THIS IS IT
A client who weighs 110pbs receives a prescription for dalteparin 150 units/kg SUBQ daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL shold the nurse administer?
0.3
When washing hands, the nurse first wets the hands and applies soap. THe nurse should complete additional actions in which sequence? Arrange from first to last action. Dry hands with paper towels Turn off the water Facet Rub hands palm to palm Interlace the fingers
1.Rub hands palm to palm 2.Interlace the fingers 3. Dry hands with paper towels 4. Turn off the water facet
A client with chlamydia infection recieves a prescription for a single dose azithromycin 1 gram PO. THe bottle labeled USP 200 mg per 5 mL. How many mL should the nurse admininster?
10 mL
A client recieves a prescription for acetaminophen 1 gram PO every 8 hours PRN for pain. The medication is available in 500mg tablets. How many tablets should the nurse instruct the patient to take with eash dose?
2 tablets
A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump?
200 (100x2=1 hour)
A client receives a prescription for a fluid blus of 0.9% sodium chloride 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program infusion pump to deliver?
400 mL (200 x2=1 hour)
A school aged client is receiving vancomycin 400mg IV every 6 hours for MRSA. The medication is diluted in 100 mL bag with instructions to infused over one and half hour. how many mL should the nurse program the infusion pump?
67 100 mL : 90 minutes = X mL : 60 minutes 90X = 6000 X = 66.66 = 67 mL/hour
The nurse notes that a client with depression has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? A Encourage the client to participate in group activities. B Engage the client in non-threatening conversations. C Schedule a daily conference with the social worker. D Encourage the client's family to visit more often.
A Encourage the client to participate in group activities.
The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately? A Mediastinal shift to the right. B Serosanguinous drainage from the chest tube. C Diminished breath sounds in the left lower lobe. D Dullness bilaterally on percussion.
A Mediastinal shift to the right.
A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement? A Recommend using a breast shield. B Offer supplemental formula feedings. C Encourage the use of ice on the areola. D Teach about the use of a breast pump
A Recommend using a breast shield.
Six weeks after the birth of a child with Trisomy 21, the parents return to the prenatal clinic for a follow-up visit. They have spoken with a genetic counselor, but are still unsure about the risk of having another child with Trisomy 21. The couple brings literature from the counselor with them, and asks the nurse to explain it. Which action should the nurse take? A Review the literature and answer any questions the nurse is able to answer. B Recommend a community support group for parents of children with Trisomy 21. C Determine their reasoning for seeking genetic counseling at this time. D Tell the couple that it is best to call the counselor with their questions.
A Review the literature and answer any questions the nurse is able to answer.
A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously schedules. What action should the nurse take? A. Advise the UAP to resume positioning the client on schedule B. Encourage the UAP to provide comfort care measures only C. Assume total care of the client to monitor neurologic function D. Assign a practical nurse to assist the UAP in turning the client
A. Advise the UAP to resume positioning the client on schedule
A client presents to the emergency department (ED) with complaints of abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client? A Begin with questions that are less sensitive in nature. B Ask questions in a vague, non-specific format. C Get the most difficult questions over with first. D Share personal values to put the client at ease.
A. Begin with questions that are less sensitive in nature
A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include sodium 129 mEq/L, glucose 54mg, and potassium 5.3 mEq/L. When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? A. Hydrocortisone B. Regular insulin C. Broad spectrum antibiotic D. Potassium chloride
A. Hydrocortisone
Which snack selection indicates to the nurse that a school-age boy with gastroesophageal reflux understands his dietary restrictions? A. Sugar cookies B. Pizza C. Chocolate milkshake D. Tacos
A. Sugar cookies
An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply) A. Teach client to use incetive spirometer q2hours while awake B. Remove urinary catheter as soon as possible and encourage voiding. C. Maintain sequential compression devices while in bed. D. Administer low molecular weight heparin as prescribed E. Assess pain level and medicate PRN as prescribed.
