An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?
Ask the AP to discuss the issue in a private area
A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client’s room?
Oral Suction Equipment
A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene?
Tells a client he will lose his phone privileges if he does not take his medication
A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include in the meal tray?
Roasted Salmon
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?
“Advance directives include a living will”
A nurse is collecting data from the caregiver of a client who has Alzheimer’s disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend?
Encourage the client to take frequent walks during the day
A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply)
Assist the client to empty her bladder
A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?
“Gently stroke her abdomen during contractions”
A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?
Use a moisture barrier on the client’s skin
A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client’s autonomy?
Allow the client to choose treatment times
A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication?
Appears greenish-brown in color
A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take?
Inform the adolescent that he might experience a headache
A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?
“I should discuss this document with my family after I sign it”
A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?
Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride
A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?
Instruct the client to remain as still as possible during the recording
A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching?
“You should increase fluid intake to relieve dysuria”
A nurse is preparing to empty a postoperative client’s closed-wound drainage system. Which of the following actions should the nurse plan to take?
Compress the container before replacing the drainage plug
A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?
Administer the medication to the toddler each evening
A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship?
Defining responsibilities
A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate?
Lower left
A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
Suction for 30 seconds
A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client?
Hypotension
A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client’s identity?
Verify the client’s identity using a photograph
A nurse in a provider’s office is collecting data from a client who has psoriasis. Which of the following statements made by the client should she report to the provider?
“I try not to look at the scales on my body”
A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls?
Medication record
A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
Complete post mortem care for a client who has died
A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?
Skin rash with fever
A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching?
“I will instruct the client to sit when putting on a pair of pants”
A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge?
A client who has a sodium level of 140 mEq/L after one episode of diarrhea
A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Administer liquid supplements
A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
“I will document in the medical record the support nurse who assists with planning care for my clients”
A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?
Urine output 12 mL/hr
A nurse is preparing the administer NPH (Novolin N) insulin to a client who has diabetes mellitus before breakfast at 0700. At which of the ff. times should the nurse plan to check the client for hypoglycemia?
1100
A nurse in a clinic is obtaining a health history from a client scheduled to un- dergo a cardiac catheterization in 2 days. Which of the ff. questions is the most im- portant for the nurse to ask?
“Do you know if you’re allergic to iodine?”
A nurse in an urgent-care facility is collecting data from a client who is scheduled for a procedure. Which of the ff. clinical manifestations indicates a possi- ble latex allergy?
Rhinorrhea
A nurse in a provider’s office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the ff. statements by the client demonstrates understanding of the teaching?
“I will rinse my mouth after taking this medication”
A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client who is at risk for a deep thrombosis. Which of the following actions the AP is applying the stockings correctly?
The AP applies the stockings before getting the client out of bed
A nurse working in a provider’s office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the ff. responses by the nurse is cor- rect?
“When all the blisters are scabbed over”
A nurse is caring for a client who just had blood drawn for an arterial blood gas analysis. Which of the ff. values should the nurse expect if the client is in respi- ratory acidosis?
PaCO2 51 mm Hg
A nurse is reinforcing teaching with a client who has a new prosthesis for an above the knee amputation of the right leg. Which of the ff. instructions should the nurse reinforce to the client?
Apply the prosthesis immediately upon waking each day
A nurse is preparing a client for the insertion of an NG tube. Which of the ff. actions should the nurse take?
Determine if the client has a deviated septum
A nurse is caring for a client who has a fractured radius and has a short arm cast applied yesterday. Which of the ff. findings should the nurse report to the provider?
Client report of decreased sensation in the finger
A nurse is contributing to the plan of care for a client who is on suicide pre- cautions. Which of the ff. interventions is appropriate for the nurse to recommend?
Encourage the client to sign a no-harm contract
A nurse is preparing to administer haloperidol (Haldol) 4 mg IM start to a client. Available is haloperidol for injection mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
0.8 mL
A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting, and fever with chills. Which of the following diagnostics tests should the nurse expect to be prescribed?
Cerebrospinal fluid analysis
A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements is appropriate for the nurse to make?
If you’d like to wear a wig, you should select it before hair loss occurs
A charge nurse in a long-term care facility observes an assistive personnel (AP) who appears to be under the influence of alcohol. Which of the following actions should the nurse take first?
Confront the AP about suspected impairment
A nurse is caring a client who has asthma and has a prescription for theophylline (theochron) 200mg PO BID. Which of the following should the nurse include in the teaching?
Discontinue drinking caffeinated beverages
While a nurse is assisting a client to ambulate, the client reports lightheadedness and begins to fall. Which of the following nursing actions demonstrates a correct understanding by the nurse about ergonomic principles?
Spread feet apart and extend one leg for the client to slide down while lowering the client to the floor
A nurse is caring for an older adult client who appears lethargic and somnolent. The nurse reviews the client’s medications prior to contacting the provider. Which of the following medication is the likely cause of the increased sedation?
Lorazepam (Ativan)
A nurse is caring for a client who had a bronchoscopy and just arrived to the medical surgical unit. Which of the following actions should the nurse perform first?
Check for a gag reflex
A client is requesting information from a nurse regarding the appointment of a health care proxy. Which of the following responses by the nurse is appropriate?
The person you appoint will make health care decision for you if you cannot do so yourself
A nurse enters client’s room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse first?
Assist the client to a nearby waiting room
A nurse is interviewing clients as part of a skin cancer screening program. Which of the following statement made by a client indicates that he may have a premalignant lesion?
I have this flat, scaly area with red edge on neck
A nurse is caring for a client who reports 12 liquid stools in the past 8hr. Which of the following findings indicates that the client is experience dehydration?
Potassium level 2.5 mg/L
A nurse is reinforcing teaching for a client undergoing radiation therapy to the neck. Which of the following should the nurse include?
Avoid exposing the neck to the cold
A nurse is providing anticipatory guidance to the parent of a 6-year old child. Which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child?
“I will encourage my child to wear a bicycle helmet whenever bike riding”
A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit?
Orthostatic hypotension
A nurse is caring for a client who is recieving warfarin (coumadin) for deep vein thrombosis. The nurse observed that the client’s INR is 3.8.Which of the following actions should the nurse take?
Withhold the ordered dose of the medication
A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant’s room indicates a need for further teaching?
The infant is lying in the crib with a stuffed animal
A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B?
Performing oral hygiene
A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse evaluates that the client understands the teaching when she states she will gain
A..?
A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx. The nurse should instruct the staff that the period of contagion for children who have this infection is which of the following?
From onset of symptoms until 24 hours of antibiotic therapy
A nurse is caring for a client who is 2 days postoperative following a partial bowel resection. The client reports that the “felt something pop” when he sneezed. The nurse observes an evisceration. After calling for assistance, which of the following actions should the nurse take first?
Cover the wound with sterile saline-soaked gauze
A nurse is caring for a client who is in balanced skeletal traction for a leg fracture. Which of the following should the nurse expect to be included in the care plan?
Increase counter traction every 24 hours.
Inspect the ropes, knots, and pulleys every 8 hours.
A nurse is using contact precautions while caring for a toddler. Which of the following actions should the nurse take?
Use a designated stethoscope for the toddler
A client’s daughter calls the nurse requesting information about her mother’s condition. The client’s chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse?
“You will need to contact your mother directly about her condition”
A nurse is reviewing the immunization records of a 9 year old child during a routine physical exam. Which of the following should indicate to the nurse the child is not current with the minimum required immunization?
