Review Q's Flashcards
1
Q
An older adult client reports recurring calf pain after walking one to two blocks that disappears with rest. The client has weak pedal pulses, and skin on the left lower leg is shiny and cool to the touch, What nursing intervention is appropriate at this time?
A
Know is arterial problem (artery)
-Position the left leg dependently
2
Q
A client receives a transfusion of packed RBC’s and tells the nurse “My IV site is painful and looks like it is swollen.” What action should the nurse take?
A
Start a new IV at another site and resume the transfusion at the new site
3
Q
A client who has recently undergone surgery for a tracheostomy is now at home. The nurse recognizes a need for immediate intervention when he does what?
A
Removes the ties before changing the tracheostomy
4
Q
A nurse admits a client who sustained a C3 spinal cord injury. What should the nurse recognize as the priority of care?
A
Respirations 10/min
5
Q
A nurse enters the room of a client who is at the foot of the bed lying on the floor. What should be the nurses initial action?
A
Assess vital signs and level of consciousness
6
Q
Four days after a ventral hernia repair, a client who is obese and has a history of COPD vomits and reports severe abdominal pain. The oxygen saturation is 90%. What action should the nurse implement first?
A
90% O2 is ok for COPD person
COPD = chronic, hernia repair = acute
Assess the surgical incision site
7
Q
A nurse arrives at a work site explosion. What client should be triaged first? A client who has…
A. Fixed pupils and agonal respirations (black tag)
B. Burns to the face and respiratory stridor
C. Type 2 diabetes mellitus who is disoriented
D. A closed fracture and a pain 3/10
A
B. Burns to the face and respiratory stridor (red tag)
8
Q
A client is exhibiting early signs of hemorrhage. Which finding should the nurse anticipate?
A. Cold, clammy skin
B. Heart rate 120/min
C. Weak, thready pulse
D. BP 80/60 mm/Hg
A
B. Heart rate 120/min (heart rate going up will be initial/early sign for a lot of things)
1, 3, 4 = late signs
9
Q
A home health nurse is performing an admission assessment on a client who had a knee arthroplasty one week ago. What client statement should concern the nurse the most?
A. I am glad to be off those blood thinners
B. I will keep a pillow under my knee when I am in bed. (might get DVT)
C. I am planning to use a wheelchair to help me get around. (should be getting around)
D. I plan to take ibuprofen instead of the prescribed hydrocodone with acetaminophen for pain control. (at risk for GI bleed)
A
A. Biggest concern, should be on blood thinners longer than 1 week
10
Q
A nurse provides care for a client who has a chest tube. The nurse notes the chest tube has become disconnected from the chest drainage system. What action should the nurse take?
A. Increase the suction to the chest drainage system
B.Reposition the client to a high-Fowler’s position.
C. Apply to the client low-flow oxygen via nasal cannula
D. Immerse the end of the chest tube in a bottle of sterile water.
A
D.
If came out from patient then intervention would be to put three sided occlusion dressing on
11
Q
A client who has just been diagnosed with rheumatoid arthritis is required to receive 3 months of methotrexate (cancer drug) therapy. The nurse recognized what are adverse effects associated with this therapy? SATA
A. WBC 1200
B. Weight gain 2.27 kg (5lb)
C. Oral temp of 37.2’C/99’F
D. Urine specific gravity 1.003
E. Platelets 5,000
A
A & E (effects regular cells, suppress inflammation, effects blood cells)
12
Q
A nurse cares for a client receiving vancomycin IV therapy. What lab value should prompt the nurse to question a medication dosage increase?
A. WBC count of 15,000
B. WBC count of 3,000
C. Serum trough level that is lower than expected, taken 15 mins prior to next dose
D. Serum trough level that is higher than expected, taken after a dosage
A
D. if at therapeutic level/higher than expected then giving higher dose will increase peak level even higher, so why give dose if at peak level already
13
Q
IV Complications (pg. 30)
A
Infiltration = elevate & apply cold compress
Catheter embolus = apply tourniquet
Extravastaion = aspirate drug if possible
Hematoma = apply light pressure
Phlebitis = apply warm compresses
14
Q
Central Lines (pg. 30)
A
PICC = central
Sterile technique
Insertion complications = go in further than supposed to or placed in wrong spot, pneumothorax/air embolism
Complications? = occlusion/infection
15
Q
Pharmacology (pg. 31)
A nurse provides teaching to a client prescribed lisinopril. What finding should be reported to the provider immediately?