A. Teach client to use incetive spirometer q2hours while awake B. Remove urinary catheter as soon as possible and encourage voiding.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her? a. The diaphragm must be refitted after childbirth. b. The diaphragm should be inserted 2 to 4 hours before intercourse. c. Vaseline lubricant can be used when inserting the diaphragm. d. The most effective form of contraception is a diaphragm
A. The diaphragm must be refitted after childbirth.
Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care? A. observe color of urine B. Measure body temperature C. Assess skin turgor D. Check for pedal edema
A. observe color of urine
A client with a history of unstable angina presents to the ER with constant chest pressure that is unrelieved with rest. After obtaining vital signs, what action should the nurse take NEXT?
Administer 81mg of aspirin
After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? palpate the temp of the area Apply light pressure over the area. note the skin color of surrounding area measure the degree of indentation
Apply light pressure over the area.
While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, what action should the nurse implement?
Attempt to distract the client with general conversation
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. Diapering will be provided since hospitalization is stressful to preschoolers B. Children usually resume their toileting behaviors when they leave the hospital C. A potty chair should be brought from home so he can maintain his toileting skills D. A retraining program will need to be initiated when the child returns home
B. Children usually resume their toileting behaviors when they leave the hospital
A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as teh control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement? A. Withhold the heparin and continue the same dose of warfarin B. Increase the warfarin dose C. Decrease the heparin dose D. Increase the heparin dose and decrease the warfarin dose
B. Increase the warfarin dose
A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? A. Bring a bedside commode to the client B. Stand on the client's right side as he walks C. Walk directly behind the client to prevent a fall D. Give the client a cane to hold in his right hand
B. Stand on the client's right side as he walks
The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress? A Left lateral position. B Reverse Trendelenburg. C High-Fowler's position. D Supine.
C High-Fowler's position.
A pre-school age child with a congetinal heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is BEST for the nurse to provide? A. "Does your child seem mentally slower than his peers also?" B. "Haven't you been feeding him according to recommended daily allowances for children?" C. "His smaller size is probably due to the heart disease." D. "You should not worry about the growth tables. They are only averages for children."
C. "His smaller size is probably due to the heart disease."
A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill". What question should the nurse ask the client next? A. When did these voices begin? B. Have you taken any hallucinogens? C. Are you planning to obey the voices? D. Do you believe the voices are real?
C. Are you planning to obey the voices?
The nurse is reviewing the recommended preventative care for clients with asthma, chronic, bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients? A. Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines. B. Use nasal or cough tissues followed by handwashing at all times. C. Avoid large crowded areas during the colder months of the year D. Ensure supplemental oxygen and respiratory medications are available at all times.
C. Avoid large crowded areas during the colder months of the year
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? A. Instruct the client that these mild symptoms can generally be controlled with changes in his diet B. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms C. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer D. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food
C. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer
The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take? A. Instruct the PN that this technique promotes infection in elderly females B. Recommend a complete bath to cleanse the perineal area more fully C. Evaluate the effectiveness of this measure to stimulate client voiding D. Suggest contacting the healthcare provider for a prescription for catheter insertion
C. Evaluate the effectiveness of this measure to stimulate client voiding
A client in the third trimester of pregnancy reports that she fells some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take? A. Tell the client to begin nipple stimulation to prepare for breast feeding. B. Reschedule the client's prenatal appointment for the following day C. Explain that this normal secretion can be assessed at the next visit D. Recommend that the client start wearing a supportive brassiere
C. Explain that this normal secretion can be assessed at the next visit
An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication? A. currently prescribed medication. B. Client's healthcare power of attorney C. Increasing confusion of the client D. Fall at home as reason for admission
C. Increasing confusion of the client
When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care? A. Assess bilateral breath sounds B. Review client's daily medications C. Initiate neurological monitoring every 2 hours D. Palpate suprapubic region for urinary retention
C. Initiate neurological monitoring every 2 hours
The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped, and a sterile field is created. Which nursing intervention should the nurse implement for client safety? A. Assess for discomfort when procedure is completed B. Verify that the client has given informed consent C. Instruct the client to keep hands under the sterile field D. Pour cleansing solution onto the sterile cloth field
C. Instruct the client to keep hands under the sterile field
While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Platelet count B. Serum sodium level C. Neutrophil count D. Hematocrit
C. Neutrophil count
The parent of a child born with myelomeningocele asks the nurse "what did i do to deserve this?". Which response is most helpful? A. You didnt do anything wrong B With surgery, your baby should have a full recovery C. This must be a very difficult time for you D. Is there any particular reason why you think this is your fault? C
C. This must be a very difficult time for you
The nurse is caring for a client with binge eating disorder. Which goal should the nurse FIRST establish with the client? a.Obtain satisfaction with appearance b. Achieve a steady weight loss c. Regulate food portions d. Institue an exercise plan
C. regulate food portions
The nurse is providing a teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management . Which response by the client indicates understanding ?