One MMR vaccine
A nurse is reinforcing teaching with a new mother on facility security measure. Which of the following statements by the mother indicates that the teaching was effective?
“I will have an identification band that matches the one my baby wears”
A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she
Develops edema of the ankles
A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate?
Monitor the client’s skin integrity on a regular schedule
A nurse is working on a mental health unit is reviewing policies for client seclusion. For which
of the following is seclusion appropriate?
Aggressive behavior
A nurse in a long-term care facility has received a change-of-shift report on four clients. Which of the following clients should the nurse attend to first?
A client who has COPD and dementia and was agitated during the night shift
A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use?
Leave space between the tip of the penis and the end of the condom catheter
A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take?
Ask the client to flex the hips and knees
A nurse is supervising an assitive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take?
Reinforce safe meal setup techniques
A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse should recognize the client’s understanding of the teaching when the client states, “I will
Install gates at the top and bottom of the stairs
A nurse is preparing a sterile field to peform a dressing change. Which of the following actions should the nurse take?
Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field
A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states,
“I guess I have to take some of the blame because of the way my friends and I dress”
A client is prescribed 2g of ampicillin. The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client?
4 tablets
A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching?
“I will walk barefoot to prevent slipping”
“I will check my smoke alarms once a month”
A Client with emphysema asks the nurse why he has difficulty exhaling. Which of the following statements by the nurse is appropriate?
“Your windpipe is inflamed and constricted”
A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal. Which of the following is an expected finding for the client?
Irritability
A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparartion classes. Which of the following responses by the nurse supports the partner’s involvement during labor?
“Breathing with your partner will help her to relax during contractions”
A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first?
Remove the tracheostomy inner cannula
A nurse in a provider’s office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching?
Wash the bed linens in hot water.
Clean the child’s toys with 1:10 bleach solution.
A nurse caring for the mother of a newborn finds the client crying in her room. The client tells th nurse, “I don’t think I can handle caring for a baby.” Which of the following nursing interventions is appropriate?
Encourage the client to share her feelings
A nurse is assisting with the care of a 36-year-old client who is at 16 weeks of gestation and is scheduled for an amniocentesis. The nurse recognizes that the client understands the amniocentesis is performed to identity
Chromosomal abnormalities
A nurse is caring for client who is requesting assistance with smoking cessation. For which of the following medications should the nurse anticipate having to reinforce teaching?
Nicotinic acid (niacin)
A nurse is caring for a client who is 12hr postpartum. The nurse observes an increase in vaginal bleeding. Which of the following actions should the nurse plan to take first?
Massage the fundus.
Obtain the client’s vital signs.
A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/ 1.25 mL. How many mL should the nurse administer?
1.5 mL
A nurse is caring for a child who has terminated cancer. Which of the following responses by the child’s school-age brother should the nurse expect?
Believes his bad behavior is causing his brother’s death
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should anticipate administering to prevent complications of withdrawal?
Lorazepam
A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy?
16 lb
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure?
Disorientation
A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first?
Observe the client during and after meals
A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client’s respirations?
Observe the movements of the client’s chest wall
A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroplasty. Which of the following information about the client should the nurse include in the report?
Time of last pain medication
An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?
I will plan to avoid grapefruit juice while taking this medication
A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching?
Engage in low-impact aerobic exercises
A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
Secure the tubing with adhesive tape to the lower abdomen
A nurse is assisting with a support group for clients who have experienced intimate partner violence. The nurse should identify which of the following client statements as indicating the greatest risk for violence?
I have decided to tell my husband I am leaving him
A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect?
Hypotension
A charge nurse working in a long-term care facility overhears two AP’s in the nurses’ stations discussing a client who was just admitted. Which of the following actions should the charge nurse take?
Tell the APs to stop the conversation
A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements made by the client indicates an understanding of the teaching?
I will feel a warming sensation after injection of the dye
A nurse is assisting with the plan of care for a client who has end-stage amyotrophic lateral sclerosis and has developed pneumonia. Which of the following actions should the nurse take?
Verify the status of the client’s advance directive
A nurse is reinforcing teaching with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
I will have an identification band that matches the one my baby wears
A nurse working at an inpatient mental health facility is contributing to the plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care?
Record the amount of food the client consumes
A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following statements indicates any understand of the teaching?
I will dispose of my needles in a plastic laundry detergent container
A nurse is visiting the home of a client who recently had a total hip arthroplasty. During Observation of the clients’ home, which of the following findings places the client at risk for falls? (select all that apply.)
Medication stored on the top shelf of the cupboard.
Client walks barefoot in the house.
A nurse is reinforcing teaching with a client who has a new prescription for nitro- glycerin (nitrostat) sublingual tablets for treatment of angina. Which of the following instructions should the nurse include?
Take up to three tablets during a single angina episode
A nurse is caring for a client who has right-sided heart failure. The client’s partner expresses concern that the client will die. Which of the following is an appropriate re- sponse by the nurse?
“It is difficult to see someone so sick. What have you been told about your partner’s prognosis?”
A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increase fatigue. Listen to the audio clip. Which of the following lung sounds should the nurse report to the provider?
Fine crackles
A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa (Epogen). Which of the following instructions should the nurse include?
Administer the medication subcutaneously
A nurse is caring for a client who has a Salem Sump tube connected to intermittent wall suction. Which of the following nursing interventions should the nurse perform?
Reposition the client every 2 hours
A nurse is provider’s office is reviewing pediculosis capitis management and pre- vention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (select all that apply)
Store the child’s clothing in a separate cubicle when at school.
Boil brushes and combs in water for 10 min.
Dry bed linens and clothing for at least 20 mins.
A nurse is contributing to the plan of care for an adolescent who has cystic fibrosis. Which of the following diets should the nurse recommend?
High-calorie
A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the medical record to the locate information about the clients personal health insurance?
Admission sheet
A nurse is reinforcing teaching with a client who has a new prescription for pred- nisone for the treatment of Addison’s disease. Which of the ff. instructions should the nurse include?
“You will need to schedule a bone density test”
A nurse is assisting in the admission of a client who has diabetic ketoacidosis to a medical unit. Which of the ff. IV solutions the nurse anticipates administering first upon admission?
0.9% sodium chloride
A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings is the priority?
Tingling around the mouth
A client who has asthma and is started on montelukast (Singular) returns to the clinic 1 month later. Which of the ff. indicates that the client is complying with this medication regimen?
The client takes the medication once daily at bedtime
A nurse is collecting data from an older adult client who is receiving a unit of packed RBCs. Which of the ff. findings should the nurse report to the provider as an indication of circulatory overload?
Crackles heard on auscultation
A nurse is preparing a client for surgery. The client states, “I’m sure this surgery will not help me get better.” Which of the ff. responses by the nurse is appropriate?
“You’re saying that you are doubtful that this procedure will benefit you”
A nurse is preparing to provide suctioning for a toddler who has a tracheostomy. Which of ff. actions should be included in the plan of care?
Allow the child to rest for 45 seconds between aspirations
A nurse in a long-term care facility is assisting with the admission of a client who requires oropharyngeal suction. Which of the ff. supplies does the nurse need to perform this task?
Yankauer catheter
A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions by the nurse is appropriate?
Wear a surgical mask within 3 feet of the client
A nurse is collecting data from a client who has cholecystitis. In which of the ff. lo- cations should the nurse expect the client to report pain?