A. A persistent dry cough
B. Rash on the torso & neck
C. Swelling of the tongue and lips
D. Lightheadedness when standing
A
C. risk for swelling - angioedema
If develop cough then can switch to ARB
Rash not related
16
Q
Antihypertensives (p. 32-34)
A
Ca Channel Blockers = May increase heart failure (stops calcium from going into cells, so if have HF then already have trouble beating, so can’t beat faster and will lead to backup of fluid in lungs)
ACE inhibitors = Can cause angioedema
Beta Blockers = Caution use w/ asthma
Vasodilators = Rapidly drops BP (drug nitroglycerin)
Alpha2 Agonists = Contraindicated with anticoagulants
17
Q
Digoxin (p. 34)
A
How does it work? - Cardiac contractility, increases contractility, so heart beats stronger not necessarily faster
Slows and strengthens heart rate
When is it used? - HF and dysrhythmias
What does the nurse monitor? - toxicity, HR, dosage, probably taking it with potassium, K+, apical pulse
Signs of toxicity? - yellow halo/changes in vision, GI issues (N/V)
18
Q
Nitroglycerin (p. 34)
A
Action - reduced preload, decreased after load
Routes - sublingual tab, translingual spray, PO, IV, topical ointment, transdermal patch, transmuccosal tab
Monitor SE - hypotension, tachycardia (compensates b/c low BP), headache (expected), tolerance (built up, IV in hospital)
Dilates veins and arteries = low BP
Nitro naive = pt. has never taken before so do not know how will respond
19
Q
Antidysrhythmic Meds
A
Amiodarone - can give PO
Atropine - HR drops causing BP to drop
20
Q
Cholesterol Lowering Meds
A
What blood tests are used to monitor effectiveness? - Lipid panel (HDL, LDL, total cholesterol, triglycerides)
Want total cholesterol to be below 200
Triglycerides below 150
HDLs to go up
LDLs to go down
Adverse effect for taking statins? - myalgias (pain in muscles), liver function, muscle aches (rhabdomyolysis)
What should should be omitted from the diet with -statins? - grapefruit
Calcium channel blockers also affected by grapefruit
21
Q
A nurse provides teaching to a client who is prescribed atorvastatin. What statement indicates effective instruction?
A. I do not need to modify my diet
B. I plan to take the medication w/ lunch
C. I will notify provider if muscle aches occur
D. I will check renal function labs every 6 mos
A
C. usually occurs in legs
22
Q
Medications to Promote Air Exchange
A
Beta2 Adrenergic Agonists - End in: -erol, Contraindicated w/ - Tachycardia/Tachy-dysrhythmia
Methylxanthines - cause rapid HR, therapeutic 10-20 mcg/mL, contraindicated with caffeine (not as common as beta2)
Anticholinergics - contraindicated w/ peanut allergy, Maximum Effects take - 2/3 weeks, can’t see can’t spit can’t pee can’t poop
Glucocorticoids - abrupt cessation may cause?: Addisonian crisis (pt.s who are on weeks/months), chronic use may cause?: Cushing’s syndrome
Leukotriene modifiers: not used for acute asthma, interacts w/ warfarin & theopylline
23
Q
Oral Hypoglycemic (p. 39)
A
Metformin is held when a contrast dye is given, 2 days prior
List two reasons to change from an oral hypoglycemic to insulin? - no longer working, easier to manage/better control
24
Q
Thyroid Medications (p. 40-41)
A
Levothyroxine: taken in morning for hypothyroid
Hyperthyroid: taken methimazole, no breast-feeding
25
A nurse cares for a client receiving levothyroxine. What finding indicates the medication dosage should be increased?
A. Tachycardia
B. Hypotension
C. Paresthesia
D. Constipation
E. Excessive sweating
F. Decreased appetite
B
D
F
26
Growth Factors
Oprelvekin - only given SubQ
Filgrastim - given SubQ or IV
27
Client Education (p. 44)
Iron Preparations: What increases absorption? - vitamin C
Calcium and tannin (found in tea, red wine, things fermented) decreases absorption
GI system affected? - dark stools, constipation
If GI upset - take w/ food or fiber
Special cautions w/ liquid iron - use straw, rinse mouth afterwards
IM iron - given IM z-track
28
Thrombolytics
Dissolves clots
Alteplase, reteplase
Contraindicated to receive: intracranial hemorrhage, active internal bleeding, aortic dissection, brain tumors
29
A nurse provides teaching to a client who is prescribed omeprazole. What indicated need of further instruction?