Check blood sugar levels every four to six hours every day.
The nurse is monitoring a client with a transcutaneous pacemaker that is periodically failing to capture. Which intervention should the nurse implement FIRST?
Confirm the lead wires are secured to pacemake generator
A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care? E Show calculator A Peripheral neuropathy. B Right lower abdominal pain. C Depression. D Confusion.
Confusion.
When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement? A Observe and palpate newborn's breast tissue for enlargement. B Explain to mother that the finding is due to increased androgen. C Review transcutaneous bilirubin levels with a bilirubinometer. D Assess for signs of fluid retention and bilateral pedal edema
D Assess for signs of fluid retention and bilateral pedal edema
The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective? A Absence of fine crackles. B Increase in breath sounds. C Absence of coarse crackles. D Increase in respiratory rate
D Increase in respiratory rate
A client has a prescription for the insertion of a nasogastric tube to low intermitent suction. When inserting the nasogastric tube, the nurse observes an immedicate return of "coffee-ground" drainage. Which action should the nurse implement? a. connect the nasogastric tube and suction as prescribe b. connect the nasogastric tube to high continous suction c.Clamp the naspgastric tube and contact health provider D. Immediately remove and reinsert nasogastric tube.
D. Immediately remove and reinsert nasogastric tube.
A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? A. A change in the sleep-wake cycle B. Mild sedation C. Dizziness reported after initial dose D. Somnambulism
D. Somnambulism
The healthcare provider prescribes 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L..... Which evaluation is MOST important for the nurse to include in this client's plan of care?
Evaluate glucose levels before and after meals
A 10 year old child arrives to the clinic accompanied by a parent three days following a right ankle fracture that required internal fixation with.. The parent reports the child is doing well but ask for pain medication about every four to six hours the parent is concerned about addiction and has been trying to administer the pain medication... which information is best for the nurse to provide the parent regarding pain management for the child?
Giving pain medication
a male client with schizophrenia tells the nurse that the hospital installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?
Impaired environmental interpretation related to paranoid delusions.
The nurse is leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the PN ?
Insert urinary catheter for uncomplicated clients
a client with bladder cancer had surgical placement of a ureteroileostomy yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately ?
Liquid brown drainage from stoma
A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
Maintain IV fluid rehydration therapy per prescription
Which needle should the nurse use to administer IV fluids via a client's implanted port?
Needle with the white clamp
The nurse applies a BP cuff around a clients L thigh. To measure the client's BP, where should the diaphragm of the stethoscope be placed? (PHOTO OF MAN FRONT AND BACK)
PLACE THE CURSOR OVER THE BACK OF LEFT KNEE ON LEFT GUY WHO HAS BACK TURNED.
The charge nurse observes the practical nurse apply sterile gloves WATCH VIDEO!!
Picking uo the second glove
Which laboratory test result is most important to report prior to hernia repair?
Serum creatinine of 5mg
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide? A Inform the client that gradual tapering must be used to discontinue the medication. B Tell the client that the medication's side effects will most likely dissipate over time. C Tell the client to discuss the medication side effects with the healthcare provider. D Remind the client that feeling better is the therapeutic effect of the medication.
Tell the client to discuss the medication side effects with the healthcare provider.
The nurse is assessing an older client who is having difficulty remembering events from earlier in the day and cocentrating on the questions..
The client is exhibiting signs of Dementia and because of age it may be permanent.
A nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardio disease. Which outcome should the nurse include in the plan of care for this client?
