oxygen is less toxic when it is humidified with a hydration source. d. taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs.

b. avoid administration of oxygen at high levels for extended periods.

the nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. the nurse should emphasize the need to report the onset of which problem? a. abdominal cramping. b. bloody emesis. c. low-grade fever. d. bruising of the skin.

b. bloody emesis.

a client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. which behaviors are most important for the nurse to monitor? a. repeated requests for attention from the nurse. b. decreased activity level and change in affect. c. periodic sighing and shaking the head. d. argumentativeness and use of profanity.

b. decreased activity level and change in affect.

the nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of vice like chest pressure. the client reports that the pain decreases at rest and continues to feel constant mid-chest pressure. the nurse should perform which intervention in the immediate management of the client? a. apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93% b. determine the presence of ST-elevations or non-ST-elevations on electrocardiogram. c. initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area. d. verify troponin level assessments are scheduled every 3-6 hours for a series of three.

b. determine the presence of ST-elevations or non-ST-elevations on electrocardiogram.

the nurse who is working the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. which intervention is most important for the nurse to implement? a. report the incident to the university's security department. b. do not allow client to shower until all evidence is obtained. c. determine the client's personal reaction to the reported rape. d. listen attentively to the client's description of the event.

b. do not allow client to shower until all evidence is obtained.

the nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. which information is most important for the nurse to include? a. prop the infant with a pillow when is a side-lying position. b. ensure that the infant's crib mattress is firm. c. swaddle the infant in a blanket for sleeping. d. place the infant in a prone position whenever possible.

b. ensure that the infant's crib mattress is firm.

which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy? a. resume antithyroid drug therapy. b. maintain a semi-fowler position. c. prepare to administer radioactive iodine treatments. d. anticipate and monitor for hypothermia.

b. maintain a semi-fowler position.

a client with purulent discharge from a venous ulcer that has been unsuccessfully treated with intravenous vancomycin has been admitted with a possible vancomycin-resistant enterococci (VRE) infection. what nursing intervention(s) should the nurse include in the plan of care? select all that apply. a. use standard precautions and wear a mask. b. monitor the client's white blood cell count. c. explain the purpose of a low-bacteria diet. d. send wound drainage for culture and sensitivity. e. institute contact precautions for staff and visitors.

b. monitor the client's white blood cell count. d. send wound drainage for culture and sensitivity. e. institute contact precautions for staff and visitors.

the nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. the nurse also observes a distinct right-sided facial droop. after reporting the findings to the hcp, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. which action should the nurse take first? a. administer aspirin to prevent farther clot formation and platelet clumping. b. raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. c. begin continuous observation for transient episodes of neurologic dysfunction. d. start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

b. raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.

a client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. which finding indicates to the nurse that the medication is effective? a. granulating tissue in foot ulcer. b. reduced level of pain. c. improved visual acuity. d. full volume of pedal pulses.

b. reduced level of pain.

an adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. the nurse anticipates the client developing which acid-base imbalance? a. respiratory acidosis. b. respiratory alkalosis. c. metabolic alkalosis. d. metabolic acidosis.

b. respiratory alkalosis.

the nurse is reviewing the laboratory results for a client who is scheduled for a cholecystectomy. which result is most important for the nurse to report to the surgeon? a. blood glucose of 90 mg/dL. b. serum creatinine of 5 mg/dL. c. hemoglobin level of 13 g/dL. d. potassium level of 4 mEq/L.

b. serum creatinine of 5 mg/dL.

a client is admitted with diabetic ketoacidosis (DKA) and is receiving an IV infusion of 0.9% sodium chloride and insulin. two hours later, the client's serum laboratory results show a decrease in the serum blood glucose from 580 to 430 mg/dL. it is most important for the nurse to monitor which additional laboratory result? a. urine ketones. b. serum potassium. c. blood urea nitrogen (BUN). d. serum sodium.

b. serum potassium.

the nurse is collecting a heel stick blood specimen for a neonatal screen. which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day-old client. when the parents ask why these tests are being conducted, which explanation should the nurse provide? a. dosages for thyroid replacement therapy will be determined by this test. b. this is a routine blood test required by law to screen for metabolic deficiencies. c. this technique is used for early detection of intellectual disabilities. d. these laboratory values will provide data to anticipate delays in growth and development.

b. this is a routine blood test required by law to screen for metabolic deficiencies.

a client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. in planning nursing care, what intervention(s) should the nurse include? select all that apply. a. encourage oral fluid intake of 3,000 mL/day. b. weigh the client daily, in the morning. c. observe for evidence of hypokalemia. d. teach the client how to restrict dietary sodium. e. monitor coagulation laboratory values.

b. weigh the client daily, in the morning. c. observe for evidence of hypokalemia. d. teach the client how to restrict dietary sodium.

a client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. following the therapy, which finding indicates to the nurse that the intervention was effective? a. increase in respiratory rate. b. absence of fine crackles. c. absence of coarse crackles. d. increase in breath sounds.

c. absence of coarse crackles.

