1 Flashcards
A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions?
A. A client who has scabies
B. A client who has pertussis
C. A client who has streptococcal pharyngitis
D. A client who has measles
4
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (sata)
A. Keep the client’s room dark at night
B. Teach the client to use the call light
C. Keep the client’s bed int he lowest position
D. Place a fall risk identification band on the clients wrist
E. Assess the client every 4 hrs
bcd
A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values?
A. Potassium levels are increased in clients who have polyuria
B. Specific gravity is decreased in clients who have hypovolemia
C. BUN is decreased in clients who have dehydration9
D. Creatinine levels are increased in clients who have kidney injury.
d
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?
125
A nurse is preparing to administer antibiotic X over 20 min. Available is antibiotic X in 50mL of 0.9% sodium chloride (NSS). The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
50
A nurse is preparing to administer ceftriaxone 1 g via intermittent IV bolus over 30 min. Available is 1 g ceftriaxone sodium in 100mL dextrose 5% in water. The nurse set the pump to deliver how many mL/hr?
200
A nurse is preparing to administer dextromethorphan 30mg PO. The amount available is dextromethorphan oral liquid 7.5 mg/5mL. How many mL should the nurse administer?
20
A nurse is preparing to administer valproic acid 400 mg PO bid for migraine headaches. Available is valproic acid 250 mg/5mL. How many mL should the nurse administer per dose?
8
nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?
Protein in the urine
Dehydration
Iron deficiency
Obesity
b
A nurse is caring for a client receiving hemodialysis for kidney disease. The nurse should monitor the client for which complication?
A. Peritonitis
B. Hepatitis B
C. Renal calculi
D. Bladder infection
b
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
A. Urinary retention
B. Low back pain
C. Incontinence
D. Confusion
d
The laboratory values of a client with renal calculi reveal a serum calcium within expected limits and an elevated serum purine. How should the nurse interpret these findings about the stone’s composition?
A. It contains cysteine
B. It contains uric acid
C. It contains calcium oxalate
D. It contains magnesium ammonium phosphate
b
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?
A. Pouring warm water over the perineum
B. Ensuring the patency of the catheter
C. Removing the catheter within 24 hours
D. Cleaning the catheter insertion site
c
The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inch(es)?
A. 2 inches
B. 1 inch
C. ¾ inch
D. 3 inches
a
The nurse performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how many seconds to the child?
A. 6-8
B. 8-10
C. 10-12
D. 12-14
A
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?
A. Ask the x-ray technician to come to the client’s room to obtain a portable x-ray
B. Have the client wear a mask
C. Notify the x-ray department that the client requires airborne precautions
D. wear a filtration mask and gloves during transport
B
A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated?
A. Identify absence of pulse
B. Give two rescue breaths with CPR mask
C. Perform the head tilt chin lift maneuver
D. Perform chest compression at a rate of 100/min
D
Hot Spot: A nurse arrives at the scene of an accident and finds a 5-month-old infant unconscious. After performing the initial steps of cardiopulmonary resuscitation (CPR), the nurse plans to locate the infant’s pulse. Which pulse site in the accompanying figure should be palpated?
Brachial artery
Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse’s first intervention?
A. Treat the victim for shock
B. Start rescue breathing immediately
C. Apply surface pressure to the foot wound
D. Safely remove the victim from the immediate vicinity
D
The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions, the nurse compresses at least how many times?
A. 60 times per minute
B. 80 times per minute
C. 100 times per minute
D. 160 times per minute
c
The nurse performing rescue breathing on a 30 year old male. The nurse delivers one breath per how many seconds to the child?
A. 6-8
B. 8-10
C. 10-12
D. 12-14
c
A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine?
A. Clarity
B. Viscosity
C. Glucose level
D. Specific gravity
a
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse takes to decrease the risk of transmission to others?
A. Insert a urinary catheter
B. Initiate droplet precautions
C. Move the client to a private room
D. Use a high-efficacy particulate air (HEPA) respirator during care
C
A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sim’s position, receiving oxygen at 2 L/ min via nasal cannula. Which action should the nurse take first?
A. Raise the client to a high fowler position
B. Obtain the apical pulse and blood pressure
C. Call the primary healthcare provider immediately
D. Monitor the pulse oximeter to ascertain the oxygen level
A
A client reports severe pain 2 days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?
A. Encourage Rest
B. Obtain vital signs
C. Administer the prescribed analgesic
D. Document the clients pain response
B
During the postoperative period after surgery for a kidney transplant, the client’s creatinine level is 3.1 mg/dL (260 mmol/L). What should the nurse do first in response to this laboratory result?