A. Ibuprofen should be avoided
B. I will eat additional dairy products
C. This medication is taken w/ each meal
D. My provider will be called if I have a cough
C. Taken once a day not w/ each meal (only taken w/ each meal if person bloats)
Long-term use: hypo magnesia, osteoporosis
30
GI System
Antacids: taken 1 hour after meals
PPPIs: do not crush or chew tablets
Mucosal Protectants: used when have gastric ulcers, take on an empty stomach
Antiemetics: may cause EPS
Antidiarrheals: monitor fluid & electrolytes
Stool softeners & laxatives: potential for abuse (anorexia)
31
Diuretics (p. 48)
Non-potassium sparing diuretics: electrolyte imbalances, hypokalemia, hyponatremia, hyperglycemia
Two K+ sparing diuretics: Spironolactone, Triamtrerene
W/ both risk of client to have orthostatic hypotension
Client at risk for falls
32
Immune System
Antimicrobials (p. 50-52)
How will provider determine most effective antibiotic? - culture and sensitivity
Two antibiotics nephrotoxic - Vancomycin, Gentamicin
Cranial nerve affected by these medications - Acoustic - 8th
33
A nurse cares for a client with diabetes mellitus who reports labia irritation and vaginal cheese-like discharge. What med should be expected?
A. Imiquimod
B. Ceftriaxone
C. Fluconazole
D. Metronidazole
C.
A. is used for precancerous lesions/genital warts
34
A nurse provides discharge teaching to a client receiving rifampin (other drug isoniazid). What instruction should be included regarding the use of contact lenses?
It's inadvisable to wear plastic contact lenses during treatment
35
A nurse provides medication teaching to a client who is taking ibandronate (taken if have osteoporosis). What instruction should the. nurse question?
A. Drink a full glass of juice when you take this medication
B. Take this med at least 30 mins before eating
C. Sit up for at least 30 mins after taking med (to treat GERD)
D. Call provider if you experience joint or muscle pain
A. drink w/ full glass of water not juice
36
Musculoskeletal Medications (p. 52-53)
Foods high in purines: red meat, organ meats, shellfish (shrimp, lobster)
37
Neurological Pharm
A nurse plans discharge teaching for a client who is prescribed phenelzine (MAOI watch for tyramine). What dietary options should the nurse instruct the client to avoid?
A. Pepperoni
B. Fresh fish
C. Lettuce
D. Cottage cheese
E. Cheddar cheese
A & E (aged cheese, cottage cheese is not aged, is fresh)
38
Short term or long-term medications
Isocarboxid: long-term antidepressant, MAOI
Alprazolam: short-term, not meant to be longterm
Lithium carbonate: for mania, long-term use
Lorazepam: short-term use
Zolpidem tartrate/ambiem: short-term sleep aid
Olanzapine: long term
Sertraline/zoloft: long-term
39
Lithium (p. 55)
Decreases: symptoms of bipolar disorder, mania
Toxicity may occur w/: hyponatremia and NSAIDS
Therapeutic level: 0.4-1.0 mEq/L
40
Antipsychotic Meds
Typical - haloperidol
Typical - thiothixene hydrochloride
Atypical - olanzapine
Atypical - aripiprazole (not PPI)
Typicals side effects: sedation, EPS, anticholinergic effects, seizures, neuroleptic malignant syndrome (overheating), agranulocytosis, tar dive dyskinesia
Atypical: lower risk of EPS and TD, added risk of weight gain, diabetes, dyslipidemia, agranulocytosis, seizures, and orthostatic hypotension
41
Parkinson's Disease (p. 57)
Goals of meds: stop tremors --> stop because have increased dopamine in brain
When meds are contraindicated: w/ MAOI, narrow angle glaucoma, no benztropine (antidote for haloperidol)
42
A nurse provides discharge teaching to a client prescribed levodopa/cardiopa. What instruction should the nurse include?