Right upper quadrant
The parents of a 12-month-old voice their concern that their child is crawling but not pulling herself up to stand like the other children at the day care center. The nurse should recommend to the parents that they
Have the child evaluated by a pediatrician
A nurse recognizes that nurse-client communication is effective when the client.
Asks the nurses to listen to potential solutions
A nurse is caring for a client who is receiving IV fluids. As the nurse enters the room, the IV pump’s alarm begins beeping. The client tells the nurse, “That happens all the time. Just turn off the alarm.” Which of the ff. actions should the nurse take first?
Observe the IV site
A nurse is caring for a client who is scheduled for colonoscopy with polyp removal. Which of the following client statements should alert the nurse that the client may be at risk for complications from the procedure?
“I needed three ibuprofens for my arthritis pain last night”
A nurse is reinforcing teaching with the parents of a newborn about physical assessments. Which of the ff. statements by the parent demonstrates understanding of the newborn hearing screening test?
“If my baby fails the hearing test, he will need to be tested in 3 months”
A nurse is reviewing instructions with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the client should take after washing his hands. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must used.)
A. Expose the glans of the penis
B. Cleanse the penis using aseptic swab
C. Begin urination
D. Pass the cup into the urine stream
E. Move the cup out of the urine stream
F. Move the cup out of the urine stream
G. Replace the foreskin
(IDK if in right order??)
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the ff. actions should the nurse take?
Provide step-by-step instructions for performing ADLs
A nurse is reinforcing teaching about breastfeeding with a pregnant client. Which of the ff. statements by the nurse is appropriate?
“Breastfeeding reduces the infant’s risk of infection”
A nurse is reviewing client positioning for a thoracentesis with a newly licensed nurse. The nurse validates that newly licensed nurse’s understanding when he indicates that the client should be placed in which of the ff. positions for the procedure?
Leaning forward over pillows
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of car seat. Which of the following statements by a parent indicates an understanding of the teaching?
“I can place a rolled towel on each side of my newborn’s head until he can hold his head up”
A nurse is preparing to apply a pulse oximeter to a client’s finger. Which of the following actions should the nurse take before applying the sensor?
Check the client’s capillary refill
A nurse is caring for a client who is asking about the technique of eTheurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique?
“It is a light stroking of the skin during a uterine contraction”
A nurse is administering hydromorphone (Dilaudid) to a client who is experiencing postoperative pain. Which of the following is an adverse effect of this medication?
Urinary Retention
A nurse is administering medication. A client states, “I know that the Inderal helps my blood pressure, but I don’t like the way it makes me feel. I don’t think I’ll take it today.” Which of the following actions should the nurse take?
Asks the client to describe what he is experiencing
A nurse is reinforcing teaching with a client regarding the use of guided imagery to relieve back pain. Which of the following statements made by the nurse is appropriate?
“Think about a pleasant memory as you visualize your pain floating away”
A nurse is caring for an older adult client who is postoperative following a total hip replacement.
The client is incontinent of stool and urine.
To prevent skin breakdown, the nurse should apply moisture-absorbing undergarments.
A client comes to the clinic with reports to nasal congestion. Which of the following medications should the nurse anticipate that the primary care provider will prescribe?
Pseudoephedrine (Sufaded)
A nurse is provider’s office is reinforcing teaching to the parents of a school-age child who has an ankle sprain. The nurse should include which of the following statements in the teaching?
“Offer aspirin every 4 hours for discomfort”
“Elevate the affected extremity to a level higher than the heart”
A nurse is caring for a client with a closed head injury. Which of the following findings should indicate to the nurse a need for futher data collection?
Inappropriate words when speaking.
Sharp sensation when touched with safety pin point.
A nurse is reinforcing teaching regarding management of penetrating eye injuries with a parent of a school-age child during a sports physical. Which of the following statements by the child’s parent indicates an understanding of the teaching?
A or C?
A nurse is reinforcing teaching to the parents of an infant who has pavlik harness. Which of the following statements should the nurse include in the teaching?
“The harness promotes hip joint development”
A nurse is caring for a client in a mental health inpatient facility who reports auditory and visual hallucinations. Which of the following should the nurse recognize as indicating the client is most in need of intervention?
States he is being told to hit his roommate
A nurse is reinforcing teaching for a client who has just started taking amitriptyline (Elavil). Which of the following should the nurse include as an adverse effect of this medication?
Orthostatic hypotension
A nurse in a long-term care facility is caring for a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The client reports daytime sleepiness. Which of the following actions should the nurse take first?
Check for proper fit of the mask on the CPAP machine.
Provide activities during the day to stimulate the client.
A nurse is caring for a client in the provider’s office who has is experiencing an episode of acute asthma. The nurse should aminister which of the following medications?
Traimcinolone (Azmacort)
A nurse is assisting with the care of a client who is recieving IV therapy of 0.9% sodium chloride. The client recieved 200mL more than prescribed in 1 hr because the infusion pump was set incorrectly. Data collection reveals that the client is stable. This incident does not meet the criteria of malpractice because
The client was not harmed as a result of the incident
A nurse is reinforcing teaching with a client who is undergoing chemotherapy to treat laryngeal cancer and has developed mucositis. Which of the following client statements indicates an understanding of the teaching?
“I will rinse my mouth with room-temperature saline solution”
A nurse is caring for a toddler who is admitted to the pediatric unit and is 2 hr postoperative following a tonsillectomy. Which of the following findings is a sign of hemorrhage?
Frequent swallowing
A nurse is caring for an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?
Absence of menses.
Elevated blood pressure.
A nurse has administered cephalexin (Keflex) to a client. Which of the following is the earliest indicator of an anaphylatic reaction?
Wheezes.
Hypotension.
A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention?
Place the client in a room that is ventilated to the outside
A nurse is providing change-of-shift report on four clients. Which of the following is most important for the nurse to include in the report?
A client had a blood glucose of 140 mg/dL
A nurse is caring for a client who has an order for NPH insulin (Humulin N) 10 units and regulat insulin (humulin R) 15 units SQ. Which of the following actions should the nurse perform first?
Inject 10 unites of air into the NPH insulin vial
A nurse discovers a fire in the trash can of a client’s room. Which of the following actions should the nurse take first?
Escort the client to a secure area
A client has a large, deep ulcer on her right hip. The primary care provider has prescribed a woman vacuum to be applied. Which of the following is an appropriate nursing action?
Maintain hydrophillic material deep into the ulcer
A nurse is reinforcing teaching to a client who has been taking dig 0.25 mg PO daily for 6 months, which of the following indicates a need for further teaching?
I will call my provider if I experience a yellow tinge to my vision
A nurse receives a verbal order for a client to receive a stat dose of meperidine (demerol) 100 mg PO. She administers the medication, charts the administration, and then realizes she has administered Phenytoin (dilantin) 100 mg PO. After obtaining the client’s vital signs, which of the following actions should the nurse take?
Notify the provider
A nurse is administering medication to a client. Which of the following actions is appropriate for the nurse to take?
Verify with another nurse when calculating a new dose of medication
A nurse is reinforcing discharge teaching to a client who is prescribed propylthiuracil. For which of the following should the nurse instruct the client to monitor and report to the provider immediately?
Sore throat
A nurse is reinforcing foot care to a client with diabetes mellitus. Which of the following clients’ statements indicate to the nurse a need for further teaching?