A. Notify the primary healthcare provider
B. Obtain current blood test results
C. Assess for decreased urine output
D. Check the intravenous (IV) infusion
C
A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. Which factors does the nurse determine were the most likely cause of the hyponatremia? (sata)
A. Diabetes insipidus
B. Profuse diaphoresis
C. Excess sodium intake
D. Removal of parathyroid glands
E. Rapid intravenous (IV) infusion of 5% dextrose in water
BE
A client’s serum potassium level is below the normal range. Which clinical indicators should the nurse determine are consistent with hypokalemia? (sata)
A. Abdominal cramping
B. Tall, peaked T wave
C. Irregular heart rate
D. Muscular weakness
E. Decreased bowel sounds
F. Hyperactive deep tendon reflexes
ACDE
A client’s parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery?
A. Constipation
B. Muscle spasms
C. Hypoactive reflexes
D. Increased specific gravity
B
A nurse anticipates that dialysis will be necessary for a patient with chronic kidney disease when the patient begins to exhibit which symptom?
A. Hypotension
B. Hypokalemia
C. Hypervolemia
D. Hypercalcemia
C
After the nurse provides education about hydrochlorothiazide, the client will agree to notify the healthcare provider regarding the development of which symptom?
A. Insomnia
B. Nasal Congestion
C. Increased thirst
D. Generalized weakness
D
A client with the diagnosis of Cushing syndrome has the following laboratory results: Na+ (sodium) 149 mEq/L (149mmol/L); K+ (potassium) 3.2 mEq/L; Hb (hemoglobin) 17 g/dL (170 mmol/L); and glucose 90 mg/dL (5 mmol/L). What should the nurse teach the client? (sata)
A. Avoid foods high in salt
B. Restrict your fluid intake
C. Eat foods high in potassium
D. Limit your carbohydrate intake
E. Continue your regular diet as before
AC
The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority. Which condition is affecting the client?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypernatremia
A
Which client should a nurse consider the greatest risk for developing hypernatremia?
A. 52-year-old who is receiving 0.45% NaCl intravenously
B. 76-year old who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a result of head trauma
C. 63-year-old who has had watery diarrhea since traveling abroad
D. 48-year-old who is admitted with a diagnosis of Addison’s disease
C
The healthcare team is conducting a physical assessment of a client. What are the priorities to assess during the breathing component?(SATA)
A. Observe for chest trauma
B. Establish a patient airway by positioning
C. Evaluate the client’s level of consciousness
D. Assess breath sounds and respiratory effort
E. Remove all clothing for a complete assessment
AD
A client with a head injury underwent a physical examination. The nurse observes that the client’s temperature assessments do not correspond with the client’s condition. An injury to which part of the brain may be the reason for this condition?
A. Pons
B. Medulla
C. Thalamus
D. Hypothalamus
D
The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment?
A. Determining drug allergies
B. Noting the general appearance
C. Examining the neck for stiffness
D. Auscultating for heart and lung sounds
A
The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant when?
A. First
B. Second
C. Third
D. Last
D
A disturbed client is brought to the emergency department by the police. What should be included in the nurse’s initial mental assessment?
Recollection of past events
Previous methods of coping with stress
Current behavior, cognitive function, and orientation
Cultural background, developmental level, and verbal skills
C
A client is brought to the emergency department after an automobile collision. The client’s blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client?
Warm, flushed skin
Increased pulse pressure
Lethargy with confusion
Reduced peripheral pulses
D
Which component of delegation is retained while the delegator is delegating the client’s care task to the nursing aide?
Authority
Supervision
Responsibility
Accountability
D
A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAP). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy?
It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration
It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine
It decreases the need for immobility, because it clears toxins in short and intermittent periods
It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion
D
A client on peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution, what should the nurse do?
Increase the rate of infusion
Auscultate the lungs for breath sounds
Place the client in a low-fowler position
Drain the fluid from the peritoneal cavity
D
. client is to have hemodialysis. What must the nurse do before this treatment?
Obtain a urine specimen to evaluate kidney function
Weigh the client to establish a baseline for later comparison
Administer medications that are scheduled to be given within the next hour
Explain that the peritoneum serves as a semipermeable membrane to remove wastes
B
When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do?
Drink a glass of water
Turn from side to side
Deep breathe and cough
Rotate the catheter periodically
B
A nurse is performing peritoneal dialysis for a client. Which action should the nurse take?
the client in a side-lying position
Warm the dialysate solution slightly before installation
Infuse the dialysate solution quickly over 5 to 10 minutes
Withhold the routine medications until after the procedure
B
What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection?
Originated primarily from an exogenous source
Is associated with drug resistant microorganism
Occurred in conjunction with treatment for an illness
Still has the infection despite completing the prescribed therapy
C
Which action performed by the nursing student during the chest examination of a client needs correction?
Placing the stethoscope over bony prominences
Palpating two ribs inferiorly in the midaxillary line
Dividing the anterior and posterior lungs into thirds
Listening to at least one cycle of inspiration and expiration
A
