exam 3

Question 1

The nurse cares for a pt with stage IV cervical cancer receiving chemo. The client states “I don’t want chemotherapy anymore but my children isist I keep going” What role will the nurse be acting for this client after her comment

Answer 1

The role of patient advocate

Question 2

A nurse is caring for a pt receiving an arthroscopy what post op information will the nurse give

Answer 2

Inspect your incision daily
Apply ice packs to the area for the first 24 hrs
Perform isometric exercises

Question 3

Seizure interventions

Answer 3

Time the seizure
stay with child
move furniture away

Question 4

The nurse is caring for a pt who begins to experience seizure activity while in bed. Which action should the nurse take

Answer 4

Loosen restrictive clothing
removing pillow and raising padded side rails
positioning the pt to the side with head flexed forward

Question 5

The nurse is instituting seizure precautions for a pt being admitted from the emergency room. Which measures should the nurse include in planning for the pts safety

Answer 5

Padding the side rails of the bed
Placing an airway at the bedside
Placing oxygen and suction equipment at the bedside
Flushing the IV catheter to ensure the site is patent

Question 6

A nurse is providing discharge teaching to parents whose infant had a VP shunt placed for the tx of hydrocephalus. Which of the following statements by the parent indicate an understanding of the teaching

Answer 6

We will notify right away if he has a fever

Question 7

Important to communicate to the surgeon after a VP shunt is placed

Answer 7

3yo returned to peds units and the right pupil is 1mm larger than the left pupil

Question 8

Stroke on the right side of the brain what would you see

Answer 8

Left sided neglect, paralyzed left side, hemiplegia

Question 9

The nurse is assigned to care for a client with complete right sided hemiparesis from stroke. Which characteristics are associated with this condition

Answer 9

The client is aphasic
The client has weakness on the right side of the body
The client has weakness on right side of face and tongue

Question 10

When caring for a pt with new right sided homonymous hemianopsia resulting from stroke, what intervention should the nurse include in plan of care

Answer 10

Place objects needed on the pts left side

Question 11

A 73yo pt with a stroke experiences facial drooping on the right side and right sided arm and leg paralysis. When admitting the pt which clinical manifestations will the nurse expect to find

Answer 11

Difficulty comprehending instructions

Question 12

Risk factors for stroke

Answer 12

High BP, TIA, Smoking, Oral contraceptives

Question 13

The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully

Answer 13

Consistently uses adaptive equipment in dressing self

Question 14

Risk factors for stroke

Answer 14

High BP, TIA, Smoking, Oral contraceptives

Question 15

A child is dx with reyes syndrome. The nurse assists to develop a nursing care plan for the child. Which statement would indicate a need for further teaching

Answer 15

Parents watch tv in the child’s room with high volume

Question 16

A child is dx with reyes syndrome. The nurse assists to develop a nursing care plan for the child and should include which intervention in the plan

Answer 16

Providing a quiet atmosphere with dimmed lighting

Question 17

When preparing the discharge plans for a pt with chronic anxiety. Which goal is most appropriate to be included in the plan of care requiring evaluation

Answer 17

The pt is able to identify triggers that produce anxiety

Question 18

A client is admitted with a recent hx of severe anxiety following a home invasion and robbery. During the initial assessment interview which statement by the client should indicate to the nurse the possible dx of PTSD

Answer 18

I keep reliving the robbery
I see his face everywhere i go
I might have died over a few dollars in my pocket

Question 19

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior

Answer 19

Communicate expected behaviors to client
Assist the client in identifying ways of setting limits on personal behaviors
Follow through on the consequences of behaviors in a non punitive manner
Have the client state the consequences for behaving in the ways that are view as unacceptable

Question 20

Intervention for client experiencing mania

Answer 20

Provide frequent breaks

Question 21

When working with a pt with dissociative amnesia the nurse should begin by

Answer 21

identifying and supporting the pts strengths

Question 22

EPS side effects

Answer 22

Parkinsonism, tremors, mark like face, drooling, dysphagia, shuffling gait

Question 23

Quetiapine side effects

Answer 23

Urinary retention
Parkinsonism
Restless
HTN

Question 24

Alcohol withdrawal protocol

Answer 24

When was your last drink
What type of alcohol, how much, for how long, and when was it last consumed
Seizure precautions

Question 25

Which interventions are most appropriate for caring for a client in alcohol withdrawal

Answer 25

Monitor vital signs Provide a safe environment Address hallucinations therapeutically Provide reality orientation as appropriate

Question 26

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse "I should get out of this bad situation" Which is the most helpful response by the nurse

Answer 26

What do you find difficult about this situation

Question 27

Post laryngectomy

Answer 27

Avoid Shower Wear high collar shirt Keep home humidified Avoid people with infection

Question 28

A nurse arrives for work to find that the medical unit is short staffed. Nursing administrators has called several staffing agencies but they are unable to send a replacement nurse for three hours. The nursing care coordinator sends a recently oriented PCA to help relieve the burden of care. Which activities should the nurse delegate to the PCA