The client's daily BP will be less than 140/80 mmHg this month
The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply
White blood cell (WBC) count Sputum culture and sensitivity
1. The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching? a) A diet of healthy fruits, such as bananas and kiwis, are best for the child b) Only foiled balloons will be used for the child's birthday party c) Rubber-free toys, such as wooden building blocks, are good choices for the child d) An epinephrine auto-injector will be on hand to treat allergic reactions.
a) A diet of healthy fruits, such as bananas and kiwis, are best for the child
The school nurse is preparing for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse (SATA) a) Thirst and frequent requests for bathroom breaks b) Shaking that changes the child's handwriting legibility c) Bruises on both knees after the weekend d) Refuses to complete written homework assignments e) Sunburn with blisters on the face, arms, and hands
a) Thirst and frequent requests for bathroom breaks b) Shaking that changes the child's handwriting legibility e) Sunburn with blisters on the face, arms, and hands
A client with Chron's disease is preparing for discharge from the hospital follow treatment for an exacerbation of diarrhea, abdominal pain and rectal bleeding. Which dietary recommendations should the nurse discuss with the client? SATA a. Limit high fiber foods such as beans popcorn, seeds b.avoid eating fried,fatty foods & large meals c.Take a vitamin supplement daily with meals d.Drink dairy and effervescent sodas for hydration e. enjoy fat food restaraunts only if dining with friends
a. Limit high fiber foods such as beans popcorn, seeds b.avoid eating fried,fatty foods & large meals d.Drink dairy and effervescent sodas for hydration e. enjoy fat food restaraunts only if dining with friends
The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? SATA a. Methods currently used to treat constipation b. Current prescribed and over the counter meds c. Level of physical activity and exercise d. Next scheduled visit with healthcare provider e. Daily food and fluid intake
a. Methods currently used to treat constipation b. Current prescribed and over the counter meds c. Level of physical activity and exercise e. Daily food and fluid intake
An older client arrives to the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement? a. Obtain a clean, voided urine specimen for analysis b. Provide protective undergarments for the client c. Evaluate the clients response to bladder training efforts d. Encourage increased fluid intake for 24 hours.
a. Obtain a clean, voided urine specimen for analysis
The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? a. Poor feeding and vomiting b.Leakage of CSF from the incisional site c.Hyperactive bowel sound d.Abdominal distention e. WBC count of 10000/mm3
a. Poor feeding and vomiting b.Leakage of CSF from the incisional site d.Abdominal distention
the nurse manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? a. employees job security b. changes in job description c. potantial changes in benefits d. new management expectations
a. employees job security
Which client will benefit from the application of pneumatic compression devices to lower extremeties? The client who.. a. is immobile on prescribed bedrest b. is confused and tries to climb out of bed c. has pressure ulcers on toes d. has diminished pedal pulse volume
a. is immobile on prescribed bedrest
Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? a. prevention through nutrition and exercise b. avoidance of foods containing purine c.application of heat and cold therapy d.immobilization of affected joints
a. prevention through nutrition and exercise
The nurse is providing care to a client having surgery to repair a retinal detachment to the Left eye. Which intervention should the nurse implement during the postoperative period? a. provide an eye shield to be worn while sleeping b. teach a family to administer eye drops c. obtain vital signs q2h during hospital stay d. encourage deep breathing
a. provide an eye shield to be worn while sleeping
The nurse is setting up equipment to assist with a sigmoidoscopy while the practical nurse positions the client in a flat prone position. WHich action should the nurse implement?
acknoweledge that the PN has positioned the client safely and correctly.
The nurse is assessin a client's breath sounds (PLAY VIDEO(
albuterol
1. Which conditions are most likely to respond to treatment with antihistamines? select all that apply. a) Bronchitis b) Allergic Rhinitis c) Otitis Media d) Contact Dermatitis e) Myocarditis
b) Allergic Rhinitis d) Contact Dermatitis
1. An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first? a) Provide a printed healthcare assessment form b) Assess the surroundings for noise and distractions c) Ask the family member to answer the questions d) Defer the health history until the client is less anxious
b) Assess the surroundings for noise and distractions
1. A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that "My favorite nurse is on duty now." Which response is BEST for the nurse to provide to this client's dichotomous tendency? a) Tomorrow I will talk to that nurse about how you were treated last night b) I am happy that you are getting better and will be able to go home c) I am glad you like me. Which nurse was acting aloof to you? d) What did the night nurse do that makes you think she is aloof?