“I will soak my feet in warm water every night”
A nurse is caring for a client who has heart failure and is taking furosemide (lasix). Which of the following statements made by the client indicates a need for the nurse to intervene?
“I have to sleep sitting up”
A nurse is reinforcing teaching to a client who has a new prescription for transdermal nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands the teaching?
“I will leave the patch on for 12 to 14 hours each day”
A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300mg with codeine 30 mg (Tylenol #3), 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper place to document this error?
Incident report
A nurse is caring for a client in a mental health unit who is pacing back and forth and wringing his hands. Which of the following interventions should the nurse implement?
Take the client for a walk to the recreation room
A nurse is caring for a client who is in bed and experiencing a toni-clonic seizure. Which of the following actions should the nurse take?
Place the bed in the lowest position
A nurse is preparing to irrigate a wound of a client who has methicillin-resistant Staphylococcus aureus (MRSA).The nurse should use which of the following personal protective equipment?
A face shield
A nurse is collecting data for a client who has been recieving medroxyprogesterone acetate (Depo- Provera) for the past 6 months. Which of the following statements made by the client should be reported to the provider?
“I’m experiencing calf pain”
A nurse is reinforcing teaching with a new mother regarding the use of breast milk. Which of the following statements by the mother indicates an understanding of the teaching?
“I can store my breast milk in the freezer for up to 6 months”
A nurse in a long-term care facility is caring for a client who has spinal cord injury. The client is demonstrating manifestations of autonomic dysreflexia. Which of the following actions should the nurse take first?
Check the client for bladder distention.
Loosen the client’s clothing.
A nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the following food choices should indicate that the client understands the teaching?
Skim milk
A nurse is caring for a client who has a new mastectomy. Which of the following statements by the client should indicate to the nurse that the client is beginning to cope with the changes in her body image?
I am afraid to discuss my concerns with my husband
A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?
Establish a daily exercise routine
What can be delegated to Assistive personnel (AP)?
- ADLs – bathing – grooming – dressing – ambulating – feeding (w/o swallow precautions) – positioning – bed making – specimen collection – I&O – VS (stable clients
A nurse on a med surge unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP?
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk with a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
C
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP?
Select all:
A. the roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
E. The client is allergic to codeine
F. the client ate 50 % of his breakfast this morning
B
C
D
An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
A. Assisting a client who is 24 hr postop to use an incentive spirometer
B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift
C. providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
D
A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all:
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances
B
C
E
A nurse manager of a med surge unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client?
A. Charge nurse
B. RN
C. LVN
D. AP
B
What is the study of conduct and character?
Ethics
What are the values and beliefs that guide behavior and decision making?
Morals
What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest
Autonomy
What are positive actions to help others
Beneficience
What is an agreement to keep promises
Fidelity
What is fairness in care delivery and use of resources
Justice
What is avoidance of harm or injury
Non-maleficence
A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificience
A
A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficience
D
A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
C
A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificence
D
Which of the following situations can be identified as an ethical dilemma?
A. A nurse on a med surge unit demonstrates signs of chemical impairment
B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him
C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill
D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form
C
Most managers can be categorized as
authoritative, democratic, and laissez faire
makes decisions of the group
motivates by coercion
communication occurs down the chain of command
Work output by the staff is usually high-good for crisis situations and bureaucratic settings
Authoritative
includes the group when decisions are made
Motivates by supporting star achievements
Communication occurs up and down the chain of command
Work output by staff is usually of good quality-good when cooperation and collaboration is necessary
Democratic
makes very few decisions and does little planning
motivation is largely the responsibility of individuals staff members
Communication occurs up and down the chain of command and between group members
Work output is low unless an informal leader evolves from the group
*the use of any of these styles may be appropriate depending on the situation
Laissez faire
The nurse should consider the hierarchy of human needs when prioritizing interventions, which are?
- Physiological needs first (oxygen, shelter, food)
- Safety & security needs (physical safety)
- Love and belonging
- Self esteem
- Self actualization
The ABC framework identifies, in order, the three basic needs for sustaining life
Airway
Breathing
Circulation
Nurses must follow what code of standards in delegating and assigning tasks
ANA codes of standards
What values would a nurse possess to be a client advocate?
- caring
- autonomy
- respect
- empowerment
What do the nurse need to keep in mind about the client when being their advocate?
Client’s religion & culture
When should planning discharge process begin?
a. at time of admission
b. 2 days after client is admitted
c. whenever the nurse has the time to do planning
d. when the physician has the discharge order
A
What is an interdisciplinary team?
A group of health care professionals from different disciplines
Fill in the blank:
- is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. _, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone.
1 & 2 = collaboration
What is the nurse’s contribution to an interdisciplinary team?
- knowledge of nursing care & its management
- a holistic understanding of the client, her/his healthcare needs & healthcare systems.
A four-month-old infant is admitted to the pediatric intensive care unit
with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse
observes nuchal rigidity. Which assessment finding would indicate an
increase in intracranial pressure?
- Positive Babinski.
- High-pitched cry.
- Bulging posterior fontanelle.
- Pinpoint pupils.
2
A client is receiving total parenteral nutrition (TPN). To determine the
client’s tolerance of this treatment, the nurse should assess for which of the
following?
- A significant increase in pulse rate.
- A decrease in diastolic blood pressure.
- Temperature in excess of 98.6°F (37°C).
- Urine output of at least 30 cc per hour.
4
The client is exhibiting symptoms of myxedema. The nursing
assessment should reveal
- increased pulse rate.
- decreased temperature.
- fine tremors.
- increased radioactive iodine uptake level.
2
A nonstress test is scheduled for a client at 34-weeks gestation who
developed hypertension, periorbital edema, and proteinuria. Which of the
following nursing actions should be included in the care plan in order to
BEST prepare the client for the diagnostic test?
- Start an intravenous line for an oxytocin infusion.
- Obtain a signed consent prior to the procedure.
- Instruct client to push a button when she feels fetal movement.
- Attach a spiral electrode to the fetal head.
3
Which of the following nursing interventions is MOST important for a
45-year-old woman with rheumatoid arthritis?
- Provide support to flexed joints with pillows and pads.
- Position her on her abdomen several times a day.
- Massage the inflamed joints with creams and oils.
- Assist her with heat application and ROM exercises.
4
The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient
- with his neck in a midline position and the head of the bed elevated 30°.
- side-lying with his head extended and the bed flat.
- in high Fowler’s position with his head maintained in a neutral position.
- in semi-Fowler’s position with his head turned to the side.
1
The nurse is teaching a 40-year-old man diagnosed with a lower motor
neuron disorder to perform intermittent self-catheterization at home. The
nurse should instruct the client to
- use a new sterile catheter each time he performs a catheterization.
- perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization.
- perform the catheterization procedure every 8 hours.
- limit his fluid intake to reduce the number of times a catheterization is needed.
2
A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
- take the medication five minutes after the pain has started.
- stop taking the medication if a stinging sensation is absent.
- take the medication on an empty stomach.
- avoid abrupt changes in posture.
4
A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if
found by the nurse at the patient’s bedside, is nonessential?
- Potassium chloride for IV administration.
- Calcium gluconate for IV administration.
- Tracheostomy set-up.
- Suction equipment.
1
A nurse recognizes that an initial positive outcome of treatment for a
victim of sexual abuse by one parent would be that the client
- acknowledges willing participation in an incestuous relationship.