A. Eat a high-protein diet
B. Change positions slowly
C. Take the med w/ food
D. Inform symptoms will improve w/in a week
E. Instruct to report regular or fast heart beats
F. Discuss potential for hallucinations or paranoia
B, C, E, F (F is common w/ Parkinson's)
43
A nurse cares for a client with a PCA. What synergistic effects of anesthetic agents and options should the nurse expect?
A. SpO2
BP 154/86
Pulse 82 min
Respirations 10/min
SpO2 89% & Respirations 10/min
44
A nurse provides care for a client who has received an epidural analgesia. What requires immediate intervention?
A. Inability ot urinate
B. Reports of a headache
C. Bilateral upper extremity itching
D. Decreased level of consciousness
D. All others are expected w/ epidural analgesia
45
Analgesics (p. 58-59) Acetaminophen, NSAIDs, Opioids
Analgesics: acetaminophen, NSAIDs, Opioids
Antipyretic: acetaminophen, NSAIDs,
Anti-inflammatory qualities: NSAIDs
Antiplatelet qualities: NSAIDs
Renal Damage s/s: acetaminophen, NSAIDs
Liver Damage s/s: acetaminophen
46
Fundamentals of Nursing
Client safety - Falls (p. 66)
Factors: elderly, medications (opioids), orthostatic hypotension, not wearing glasses/poor eyesight, confusion, age, impaired mobility
Interventions: assessment, safe environment
47
A nurse documents "client placed in restraints after wandering and refusing to return to bed." What conclusion should be made about the documentation?
A. It is an objective account of this client's potentially harmful behavior
B. It provides insufficient evidence to support the need to restrain the client
C. It legally requires the signature of two nurses to support use of restraints
D. It needs to describe attempts to resolve insomnia before using restraints
B.
48
A nurse considers the use of a wrist restraint for a client with a peripheral IV. what finding should be evaluated before applying the restraint?
A. The time required to restart the IV if the site is compromised
B. The current staffing level of the nursing unit
C. The presence of family members at the bedside
D. The reason the client may potentially pull out the IV
D. The reason the client may potentially pull out the IV
49
Seizures (p. 66)
Pre-Seizure - seizure precautions, pad bed, suction equipment, O2
During: turn patient to side, don't put anything in mouth, assess airway, time started
Post-Seizure - turn pt. to side, neuro check, vital signs
50
Fire (p. 67)
R: Rescue - protect and evaluate clients in immediate danger
A: Alarm - report the fire
C: Contain - close windows/doors
E: Extinguish - use approved extinguishers
51
A nurse cares for a client who is receiving chemotherapy. What action should be implemented if the IV tubing separates?
A. Notify housekeeping to clean the spilled solution
B. Complete incident report about the spill of chemotherapy
C. Use towel to clean solution and dispose in a biohazard bag
D.Obtain chemotherapy spill kit and use according to directions
D. Obtain chemotherapy spill kit and use according to directions
52
Ergonomics & Positioning (p. 67-68)
Positioning
Improve condition: respiratory (sitting up), prevent pressure ulcers (turning), blood flow, high-fowlers
Promote comfort - therapeutic touch, warm blanket, guided imagery, music
53
A nurse instructs the use of a cane to a client with life-sided weakness. What should be included?
A. Place the cane in the left hand
B.Hold the cane on the right side and advance left food forward
C.Advance the cane 12-16 in with each step
D. Keep elbow flexed and move the right foot forward
B.
Should be 6-10 in
54
A nurse provides discharge teaching to a client who has acquired immunodeficiency syndrome. What spill management technique should be included?
A Clean area with detergent and rinse with ammonia
B. Disinfect area with 10% bleach solution after initial cleaning
C. Clean area thoroughly with child water and allow to air dry
D. Disinfect area with 70% isopropyl alcohol after initial cleaning
B.
54
A nurse provides discharge teaching to a client who has acquired immunodeficiency syndrome. What spill management technique should be included?
A Clean area with detergent and rinse with ammonia
B. Disinfect area with 10% bleach solution after initial cleaning
C. Clean area thoroughly with child water and allow to air dry
D. Disinfect area with 70% isopropyl alcohol after initial cleaning
B.