b) I am happy that you are getting better and will be able to go home
A client who is admitted to the ICU with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasing anxious and complains of difficulty breathing. The nurse determines the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? a) Continuous bubbling in the water seal chamber b) Tracheal deviation toward the left lung c) Decreased bright red bloody drainage d) Tachypnea with difficulty breathing
b) Tracheal deviation toward the left lung
A client is scheduled to receive an IV dose of ondansetron eight hours after receiving chemo. The client has peripheral IV access and is sleeping quietly without any restlessness . The nurse caring for the client is not certified in chemo administration. Which action should the nurse take? a-Ask a chemotherapy-certified nurse to administer the Zofran b-Administer the Zofran after flushing the saline lock with saline c-Hold the scheduled dose of Zofran until the client awakens d-Awaken the client to assess the need for administration of the Zofran.
b-Administer the Zofran after flushing the saline lock with saline
The nurse is providing education about disease transmission to a client with HIV who is pregnant. Which action should the nurse recognize as the client demonstrating an understanding of the disease transmission? a. Sanitize the bathroom between eash use b. Acknowledge the risk of HIV transmission through breast milk c. Understand that the child will be born with HIV d. Avoid sharing food, dishes and utensils with other people.
b. Acknowledge the risk of HIV transmission through breast milk
A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms? a. Were your legs ever suddenly swollen, red, warm, and painful? b. Does the calf pain occur when walking short distances? c. Did you receive treatment for weeping ulcers on lower legs? d. Have you experienced ankle edema and varicose veins?
b. Does the calf pain occur when walking short distances?
When caring for a client with diabetes insipidus, it is most important for the nurse to include frequent assessment for which conditions in the client's plan of care? a. elevated BP, petechiae b. dry mucous membranes, hypotension c. decreased appetite, headache d. nausea and vomiting and muscle weakness.
b. dry mucous membranes, hypotension
A client is being dischrged home after being treated for heart failiure HF. which instruction should the nurse include in this client's discharge teaching plan? a. weigh every morning b. limit fluid intake c. eat high protein diet d. perform range of motion exercises
b. limit fluid intake
A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. Which intervention is MOST important for the nurse to include in the plan of care? a. assess warmth of extremeties b. maintain strict intake and output c. Monitor blood glucose level d.keep head of bed raised 45 degrees
b. maintain strict intake and output
When performing suctioning to a client with a tracheostomy which action should the nurse take? a. instruct the client to cough as the suction is removed b. wear protective goggles c.nstil 3mL of sodium chloride d.apply water soluble lubricant to catheter
b. wear protective goggles
An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? a.Obtain a urine specimen for culture and sensitivity b.Palpate the client's suprapubic area for distention c.Advise the client to maintain a voiding diary for one week d.Instruct in effective technique to cleanse the glans penis
b.Palpate the client's suprapubic area for distention
After receiving shift report, the nurse working on postpartum unit should assess which client first? a. ceserean birth of twins today who is complaining of pain b.multipara vaginal birth yesterday who is saturating two pads/hour c.Vaginal birth whosse infant is refusing to breastfeed. d.Post-cesearn birth today with fundus at the umbilicus
b.multipara vaginal birth yesterday who is saturating two pads/hour
The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the client's discharge teaching plan? (SATA) a) Cross legs at knee but not at ankle b) Maintain the bed flat while sleeping c) Continue wearing compression stockings d) Avoid prolonged standing or sitting e) Use recliner for long periods of sitting
c) Continue wearing compression stockings e) Use recliner for long periods of sitting d) Avoid prolonged standing or sitting
An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal "increase daily intake of fluids". What nursing intervention is most useful in assisting the resident to meet this goal? a) Increase fluids provided with the client's meals b) Record the client's intake and output every shift c) Offer a glass of fluid every hour while awake d) Maintain a full pitcher of water at the bedside
c) Offer a glass of fluid every hour while awake
Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? a) Frequently apply moisturizers to prevent dry skin b) Protect the site from getting wet during bathing c) Use a sponge to debride the affected area d) Gently pat the skin dry after rinsing with water
c) Use a sponge to debride the affected area
The nurse is caring for a client who receives a prescription for parenteral lidocaine. Prior to administering the medication, the nurse should review the medical record for which condition? a. gastric ulcers b. Diabetes c. Heart block d. Glaucoma
c. Heart block
A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? a.Collect a clean catch urine specimen. b.Instruct the client to empty the bladder. c.Obtain vital signs and breath sounds. d.No specific nursing action is required
c. Obtain vital signs and breath sounds.