- reestablishes a trusting relationship with his/her other parent.
- verbalizes that s/he is not responsible for the sexual abuse.
- describes feelings of anxiety when speaking about sexual abuse.
3
An adolescent client is ordered to take tetracycline HCL (Achromycin)
250 mg PO bid. Which of the following instructions should be given to this
client by the nurse?
- “Take the medication on a full stomach, or with a glass of milk.”
- “Wear sunscreen and a hat when outdoors.”
- “Continue taking the medication until you feel better.”
- “Avoid the use of soaps or detergents for two weeks.”
2
After a client develops left-sided hemiparesis from a cerebral vascular
accident (CVA), there is a decrease in muscle tone. Which of the following
nursing diagnoses would be a priority to include in his care plan?
- Alteration in mobility related to paralysis.
- Alteration in skin integrity related to decrease in tissue oxygenation.
- Alteration in skin integrity related to immobility.
- Alteration in communication related to decrease in thought processes
2
A client has a history of oliguria, hypertension, and peripheral edema.
Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be
restricted in the client’s diet?
- Protein.
- Fats.
- Carbohydrates.
- Magnesium.
1
An extremely agitated client is receiving haloperidol (Haldol) IM every
30 minutes while in the psychiatric emergency room. The MOST important
nursing intervention is to
- monitor vital signs, especially blood pressure, every 30 minutes.
- remain at the client’s side to provide reassurance.
- tell the client the name of the medication and its effects.
- monitor the anticholinergic effects of the medication.
1
The nurse is caring for clients in the skilled nursing facility. Which of the
following clients require the nurse’s IMMEDIATE attention?
- A client admitted for a cerebral vascular accident (CVA) whose prescription for
warfarin (Coumadin) expired two days ago. - A client in pain who was receiving morphine in an acute care institution and was
transferred with a prescription for acetaminophen with codeine. - A client who has dysuria and foul-smelling, cloudy, dark amber urine.
- An immunosuppressed client who has not received an influenza immunization.
1
The nurse is observing care given to a client experiencing severe to
panic levels of anxiety. The nurse would intervene in which of the following
situations?
- The staff maintains a calm manner when interacting with the client.
- The staff attends to client’s physical needs as necessary.
- The staff helps the client identify thoughts or feelings that occurred prior to the
onset of the anxiety. - The staff assesses the client’s need for medication or seclusion if other
interventions have failed to reduce anxiety.
3
A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse?
- The client complains of pain during the inflow of the dialysate.
- The client complains of constipation.
- The dialysate outflow is cloudy.
- There is blood-tinged fluid around the intra-abdominal catheter.
3
The clinic nurse is performing diet teaching with a 67-year-old client
with acute gout. The nurse should teach the client to limit his intake of
- red meat and shellfish.
- cottage cheese and ice cream.
- fruit juices and milk.
- fresh fruits and uncooked vegetables.
1
A client is scheduled for a left lower lobectomy. The physician has
ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine
that the medication is appropriate if the client displays which of the
following symptoms?
- Agitation and decreased level of consciousness.
- Lethargy and decreased respiratory rate.
- Restlessness and increased heart rate.
- Hostility and increased blood pressure.
3
A 59-year-old woman with bipolar disorder is receiving haloperidol
(Haldol) 2 mg PO tid. She tells the nurse, “Milk is coming out of my
breasts.” Which of the following responses by the nurse is BEST?
- “You are seeing things that aren’t real.”
- “Why don’t we go make some fudge.”
- “You are experiencing a side effect of Haldol.”
- “I’ll contact your physician to change your medication.”
3
The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for
a client. The nurse should advise the client the BEST time to take this
medication is
- before breakfast.
- with dinner.
- with food.
- at hs.
4
. If a client develops cor pulmonale (right-sided heart failure), the nurse
would expect to observe
- increasing respiratory difficulty seen with exertion.
- cough productive of a large amount of thick, yellow mucus.
- peripheral edema and anorexia.
- twitching of extremities.
3
The nurse is performing triage on a group of clients in the emergency
department. Which of the following clients should the nurse see FIRST?
- A 12-year-old oozing blood from a laceration of the left thumb due to cut on a
rusty metal can. - A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister
but not the place
and time. - A 49-year-old with a compound fracture of the right leg who is complaining of
severe pain. - A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of
470 mg/dL.
2
The nurse in the outpatient clinic teaches a client with a sprained right
ankle to walk with a cane. What behavior, if demonstrated by the client,
would indicate that teaching was effective?
- The client advances the cane 18 inches in front of her foot with each step.
- The client holds the cane in her left hand.
- The client advances her right leg, then her left leg, and then the cane.
- The client holds the cane with her elbow flexed 60°.
2
A client returns to his room following a myelogram. The nursing care
plan should include which of the following?
- Encourage oral fluid intake.
- Maintain the prone position for 12 hours.
- Encourage the client to ambulate after the procedure.
- Evaluate the client’s distal pulses on the affected side.
1
The nurse is caring for a patient following an appendectomy. The patient
takes a deep breath, coughs, and then winces in pain. Which of the
following statements, if made by the nurse to the patient, is BEST?
- “Take three deep breaths, hold your incision, and then cough.”
- “That was good. Do that again and soon it won’t hurt as much.”
- “It won’t hurt as much if you hold your incision when you cough.”
- “Take another deep breath, hold it, and then cough deeply
1
A young woman is transferred to a psychiatric crisis unit with a
diagnosis of a dissociative disorder. The nurse knows which of the following
comments by the client is MOST indicative of this disorder?
- “I keep having recurring nightmares.”
- “I have a headache and my stomach has bothered me for a week.”
- “I always check the door locks three times before I leave home.”
- “I don’t know who I am and I don’t know where I live.”
4
A 23-year-old man is admitted with a subdural hematoma and cerebral
edema after a motorcycle accident. Which of the following symptoms should
the nurse expect to see INITIALLY?
- Unequal and dilated pupils.
- Decerebrate posturing.
- Grand mal seizures.
- Decreased level of consciousness.
4
. The nursing team includes two RNs, one LPN/LVN, and one nursing
assistant. The nurse should consider the assignments appropriate if the
nursing assistant is assigned to care for
- a client with Alzheimer’s requiring assistance with feeding.
- a client with osteoporosis complaining of burning on urination.
- a client with scleroderma receiving a tube feeding.
- a client with cancer who has Cheyne-Stokes respirations.
1
An elderly client is returned to her room after an open reduction and
internal fixation of the left femoral head after a fracture. It is MOST
important for the nursing care plan to include that the client
- eat a high-protein, low-residue diet.
- lie on her unoperated side.
- exercise her arms and legs.
- cough and deep breathe.
4
Which of the following is a correctly stated nursing diagnosis for a client
with abruptio placentae?
- Infection related to obstetrical trauma.
- Potential for fetal injury related to abruptio placentae.
- Potential alteration in tissue perfusion related to depletion of fibrinogen.
- Fluid volume deficit related to bleeding.
4
An 8-year-old client is returned to the recovery room after a
bronchoscopy. The nurse should position the client
- in semi-Fowler’s position.
- prone, with the head turned to the side.
- with the head of the bed elevated 45° and the neck extended.
- supine, with the head in the midline position.
1
Which of the following assessment findings would indicate to the nurse
the need for more sedation in a client who is withdrawing from alcohol
dependence?
- Steadily increasing vital signs.
- Mild tremors and irritability.
- Decreased respirations and disorientation.