55
Infection Control (p. 70-73)
Tier 1: Standard - hand washing, additional PPE as needed
Tier 2: Contact - gloves & gown
Tier 2: Droplet - mask
Airborne - N95
56
A nurse cares for a client 6 hours post total laryngectomy who has a history of Hep C and HIV. What equipment is recommended during direct care?
Gloves, Gown, Mask & Goggles
57
A child is entering college and the parent asks about the need for a meningococcal conjugate vaccine. What information should guide the nurses response?
A. Upper respiratory infections are more common on college campuses.
B. Living in a dorm increase the risk of exposure to the disease
C. Adults who contract meningitis frequently have complications
D. Receiving the treatment provides guaranteed immunity
B. Living in a dorm increase the risk of exposure to the disease
58
Health Promotion & Disease Prevention (p. 73-74*)
Primary: EDUCATION, immunization, car seat safety
Secondary: SCREENINGS, early detection
Tertiary: FURTHER COMPLICATIONS, how to manage, when it becomes chronic
59
A nurse plans care for a client who is diagnosed with a cerebrovascular accident. What members of the inter professional team should participate in planning care?
A. Dietitian
B. Hospice nurse,
C. Speech therapist
D. Physical therapist
E. Rapid Response Team
A. C. D. Dietitian, Speech therapist, Physical therapist
60
A nurse provides care for a client who recently had a tracheostomy placed. Which equipment should be placed at bedside? SATA
A. Nasal cannula
B. Oxygen set-up
C. Suction equipment
D. Manual ventilation bag
E. Two tracheostomy tubes
Have Trach so do not need nasal cannula
B. C. D. & E
Size of trach's: same size & one smaller
61
A client plans to leave the facility "Against Medical Advice". What action should the nurse implement? SATA
A. Contact the provider
B. Notify the security department
C. Ask the client to sign an informed consent
D. Obtain a discharge prescription immediately
E. Inform the client of complications that may occur without treatment
A & E
62
A community health nurse provides teaching about the Zika virus to clients who live in an at risk area. What information should be included?
A. Flu-like symptoms should be reported to HCP
B. Vaccination is recommended for prevention
C. The virus can spread through sexual intercourse
D. Infection during pregnancy can cause severe fetal defects
E. Mosquito repellent should be applied when going outdoors
A, C, D, E
No vaccine for Zika
63
Nursing Leadership & Management
Management Styles (p. 10)
Authoritative: used during a CODE blue
Laissez-Faire: every nurse at bedside uses this based on their own needs, what tasks they're going to complete first, etc., allows for freedom
Democratic: nursing managers/charges
64
Conflict Resolution (p. 11)
Categories: intrapersonal, interpersonal, intergroup (committee)
Best resolution?: Collaborating = win-win
Competing? = win-lose
Cooperating = lose-win
Smoothing = lose-lose
Avoiding = lose-lose
65
A nurse prepares a staff in-service on incident reports. What information should the nurse include?
A. Risk management investigates the incident
B. A copy of report is placed in client's health record
C. Reports include description of incident and actions taken
D. Reports are confidential and not shared with noninvolved staff
E. Completion of report should be documented in nurses notes
A, C, D
66
A nurse is unsure of the proper technique when caring for a client who is prescribed enteral feedings. What action should the nurse take?
A Ask the charge nurse for step-by-step directions
B. Call the provider for specific instructions
C. Consult the unit procedure manual for guidance
D. Delegate task to LPN to complete the feedings
C. Consult the unit procedure manual for guidance
67
A nurse admits a client from a long-erm care facility. What action should be implemented? SATA
A. Verify the admission medications prescribed by the provider
B. Review the current medication regimen with the client
C. Obtain the most recent list of meds from the long-term care facility
D. Locate a list of discharge meds from the most recent hospitalization
E. Discuss any discrepancies with the health are provider
A, B, C, & E
68
Rights of Delegation
Right person, task, supervision, directions, circumstances
69
A nurse cares for a client with terminal lung cancer. What action should be delegated to the UAP?
A. Encourage client to express feelings about the terminal diagnosis
B. Assist the client to ambulate to the bedside chair twice a day
C. Demonstrate to client the proper use of a bronchodilator inhaler
D. Complete vital signs that include oxygen saturation every four hr
E. Obtain a urine specimen from the client's indwelling bladder catheter
B & D
A is a form of therapeutic communication
C is a form of teaching
and E is a sterile procedure
All can't be done by UAP
70
A nurse cares for a group of clients on a med-surf unit. What client should be delegated to the LPN?
