401-500 Flashcards
A Native-American male client diagnosed with pneumonia states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed?
Participated actively in all treatments regimens
A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client’s admission prescription include radiation therapy. What action should the nurse implement?
Ask the client about his expected goals for the hospitalization
A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results show that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?
Observe rhythm on telemetry monitor
A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
Last menstrual period was 7 weeks ago
A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only
7
The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?
Oral temperature of 100.6 F
A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse?
Chest discomfort one hour after consuming a large, spicy meal
The nurse is planning to assess a client’s oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and thready. What action should the nurse take?
Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading
A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult. Which response is best for the nurse to provide?
Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?
Overlook the client’s behavior
A client is discharged with automated peritoneal dialysis (PD) to be used nightly. Which instructions should the nurse include?
Wash hands before cleaning exit site
The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse?
Picking up the second glove
A male client reports to the clinic nurse that he hasn’t been feeling well and is often “dizzy.” His blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition?
Stroke
The nurse ask the parent to stay during the examination of a male toddler’s genital area. Which intervention should the nurse implement?
Examine the genitalia as the last part of the total exam
The nurse is changing a client’s IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is….which action should the nurse take to ensure adequate filling of the drip chamber?
Compress the drip chamber
An insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar…in addition to the client’s glucose, which laboratory value is most important for the nurse to monitor?
Serum potassium
A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?
Altered consciousness within the first 24 hours after injury.
In planning strategies to reduce a client’s risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?
Infectious process
A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?
The family reports a great reduction in client’s maniac behavior
Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm?
Assess IV site frequently for signs of extravasation
A client with a serum sodium level of 125 mEQ/mL should benefit most from the administration of which intravenous solution?
0.9% sodium chloride solution (normal saline)
A client with Alzheimer’s disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse?
Left forearm hematoma
The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately?
Headache, photophobia, and nuchal rigidity
An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?
Nausea and projectile vomit
After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client’s superior vena cava. Which action should the nurse implement?
Initiate intravenous fluid as prescribed
The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?
Participation of community leaders in planning the program
The home care nurse provides self-care instruction for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instructions should the nurse include in the client’s discharge teaching plan? Select all that apply.
1) Avoid prolonged standing or sitting
2) Use recliner for long period of sitting
3) Continue wearing elastic stocking
The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?
Muscle spasms of the back and neck
A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first?
Determine the client’s responsiveness and respirations
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?
The client has asymmetrical chest wall expansion
A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?
1000 units/hour
The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client’s discharge teaching plan?
Monitor for an elevated temperature
The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman’s risk for developing osteoporosis?
20 pack-year history of cigarette smoking
A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement?
Determine current sexual practice
The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider?
Elevated liver function tests
A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
Auscultated bilateral breath sounds
The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer’s disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?
Affirm that the UAP is using and effective strategy to reduce the client’s anxiety.
An older female who ambulates with a quad-cane prefers to use a wheelchair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply)
1) Move personal items within client’s reach
2) Lower bed to the lowest possible position
3) Give directions to call for assistance
4) Assist client to the bathroom in 2 hours.
In evaluating the effectiveness of a postoperative client’s intermittent compression devices, which assessment is most important for the nurse to complete?
Observe both lower extremities for redness and swelling
A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).
0.4