- Stomach distress and inability to sleep.
1
The home care nurse is instructing a client recently diagnosed with
tuberculosis. It is MOST important for the nurse to include which of the
following as a part of the teaching plan?
- During the first two weeks of treatment, the client should cover his mouth and
nose when he coughs or sneezes. - It is necessary for the client to wear a mask at all times to prevent transmission of
the disease. - The family should support the client to help reduce feeling of low self-esteem and
isolation. - The client will be required to take prescribed medication for a duration of 6-9
months.
4
The nurse’s INITIAL priority when managing a physically assaultive
client is to
- restrict the client to the room.
- place the client under one-to-one supervision.
- restore the client’s self-control and prevent further loss of control.
- clear the immediate area of other clients to prevent harm.
3
A client with newly diagnosed type I diabetes mellitus is being seen by
the home health nurse. The physician orders include: 1,200-calorie ADA
diet, 15 units of NPH insulin before breakfast, and check blood sugar qid.
When the nurse visits the client at 5 PM, the nurse observes the man
performing a blood sugar analysis. The result is 50 mg/dL. The nurse would
expect the client to be
- confused with cold, clammy skin and a pulse of 110.
- lethargic with hot, dry skin and rapid, deep respirations.
- alert and cooperative with a BP of 130/80 and respirations of 12.
- short of breath, with distended neck veins and a bounding pulse of 96.
1
The nurse is supervising the staff providing care for an 18-month-old
hospitalized with hepatitis A. The nurse determines that the staff’s care is
appropriate if which of the following is observed?
- The child is placed in a private room.
- The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- The staff offers the child french fries and a vanilla milkshake for a midafternoon
snack. - The staff uses standard precautions.
1
When using restraints for an agitated/aggressive patient, which of the
following statements should NOT influence the nurse’s actions during this
intervention?
- The restraints/seclusion policies set forth by the institution.
- The patient’s competence.
- The patient’s voluntary/involuntary status.
- The patient’s nursing care plan.
3
The nurse is caring for an 80-year-old client with Parkinson’s disease.
Which of the following nursing goals is MOST realistic and appropriate in
planning care for this client?
- Return the client to usual activities of daily living.
- Maintain optimal function within the client’s limitations.
- Prepare the client for a peaceful and dignified death.
- Arrest progression of the disease process in the client.
2
A client with a peptic ulcer had a partial gastrectomy and vagotomy
(Billroth I). In planning the discharge teaching, the client should be
cautioned by the nurse about which of the following?
- Sit up for at least 30 minutes after eating.
- Avoid fluids between meals.
- Increase the intake of high-carbohydrate foods.
- Avoid eating large meals that are high in simple sugars and liquids.
4
A nurse is caring for a 37-year-old woman with metastatic ovarian
cancer admitted for nausea and vomiting. The physician orders total
parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of
the following is the BEST indication that the patient’s nutritional status has
improved after 4 days?
- The patient eats most of the food served to her.
- The patient has gained 1 pound since admission.
- The patient’s albumin level is 4.0mg/dL.
- The patient’s hemoglobin is 8.5g/dL.
3
A 23-year-old woman at 32-weeks gestation is seen in the outpatient
clinic. Which of the following findings, if assessed by the nurse, would
indicate a possible complication?
- The client’s urine test is positive for glucose and acetone.
- The client has 1+ pedal edema in both feet at the end of the day.
- The client complains of an increase in vaginal discharge.
- The client says she feels pressure against her diaphragm when the baby moves.
1
After abdominal surgery, a client has a nasogastric tube attached to low
suctioning. The client becomes nauseated, and the nurse observes a
decrease in the flow of gastric secretions. Which of the following nursing
interventions would be MOST appropriate?
- Irrigate the nasogastric tube with distilled water.
- Aspirate the gastric contents with a syringe.
- Administer an antiemetic medicine.
- Insert a new nasogastric tube.
2
After sustaining a closed head injury and numerous lacerations and
abrasions to the face and neck, a five-year-old child is admitted to the
emergency room. The client is unconscious and has minimal response to
noxious stimuli. Which of the following assessments, if observed by the
nurse three hours after admission, should be reported to the physician?
- The client has slight edema of the eyelids.
- There is clear fluid draining from the client’s right ear.
- There is some bleeding from the child’s lacerations.
- The client withdraws in response to painful stimuli.
2
The nurse is caring for a manic client in the seclusion room, and it is
time for lunch. It is MOST appropriate for the nurse to take which of the
following actions?
- Take the client to the dining room with 1:1 supervision.
- Inform the client he may go to the dining room when he controls his behavior.
- Hold the meal until the client is able to come out of seclusion.
- Serve the meal to the client in the seclusion room.
4
A client is given morphine 6 mg IV push for postoperative pain.
Following administration of this drug, the nurse observes the following:
pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the
following nursing actions is MOST appropriate?
- Allow the client to sleep undisturbed.
- Administer oxygen via facemask or nasal prongs.
- Administer naloxone (Narcan).
- Place epinephrine 1:1,000 at the bedside.
3
What type of infectious diseases are required to be reported to the health department?
- severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA)
What is the process of taking a telephone order from a provider?
Patient name, drug, dose, route, frequency
read back for accuracy
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA
a) Place the client in a negative pressure room
b) wear gloves when assisting the client with oral care
c) limit each visitor to 2 hr increments
d) wear a surgical mask when providing care
e) Use antimicrobial sanitizer for hand hygiene
A
B
E
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching?
a) Assign the client to a room with a negative air-flow system
b) Use alcohol-based hand sanitizer when leaving the clients room
c) clean contaminated surfaces in the clients room with a phenol solution
d) have family members wear a gown and gloves when visiting
D
A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?
a) place a warm compress over the IV site
b) record the findings in the client’s chart
c) notify the client’s primary care provider
d) prepare to insert a new IV catheter
A
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client?
a) use a bed exit alarm system
b) raise 4 side rails while client is in bed
c) apply one soft wrist restraint
d) dim the lights in the client’s room
A
A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?
a) implement a regular toileting schedule
b) encourage the client to wear athletic socks when ambulating
c) place all 4 bed rails in the upright position
c) require a family member to remain at the bedside
A
Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?
a) insert the suction catheter while the client is swallowing
b) apply intermittent suction when withdrawing the catheter
c) place the catheter in a location that is clean and dry for later use
d) hold the suction catheter with the clean, non-dominant hand
B
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client’s independence?
a) request an occupational therapy consult to determine the need for assistive devices
b) assign assistive personnel to perform self-care tasks for client
c) instruct the client to focus on gradually resuming self-care tasks
d) ask the client if a family member is available to assist with his care
C
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?
a) serum albumin level of 3 g/dL
b) HDL level of 90 mg/dL
c) Norton scale score of 18
d) Braden scale score of 20
A
A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
a) “I had a bowel movement, but I was able to save the urine”
b) “I have a specimen in the bathroom from about 30 minutes ago”
c) “I flushed what I urinated at 7 am and have saved the rest since”
d) “I drink a lot, so I will fill up the bottle and complete the test quickly”
C
A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance?
a) tap water
b) sterile water
c) 0.9% sodium chloride
d) 0.45% sodium chloride
C
A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching?
a) use the cane on the weak side of the body
b) advance the cane and the atrong leg simultaneously
c) maintain two points of support on the floor
d) advance the cane 30 to 45 cm (12-18 in) with each step
C
Which of the following should indicate to a nurse the need to suction a client’s tracheostomy?
a) irritability
b) hypotension
c) flushing
d) bradycardia
A
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
a) wear sterile gloves when removing the old dressing
b) warm the irrigation solution to 40.5C (105F)
c) cleanse the wound from the center outwards
d) use a 20 mL syringe to irrigate the wound
C
A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid?
a) lemon-lime sports drinks
b) ginger ale
c) black coffee
d) orange sherbet
D
A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take?
a) assess for bladder distention after 6 hr
b) encourage the client to use a bed pan in the supine position
c) restrict the clients intake of oral fluids
d) pour warm water over the clients perineum
D
When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?