A. Newly diagnosed diabetes mellitus type II
B. Facial lacerations and a subdural hematoma
C. Bronchitis receiving bronchodilator treatment
D. Exacerbation of myasthenia graves admitted three Horus ago
E. Advanced regular diet two days postoperative cholecystectomy
LPN's can't give IV bolus pushes, can't teach for first time but can reinforce
Can: C & E
Can take care of stable patients
71
Scope of Practice (p. 13-14_
UAP: ADLs, vital signs, weight, I&O's, safety
Do not teach, assess, do sterile procedures
LPN: stable client, data collection, reinforce teaching (cannot do discharge teaching), can mark on care plan that has been started, can take out IV
RN: unstable patients, assess, teach, completes care plan/plan care
72
Nurse assigns four clients to LPN. What finding should the LPN immediately report to nurse?
A. Receiving long-term IV antibiotics who has a rash in his left groin
B. with baseline regular apical pulse of 88 who has an irregular apical pulse of 120 today
C. Who has a recent diagnosis of terminal cancer and refuses to eat or participate in hygiene care
D. Eight hours post laparoscopic surgery who reports abdominal distention and shoulder pain
B is correct
D. shoulder pain is expected w/ this surgery
73
A nurse plans to administer the following meds. What med should the nurse administer first?
A. A scheduled IV antibiotic for a client with resolving pneumonia
B. Pain medication to a client who rates their pain a 4-5 on a 0-10 scale
C. A antidiarrheal for a client with one diarrhea stool in the last hour
D. An antipyretic to a client with a temp of 100.7'F (38.2'C)
A. Scheduled IV, small window to give to pt., lose therapeutic level
74
Leadership Q's
After receiving morning report on an adult medical unit, what client should the nurse assess first?
A. Client with acute glomerulonephritis with urine output of 160ml total on prior shift.
B. A client with bubbling in the suction control chamber of closed chest drainage system
C. Client three days postoperative for left mastectomy who is tearful and withdrawn
D. Client with a wound infected with MRSA who wants to leave against medical advice
A. Not WNL
75
A nurse cares for a group of clients. What should be the nurse's initial action?
A. Ask the UAP to assist the transfer of a client to radiology for an echocardiogram
B. Print a menu for family members of a client with newly diagnosed DM
C. Notify the provider of a normal heart rate that changes to sinus tachycardia with a rate of 110
D. Request a repeat potassium serum level for an asymptomatic client with a prior level of 5.7 mEq/L
D. priority 0.7 is way out of bounds (normal 3.5-5.0)
C. Still in sinus and don't know what pt. was doing at time taken
76
Prioritization (p. 14-15)
Maslow
ABC's
Safety
Risk Reduction
Nursing Process
77
Ethical & Legal Issues (p. 16)
A nurse cares for a group of clients. What information can be disclosed about client.
A. HIV status to the clients coworkers
B. Stage IV cancer diagnosis to the clients family
C. Uncontrolled seizure disorder to DMV
D. Alcohol detoxification recovery status to the clients employer
C.
True ethical issue when lose-lose situation
78
Fidelity & Nonmalificence
RN returns to the client as promised 30 minutes after giving an analgesic - Fidelity
The nurse contaminates her sterile glove but continues to insert the urinary catheter - what was ignored? - Nonmalificence
79
Consent
Who can give consent? - POA, patient, parents/guardians, next of kin, If unconscious general consent
Types of consent - general (RN is witness), implied (unconscious), informed
80
A nurse notes the 16 year old signed the consent form for a surgical procedure. What action should be first?
Cancel the surgical procedure until a valid consent form can be signed
Verify the signature is witnessed appropriately and sent the client for surgery
C. Determine whether the client meets legal requirements to sign the consent form
D. locate the clients parent or guardian to sign the consent form
C. (meet requirements = married, 16 YO, emancipated, pregnant)
81
A nurse administers a prescribed excessive dose of IV gentamicin and the client experiences
82
Negligence (p. 17)
The RN hung an incorrect bag of IVI fluid. AFter noting the error, the infusion was corrected. The clients IV site and VS were normal. Did negligence occur?