Answer 28

Making occupied beds Taking routine vital signs Answering clients call lights

Question 29

When caring for a preoperative pt on the day of surgery which actions included in the plan of care can the nurse delegate to UAP

Answer 29

Polish and apply pulse ox Transport the pt by stretcher to the operating room Obtain and document baseline vital signs

Question 30

Which nursing actions can the nurse working in a women's health clinic delegate to UAP

Answer 30

Assist the HCP with performing a pap test Draw blood for a CA 125 levels for a pt with ovarian cancer

Question 31

Accountability is the acceptance of responsibility for one's choices, decisions, and actions. The nurse is always responsible for their actions when providing care to a client. Which actions in the delegation process represent accountability

Answer 31

Monitoring client care Seeking the outcome report

Question 32

Which activity performed by the by the RN indicates effective delegation

Answer 32

Supervising and monitoring the LPN about the different activities

Question 33

Patient slurring words and has right sided weakness what would the nurse assess first

Answer 33

Airway, Breathing, Circulating

Question 34

Consider when creating a care plan for a client in a crisis state

Answer 34

Clients response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client

Question 35

An 8yo child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parents wonder if this abnormal behavior picked up from playing video games. What is the best response

Answer 35

School aged children are inquisitive and ask a lot of questions about death

Question 36

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which action in care of this client

Answer 36

Obtain a telephone consent from a family member following agency policy

Question 37

Hepatitis A

Answer 37

Fecal Oral Wash hands No sea foods clean toilets

Question 38

A client with hepatitis A is newly admitted to the unit. Which action would be the priority to include in this pts plan of care within the initial 24 hours

Answer 38

Wear gown a gloves during pt contact

Question 39

Following change of shift report on an orthopedic unit which client should the nurse see first

Answer 39

72yo recovering from surgery after a hip replacement 2 hours ago

Question 40

During nursing rounds which of these assessments would require immediate corrective action and further instruction to the LPN about proper care

Answer 40

a client with a hip prosthesis 1 day post op is lying in bed with internal rotation and adduction of the affected leg

Question 41

The nurse is teaching a client who has a hip prosthesis following a total hip replacement which of the following should be included in the instructions for home care

Answer 41

do not cross your legs

Question 42

A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially

Answer 42

Ensure that the stump is elevated the first day post op

Question 43

Who's at risk for osteoporosis

Answer 43

Menopausal Sedentary over 65 excessive alcohol intake cigarette smoking female family hx early menopause steroid use insufficient intake of calcium or vitamin D

Question 44

A registered nurse (RN) cares for a client with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching?

Answer 44

The RN checks the initial blood pressure in one arm. The RN palpates the neck to assess thyroid size The RN offers warm blankets for the clients cold feet

Question 45

What information will a review of a patient’s glycol hemoglobin (A1C) results provide to the nurse?

Answer 45

Glucose control over the past 90 days

Question 46

The nurse is instructing a 65 vear-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

Answer 46

exercise doing weight bearing activities

Question 47

The nurse is teaching a group of women in a community clinic about prevention of osteoporosis. Which of the following over-the-counter medications should the nurse recognize as having the most elemental calcium per tablet

Answer 47

Calcium carbonate

Question 48

In preparation for which test should the nurse teach the patient to minimize physical and emotional stress?

Answer 48

A 24-hour urine test for free cortisol

Question 49

Which finding for a 77-yr-old patient seen in the outpatient clinic is the highest priority for further nursing assessment and intervention?

Answer 49

History of recent loss of balance and fall

Question 50

The nurse assesses a client who is 30 minutes postoperative from an insertion of a permanent pacemaker. Which finding would require immediate follow up by the nurse

Answer 50

Report of shortness of breath

Question 51

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is MOST APPROPRIATE

Answer 51

document the findings

Question 52

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?

Answer 52

"I need to report a fever or swelling to my health care provider.

Question 53

The nurse is reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the health care provider before surgery?

Answer 53

White blood cell count of 16,000

Question 54

The nurse is conducting discharge teaching for a client with a new dx of HTN. What should the nurse include in the teaching

Answer 54

Keep a diary of regular bp readings instruct client to bake, roast, and boil food Avoid OTC meds

Question 55

The nurse is caring for a child who was admitted with chronic renal failure. What assessment finding would the nurse expect in this client

Answer 55

Increased BUN Decreased GFR Azotemia Oliguria

Question 56

Stage one HTN education

Answer 56

diet, exercise, low sodium, no caffine, veggies daily

Question 57

What are dietary teachings that should be provided to the client post cholecystectomy

Answer 57

Instruct the client with chronic cholecystitis to eat small, low-fat meals. avoid gas forming foods (beans, cabbage, cauliflower, broccoli) take fat-soluble vitamins or bile salts as Rx