- Cancer of any kind.
- Impaired hearing.
- Prescription drug intoxication.
- Heart failure.
3
Which of the following is essential when caring for a client who is experiencing delirium?
- Controlling behavioral symptoms with low-dose psychotropics.
- Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation.
- Decreasing or discontinuing all previously prescribed medications.
2
Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?
- Explain the experience of having delirium.
- Resume a normal sleep-wake cycle.
- Regain orientation to time and place.
- Establish normal bowel and bladder function.
3
A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client’s safety while walking in the halls, the nurse should do which of the following?
- Administer PRN haloperidol (Haldol) to decrease the need to walk.
- Assess the client’s gait for steadiness.
- Restrain the client in a geriatric chair.
- Administer PRN lorazepam (Ativan) to provide sedation.
2
During a home visit to an elderly client with mild dementia, the client’s daughter reports that she has one major problem with her mother. She says, “She sleeps most of the day and is up most of the night. I can’t get a decent night’s sleep anymore.” Which suggestions should the nurse make to the daughter? Select all that apply.
- Ask the client’s physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.
- Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.
- Promote relaxation before bedtime with a warm bath or relaxing music.
- Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.
2
3
4
The physician orders risperidone (Risperdal) for a client with Alzheimer’s disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?
- Sleep disturbances.
- Concomitant depression.
- Agitation and assaultiveness.
- Confusion and withdrawal.
3
The nurse is making a home visit with a client diagnosed with Alzheimer’s disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider?
- Paradoxical excitement.
- Headache.
- Slowing of reflexes.
- Fatigue.
1
When providing family education for those who have a relative with Alzheimer’s disease about minimizing stress, which of the following suggestions is most relevant?
- Allow the client to go to bed four to five times during the day.
- Test the cognitive functioning of the client several times a day.
- Provide reality orientation even if the memory loss is severe.
- Maintain consistency in environment, routine, and caregivers
4
What are some ways to identify a patient before giving a medication?
The Joint Commission requires 2 client identifiers be used when administering medications.
- clients name
- assigned identification number
- telephone number
- birth date or other personal-specific identifiers. Bar code scanners may be used to identify clients
What are some things to teach about home safety with elderly patients?
- Removing items that could cause the client to trip, such as throw rugs and loose carpets
- Placing electrical cords and extension cords that against a wall behind furniture
- Making sure that steps and sidewalks are in good repair
- Placing grab bars near the toilet and in the tub or shower and installing a stool riser
- Using a non-skid mat in the tub or shower
- Placing a shower chair in the shower
- Ensuring that lighting is adequate both inside and outside of the home
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in
his home. Which of the following should the nurse teach the client about using oxygen safely in his
home? (Select all that apply.)
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen.
C. A “No Smoking” sign should be placed on the front door.
D. Cotton bedding and clothing should be replaced with items made from wool.
E. A fire extinguisher should be readily available in the home.
B
C
E
A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk
with the appropriate instruction.
_ Passive smoking Carbon monoxide poisoning
___ Food poisoning
A. Have water heaters inspected on an annual
basis.
B. Cook all meat at an appropriate temperature.
C. Avoid enclosed areas with others who may be
smoking.
C
A
B
When performing nasotracheal suctioning what technique should be used?
Sterile asepsis bc the trachea is considered sterile and prevents infections
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
A
What do you do when a client has a seizure
- lower to bed/floor
- protect head, move nearby furniture, provide privacy, – – put on side with head flexed slightly forward, and loosen clothing to prevent injury
-in event of seizure, stay with client and call for help
-admin meds as ordered
-note duration of seizure and sequence and type of movement
seclusion and restraints
-must be ordered
-should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient
-a client may voluntarily request temp seclusion
-restraints can be physical or chemical
-if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min
What position is good to use for a patient who is at high risk for a pressure ulcer
30 degree lateral position is recommended for clients at risk for pressure ulcers
health promotion (injury prevention-suffocation): infant (birth-1 yr)
-avoid plastic bags
-keep balloons out of reach
-ensure crib mattress fits snugly
-ensure crib slats are no more than 6 cm (2.4 in) apart
-remove crib mobiles and gyms by 4-5 months
-do not use pillows in crib
-place infant on back for sleep
-keep toys with small parts out of reach
-remove drawstrings from jackets and other clothing
hypotension is classified with a reading below normal;
systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation
What temperature should pork be cooked at
160 degrees
What is the safest way to thaw out frozen foods
In the refrigerator
What are the precautions for vancomycin resistant enterococcus
Standard precautions including hand washing and gloving should be followed
What does a newborns poop look like
If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency
What is appropriate for an adolescent in the hospital?
Puzzles and books
What is the proper nutrition during pregnancy
- Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida
- green leafy vegetables and brown rice
What should be avoided during pregnancy
Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby
What is the most appropriate method for contraception for an adolescent
IUD or implant
If a patient has anorexia nervosa and works out constantly
Allow them to workout and continue their regimen
What medications can be taken to help with smoking cessation
Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a generic. Varenicline (chantix)
What are the five stages of grief
denial
anger
bargaining
depression
acceptance
discrete and applies the letting go of an object or person before the loss as in the case of terminal illness
individuals have the opportunity to greet before the actual loss
anticipatory grief
involves difficult progression through the expected stages of the grieving process
grief work is prolonged and manifestations more severe
client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem
somatic complaints persist for an extended period of time
dysfunctional grief
Signs for meningococcemia
Vomiting, febrile, petechial rash
(unstable)
Levothyroxine effects
Used to restore client’s metabolic rate
- Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension
Multiple Sclerosis Patient
Mitoxantrone SE’s Mitoxantrone IV every 3 months (chemo drug)
- Report Sore Throat
(greatest risk for client is severe infection due to myelosuppression from mitoxantrone) - Vomiting = causes dehydration
- Hair Loss = emotional distress
- Amenorrhea = emotional distress
Malnourished COPD patients
(1) Limit liquid intake at meal times
(2) Consume foods w/ protein (like eggs)
(3) Maintain an upright position (High Fowler’s position) to promote ventilation
(4) Use milk instead of water when making soup
Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others
“I don’t deserve to die, this isn’t fair”
Anger stage
Which Grief Process when Client acknowledges the impending loss while remaining hopeful
“If I could just make it through this, I’d never smoke again”
Bargaining Stage
How should you respond when client wants to discontinue dialysis
“What has changed to make you decide this?”
= Seek clarification from client to establish mutual understanding while staying therapeutic
What should the nurse do when one member of a support group expresses anger repeatedly?
Focus more on the group members who have a positive outlook
(Speak to group member privately to uncover source of anger)
What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given?
Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella)
Should give = TDaP (Tetanus, Diphtheria, Pertussis)
Long term effects of NSAIDS (Ibuprofen)
Gastric Ulcerations, perforations, hemorrhage, hypertension
Alcohol Use Manifestations of Withdrawal
Body burns 0.5 oz of alcohol per hour
- Withdrawal appears within 4-12 hours
- Irritability + Tremors + Anxiety
- Nausea + Vomiting + HA
- Diaphoresis
- Sleep Disturbances
- TACHYCARDIA + HTN
Use Benzodiazepines = tx
Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium)
When does Discharge planning begin?
At Admission
Case Management nursing involves:
*Decreasing cost by improving client outcomes
- Providing education to optimize health participation
- Advocating for services + client’s rights
What is bipolar disorder?
Bipolar disorder is a mood disorder with recurrent episodes of depression and mania.
What comorbidities may be observed with a patient who is bipolar?
Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD.
What therapy will be useful for patients with bipolar?
Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior.
What kind of medications are indicated for abstinence maintenance of alcohol?
Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)
Teaching points for naltrexone (Vivitrol)?
Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen.
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
a) restrict fluid intake to 1 qt (1,000 ml)/day.
b) drink liquids only between meals.
c) don’t drink liquids 2 hours before meals.
d) drink liquids only with meals.
B
A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient?
a) Instruct the patient to keep a record of food intake
b) Instruct the patient to avoid prune or apple juice
c) Suggest fluid intake of at least 2 L per day
d) Assist the patient regarding the correct diet or to minimize food intake
C
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?
a) Left lower quadrant
b) Left upper quadrant
c) Right upper quadrant
d) Right lower quadrant
D
Which outcome indicates effective client teaching to prevent constipation?
a) The client reports engaging in a regular exercise regimen.
b) The client limits water intake to three glasses per day.
c) The client verbalizes consumption of low-fiber foods.
d) The client maintains a sedentary lifestyle.
A
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia?
a) Hypotension
b) Bradycardia
c) Warm moist skin
d) Polyuria
A
The nurse is assessing a client with a bleeding gastric ulcer. When examining the client’s stool, which of the following characteristics would the nurse be most likely to find?
a) Green color and texture
b) Black and tarry appearance
c) Clay-like quality
d) Bright red blood in stool
B
After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected?
a) Large intestine
b) Ileum
c) Stomach
d) Liver
C
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
a) Skim milk
b) Nothing by mouth
c) Regular diet
d) Clear liquids
B
Bladder retraining for the treatment of urge incontinence:
- Use timed voidings to increase intervals between voidings/decrease voiding frequency.
- Perform pelvic floor (Kegel) exercises.
- Perform relaxation techniques.
- Offer undergarments while the client is retraining.
- Teach the client not to ignore the urge to void.
- Provide positive reinforcement as client maintains continence.
- Eliminate or decrease caffeine drinks.
- Take diuretics in the morning.
what are normal creatinine levels?
what are normal BUN levels?
0.8-1.4 mg/dL
8-25 mg/dL
What are total serum protein values (normals)
6-8 g/dL
Describe pre-albumin
this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin’s half-life is 2-3 weeks)
what is normal pre-albumin values?
what are normal serum levels of magnesium ?
what is a normal potassium serum level?
17-40 mg/dL
1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia)
3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia)
what are good sources of folic acid?
Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf’s liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils.
Sources of potassium
beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas
what is important about the diet of someone taking ACE inhibitors?
can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas)
Taking Coumadin. Which foods should the client limit?
Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes
what is a normal hematocrit level in a female?
What are normal Hgb values (female)?
what are normal values for WBCs?
37-48% (male is 42-52%)
12-16 g/dL (male 13-17)
4500-11,000 / uL
what foods should you avoid if you have diverticulitis?
avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber)
When taking MAOI’s, limit your consumption of
thyramine–it can cause elevated BP. This is found in “aged” products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce…Examples of MAOI’s are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar…
At what age does bone loss begin with osteoporotis
what are normal Calcium levels?
at age 35 (women)
8.6-10 mg/dL
A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of
calcium gluconate (because hypocalcemia causes Chvostek’s sign)
What are the S/S of lithium toxicity?
(depakote for bipolar disorder)
fine hand tremors, mild GI upset, slurred speech and muscle weakness
a nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin) . which of the following over the counter medication should the nurse instruct the client to avoid
Aspirin
a nurse responsible for a client receiving a antihypertensive medication is to
teach the client to change position slowly to avoid dizziness or fainting
a client should receive a dose of flumazenil ( romazicon) to treat symptoms of
benzodiazepine overdose
a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teaching
I will tell my doctor before I stop taking the medication
a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include
- change position slowly to minimize dizziness
- chewing sugarless gum to prevent dry mouth
a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid ibuprofen. why or why not ?
what , if any is the appropriate action for the nurse to take NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should notify the provider of client headache and ibuprofen us
a client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medication
thrombocytes, amylase count and liver function test
alcohol withdrawal
heroin withdrawal
nicotine withdrawal
alcohol abstinence
opioid over dose
chlordiazeproxide( Librium)
methadone( dolophine)
bupropion ( wellbutrin)
disulfiram ( antabuse)
naloxone (narcan)
a client who has parkinson’s disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for which of the following should the nurse monitor this client
orthostatic hypotension
a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV) . for what adverse effect should the nurse monitor this client
the nurse should monitor the client respiratory depression
a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider
serum potassium 5.2
a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at risk
Toxic level of digoxin
a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching
i should decrease the amount of calcium in my diet while taking the medication
A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity?
- Verapamil (Calan)
Adverse effect of Verapamil
Avoid grapefruit juice
Interaction of diuretics and ACE inhibitors
excessive reduction in blood pressure and symptomatic hypotension or hyperkalemia
What can prevent MI, stroke, or death in high-risk patients
Ramipril
What to monitor for when taking enoxaparin (lovenox)
Hyperkalemia
Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported
What are the therapeutic effects of protamine
Antidote to severe heparin overdose + Reversal of heparin administered during procedures
How to prevent adverse effects of oxycodone
can cause respiratory depression.
What is the nursing intervention and/or client education ? Monitor vital signs.
› Stop opioids for respiratory rate less than 12/min, and notify the provider.
› Have naloxone and resuscitation equipment available.
› Avoid use of opioids with CNS depressant medications (barbiturates,
benzodiazepines, consumption of alcohol).
opioid agonists can cause Constipation
What is the nursing intervention and/or client education ?
Advise the client to increase fluid/fiber intake and physical activity.
› Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract
decreased bowel motility, or a stool softener such as docusate sodium (Colace)
to prevent constipation.
Adverse effects of ferrous sulfate
constipation;
upset stomach;
black or dark-colored stools; or.
temporary staining of the teeth.
Baclofen (Lioresal) therapeutic outcome:
Decrease the frequency and severity of muscle spasms (MS).
What is the difference between respiratory acidosis and respiratory alkalosis?
Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45.
Bowel elimination how to get a specimen collection
Collect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine.
Identifying manifestations of transient ischemic attacks
symptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke.
Musculoskeletal congenital disorders
Monitor skin for breakdown areas and prevent pressure sores.
The nurse caring for a child in Buck’s skin traction will keep the:
Child pulled up in bed
Where should the cath bag be placed when urinary catheterization
Make sure the catheter bag/system is at a level below the client’s bladder to avoid reflux.
What are the signs and symptoms of fluid volume deficit
loss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension.
What is the nursing action for dehiscence
Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler’s .