A client with osteomyelitis from a compound fracture to the left tibia has an open draining wound and is admitted with possible MRSA. Which interventions should the nurse include in the plan of care? SATA a. Use standard precautions and wear a mask b.explain the purpose of low bacteria diet c. monitor the clients WBC d. send wound draininage for culture e.institute contact precautions for staff/visitors
c. monitor the clients WBC d. send wound draininage for culture e.institute contact precautions for staff/visitors
A client with a hip fracture is requesting pain medications prior to being respositioned in the bed. To assess the quality of the client's pain, which approach should the nurse use? a. Identify effective pain relief measures b. Ask the client to describe the pain c. provide a numeric pain scale d. observe the body language and movement
c. provide a numeric pain scale
One hour after arriving on the posoperative unit, a woman who receievd spinal anesthesia 5 hours ago is complaining of severe abdominal incision pain... a. provide pillow b. high fowlers position c.administer IV analgesic d.assess IV site for patency
c.administer IV analgesic
In planning care for a client with early stage Alzheimer's dosease, the nurse establishes the nursing problem og "risk for injury related to impaired judgment". Which intervention is MOST important for the nurse to include in the client's plan of care? a. offer the client frequent reassurances of their safety. b.assign an UAP to provide client with total personal care c.arrange the client's environment so the client can move about freely d.encourage the client in regularly scheduled activities during the day
c.arrange the client's environments so the client can move about freely
The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first? a. dosage of ibuprofen taken b. amount of pain control c.prescence of gastric pain d. reason for taking the aspirin
c.prescence of gastric pain
After diagnosis and treatment of a pre-school aged child with cystic fibrosis, the nurse provides home care instructions to the parents. Which satement by the child's parents indicates that understanding of the home care treatment to promote pulmonary function?
chest physiotherapy should be performed twice a day before a meal
1. When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? (SATA) a) Weeping serosanguineous fluid with wounds b) Sloughing tissue around wound edges c) Change in the quality of the peripheral pulses d) Loss of sensation to the left lower extremity e) Complaint of increased pain and pressure
d) Loss of sensation to the left lower extremity e) Complaint of increased pain and pressure c) Change in the quality of the peripheral pulses
The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? a. A young man with schizophrenia who wants to stop taking his medication b. The mother of a child who was involved in a physical fight at school today. c. A client diagnosed with depression who is experiencing sexual dysfunction. d. A family member of a client with dementia who has been missing for five hours
d. A family member of a client with dementia who has been missing for five hours
A client receives a prescription for itraconazole. Which statement by the client requires additional instructions by the nurse? a. Monitoring for changes in stool color is important. b. If i experience any difficulty breathing I will report it c. Drinking grapefruit juice will reduce the effects of the medication d. I should take the medication with antacids
d. I should take the medication with antacids
The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first? a. Clean up the spilled blood to reduce infection transmission. b. Notify the healthcare provider that the client appears to be bleeding. c. Apply direct pressure to the client's IV site. d. Identify the source and amount of bleeding.
d. Identify the source and amount of bleeding.
An older client is being admitted to a short-term rehab facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement? a. Ask the client how often episodes of sundowning are experienced. b. Assist the client with values clarification about end-of-life care option. c. Encourage the client to lie as still as possible during then assessment. d. Question the client about the frequency of falls in recent months.
d. Question the client about the frequency of falls in recent months.
When teaching a group of school age children how to reduce the risk for Lyme disease, which instruction should the camp nurse include? a. Wash hands frequently b. Avoid drinking lake water c. Do not share personal products d. Wear long sleeves and pants
d. Wear long sleeves and pants
In assessing a client at 34-weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? Reference Range Hematocrit [Reference Range: female: 37% to 47% (0.37 to 0.47 volume fraction)] • A Systolic murmur. B Elevated thyroid hormone level. • C Hematocrit of 28% (0.28 volume fraction). D Heart rate of 92 beats per minute.
• C Hematocrit of 28% (0.28 volume fraction).