nurse uses modified caregiver strain index and determines that daughter is under significant stress caused by assumption of her mother's care. nurse is planning to have a discussion with daughter on decreasing the stress she is experiencing as a caregiver. select 3 statements the nurse should include when discussing caregiver stress with the client's daughter. a. you made a promise to your mother that you need to keep. b. helping your mother should be easier than raising a child. c. avoid discussion of negative situations that may occur in the future. d. involve your mother in the decision making process. e. take time for yourself and the other relationships that you care about. f. moving your mother into a care facility will show her that you do not love her. g. saying 'no' to things involving the care of your mother is a selfish action. h. it is okay not to love or like your mother when you are caring for her.

c. avoid discussion of negative situations that may occur in the future. d. involve your mother in the decision making process. e. take time for yourself and the other relationships that you care about.

an adolescent client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. the hcp collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. which action should the nurse implement first? a. bivalve the cast for distal compromise. b. provide a high-calorie, high-protein diet. c. begin parenteral antibiotic therapy. d. administer antiemetic agents.

c. begin parenteral antibiotic therapy.

H&P - client is a 26 y/o female who fell from an apartment balcony. she was transported to the hospital via ambulance. client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. for the primary survey, what 2 things should the nurse do first? a. palpate the abdomen. b. call for an x-ray. c. check the airway for patency. d. feel for a pulse. e. measure the respiratory rate. f. stabilize the cervical spine.

c. check the airway for patency. f. stabilize the cervical spine.

prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain? a. previous history of urinary tract infections. b. client's ability to increase fluid intake. c. client allergies to antiseptic solutions. d. color, clarity and odor of urine.

c. client allergies to antiseptic solutions.

an adult client is admitted to the psychiatric unit because of a daily, complex hand-washing ritual that takes two hours or longer to complete. the client worries about staying clean and refuses to sit on any of the chairs in the day area. the client's hand-washing is an example of which clinical behavior? a. phobia. b. addiction. c. compulsion. d. obsession.

c. compulsion.

a mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. the child smells of chemicals on the hands, face, and on the front of the child's clothes. after ensuring the airway is patent, which action should the nurse implement first? a. call poison control emergency number. b. assess child for altered sensorism. c. determine type of chemical exposure. d. obtain equipment for gastric lavage.

c. determine type of chemical exposure.

the parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. how should the nurse respond? a. suggest that the child be encouraged to participate in a team sport to encourage socialization. b. provide a list of alternative activities that are less likely to cause the child to experience fatigue. c. encourage the parents to allow the child to continue attending swimming lessons with supervision. d. explain that their child is too young to understand the risks associated with swimming.

c. encourage the parents to allow the child to continue attending swimming lessons with supervision.

an adult client with type 2 diabetes mellitus is to be admitted within the next hour to be medical unit from the emergency department. the client's laboratory findings indicate that the serum glucose is 175 mg/dL and the A1c is 9%. when requesting a dinner tray for the client, which menu should the nurse select? a. vegetarian lasagna with cheese and spinach, tossed green salad with ranch dressing, and fresh fruit. b. lean hamburger with cheese, tomato, and lettuce on whole-wheat bun, and angel food cake. c. grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine. d. fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie.

c. grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine.

a client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. which is the best initial nursing action? a. instruct the family about withdrawal symptoms. b. obtain a serum drug screen. c. initiate seizure precautions. d. administer naloxone per PRN protocol.

c. initiate seizure precautions.

when entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. which action should the nurse implement? a. tell the client to stop the inappropriate behavior. b. complete an unusual occurrence report. c. leave the room and close the door quietly. d. ignore the behavior and hang the IV antibiotic.

c. leave the room and close the door quietly.

an adult client comes to the clinic and reports concern over a lump that, "just popped up on my neck about a week ago." while performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. there is no overlying tissue inflammation. which do these findings suggest? a. viral infection. b. bacterial infection. c. malignancy. d. lymphangitis.

c. malignancy.

the nurse observes erythema under the chin of a client receiving oxygen at 2 L/minute per nasal cannula. which intervention should the nurse implement? a. discontinue the use of the nasal cannula. b. decrease the flow rate to 1 L/minute. c. place padding around the cannula tubing. d. apply lubricant to the cannula tubing.

c. place padding around the cannula tubing.

restricted activity is prescribed for a client with crohn's disease. the nurse should explain that the primary purpose of the activity restriction is to obtain which outcome? a. decrease abdominal pain. b. control diarrhea episodes. c. reduce intestinal activity. d. promote healing process.

c. reduce intestinal activity.

a client with influenza needs help in transferring to the bedside commode. the nurse observes the UAP donning gloves and a gown to assist the client. which action should the nurse take? a. remind the UAP to apply a fitted respirator mask before entering the client's room. b. assign the UAP to provide care for another client and assume full care of the client. c. review the need for the UAP to wear a face mask while in close contact with the client. d. instruct the UAP to notify the nurse of any changes in the client's respiratory status.

c. review the need for the UAP to wear a face mask while in close contact with the client.

in formulating the nursing care plan for a client diagnosed with parkinson's disease, which nursing problem has the highest priority? a. impaired physical mobility relative to muscle rigidity. b. risk for constipation relative to immobility. c. risk for aspiration relative to muscle weakness. d. self-care deficit relative to motor disturbance.

c. risk for aspiration relative to muscle weakness.

a client with schizophrenia reports auditory hallucinations when admitted to the hospital. which question is most important for the nurse to include in the assessment of this client? a. "which medication works best?" b. "how do you cope with the voices?" c. "when do you hear voices?" d. "what are the voices saying?"

d. "what are the voices saying?"

the nurse is developing the plan of care for a client diagnosed with cushing's syndrome and identifies that the client's risk factors include poor wound healing, decreased bone density, and increased capillary fragility. which outcome statement should the nurse include in the plan of care? a. client experiences a normal fluid balance. b. client demonstrates improved body image. c. client describes ways to control the disease. d. client implements measures to prevent injury.

d. client implements measures to prevent injury.

the nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. what is the primary purpose of this drug classification? a. neutralizes hydrochloric acid (HCl) in the stomach. b. destroys microorganisms causing stomach inflammation. c. inhibits the action of acetylcholine by blocking parasympathetic nerve endings. d. decreases the amount of HCl secretion by the parietal cells in the stomach.

d. decreases the amount of HCl secretion by the parietal cells in the stomach.

a male adult is admitted because of an acetaminophen overdose. after transfer to the mental health unit, the client is told he has liver damage. which information is most important for the nurse to include in the client's discharge plan? a. eat a high carbohydrate, low fat, low protein diet. b. avoid exposure to large crowds. c. call the crisis hot line if feeling lonely. d. do not take any over-the-counter medications.

d. do not take any over-the-counter medications.

a client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. which schedule should the nurse implement to assess the client's blood pressure after this procedure? a. every 5 minutes for 30 minutes, then every 4 hours thereafter. b. every 1 hour for 2 hours. c. every 5 minutes for 1 hour. d. every 15 minutes for one hour, then every 1 hour for 2 hours.

d. every 15 minutes for one hour, then every 1 hour for 2 hours.

a client is brought to the emergency department after falling from a ladder and is showing signs of confusion and disorientation. the spouse states the client appeared to have lost consciousness. the nurse is provided with a list of current medications and healthcare power of attorney. when reporting to the hcp using SBAR communication, which information should the nurse provide first? a. currently prescribed medications. b. client's healthcare power of attorney. c. falling from a ladder as reason for admission. d. increasing confusion of the client.

d. increasing confusion of the client.

a client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. the nurse administers an IV dose of regular insulin per sliding scale. which intervention is most important for the nurse to include in this client's plan of care? a. maintain venous access with an infusion of normal saline. b. evaluate hourly urine output for return of normal renal function. c. assess glucose via fingerstick every 4 to 6 hours. d. monitor the client's cardiac activity via telemetry.

d. monitor the client's cardiac activity via telemetry.

49 y/o male who reports flu-like symptoms including fever and chest congestion for 4 days. he came to ED last night when he was having more difficulty breathing. he has a history of one-half pack a day cig. smoking for 20 years. he has no significant medical or surgical history. which 2 orders should the nurse complete first? a. chest xray. b. acetaminophen 350 mg PO q6h for temp >101. c. sputum culture. d. place client on cardiorespiratory monitor. e. run 0.9% sodium chloride IV infusion at 150 mL/hr. f. start oxygen 3L/minute via NC. g. start a peripheral IV. h. NPO

d. place client on cardiorespiratory monitor. f. start oxygen 3L/minute via NC.

a client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the IV line. the abdominal dressing is no longer occlusive, and the IV insertion site is pink. which intervention should the nurse implement? a. replace the IV site with a smaller gauge. b. apply soft bilateral wrist restraints. c. leave the lights on in the room at night. d. redress the abdominal incision.

d. redress the abdominal incision. rationale: The patient's confusion and picking at the abdominal surgical dressing and IV tape could lead to potential harm, such as infection or injury.

the nurse is assigned to care for a client diagnosed with psoriasis. which behavior by the nurse addresses this client's psychosocial need for acceptance? a. wearing gloves when interviewing the client. b. allowing the client to ventilate feelings. c. encouraging the client to join a support group. d. shaking the clients hand during the introduction.

d. shaking the clients hand during the introduction. rationale: touch, more than any other gesture, communicates acceptance of the client with a skin problem such as psoriasis (D). (B and C) are worthwhile nursing interventions, but do not address this client's need for acceptance. (A), when not touching the affected area, shows rejection, not acceptance of the skin problem.

in providing nursing care for a client after gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems? a. aching leg. b. headache. c. nausea. d. sore throat.

d. sore throat.

the nurse is teaching a group of women about osteoporosis and exercise. the nurse should emphasize the need for which type of regular activity? a. muscle stretching and toning. b. aerobic exercise. c. core strengthening. d. weight-bearing exercise.

d. weight-bearing exercise.