No; nothing permanent/long-term harm, potential for harm but no damage occurred, just an error
Definition: nurse has a duty, there is a breach of duty, there has to be a cause aka causes something, has to be harm
83
A nurse prepares t document client assessment data to the units computer system ad has forgotten the login password. What action should the nurse take?
A. Ask to use a coworkers password
B. Let another nurse complete the data entry
C. Request assistance from facilities IT department
D. Document on paper to enter the computer at a later time.
C.
84
A nurse provides phone triage with a client who was exposed to Ebola 1 week ago and denies symptoms. What's the best response by the nurse?
A. I will need to tell the Health Department
B. All household members should be vaccinated
C. Since you are symptom-free, you were not infected
D. A throat culture is an effective way to check for Ebola
A.
No vaccine for Ebola
Once exposed symptoms may not appear for 7-21 days
Is a blood test not throat culture
85
A nurse prepares a staff in-service of community Health. Which information identifies the role of the nurse? SATA
A. Provides tertiary care to families
B. Screens for Giardia with county water authority
C. Develops influenza vaccinati program for refugee center
D. Speaks to adolescents about the impact of alcohol consumption
E. Focuses on medical model to guide practice
A, C, D
E - nurses focuses on nursing process not medical model
86
A fire is forcing evacuation of clients from a nursing unit. Which client should be evacuated first? A client who is
A. Admitted with pancreatitis with nasogastric tube and PCA device
B. 48-hr post hip replacement whose son and daughter are visiting
C. Receiving IV antibiotics every 6 hr via saline lock for right leg ulcerations
D.
C. take least acute first and most acute last
87
The ED nurse manager prepares for the arrival of numerous victims from an accident. What should be the nurse's first action?
A. Provide discharge teaching to stable clients
B. Transfer all ED clients to inpatient nursing units
C. Determine available staff members on duty
D. Notify on-call staff members to report to work
C. ASSESSING what can take on
88
Disaster Planning (p. 20-23)
Phases of Planning: disaster preparedness, response, recovery
Disaster plan includes: first responders, warning system, nursing roles, chain of command
ED triage: treat most severely injured first
Mass casualty triage: do the greatest good for the greater number
Red- immediate
Yellow- delayed (have up to 2 hrs)
Green- minor
Black- expected to die
89
Culturally Competent Care
A nurse prepares discharge instructions for a client who only speaks Vietnamese. What action should the nurse implement?
A. Contact a hospital assigned interpreter
B. Refer client to use of graphic, visual aids
C. Ask an English speaking family member to translate
D. Download a Vietnamese translation from computer
A.
90
A case. management nurse plans discharge for an older adult. What actions reflect effective care coordination? SATA
A. Resolving the plan of care
B. Arranging home health services
C. Administering scheduled medications
D. Performing nasogastric tube insertion
E. Facilitating referrals for community services
F. Scheduling follow-up provider appointments
A, B, E, F
No bedside care
91
A nurse provides care for a client who has recently returned from West Africa. What symptoms should be reported immediately. SATA
A. Fever
B. Dysuria
C. Epistaxis
D. Diarrhea
E. Vomiting
Hemorrhagic disease
A, C, D, E
92
A nurse identifies the client is disposing of sharps at home using unsafe practices. What actions did the nurse observe?
A. Placed insulin needles in recycling bin
B. Recapped the needle prior to disposal
C. Removed the needle before placing syringe in trash
D. Used a portable sharps container when traveling
E. Requested the provider to dispose of sharps container
A, B, C
93
Adult Med-Surg Nursing
A nurse admits a client who has dehydration secondary to vomiting. What lab value should the nurse expect too e elevated SATA
A. Serum pH
B. Hematocrit
C. Urine osmolarity
D. Serum potassium
E. Urine specific gravity
A, B, C, E
94
A nurse admits a client who has a potassium level of 3.2 mEq/L. What response does the nurse recognize as therapeutic to the prescribed KCL 40 mEq/L IV infusion over four hours. SATA
A. Trousseau's sign becomes negative. (for Ca)
B. Reports leg cramps are no longer present
C. Serum potassium is 3.6 mEq/L after infusion
D. Heart rate decreased from 110 bpm to 85 bpm. (body compensating)
E. Peaked T-Waves disappeared from electrocardiogram. (will have U wave due to decrease potassium)
B, C
95
Types of Fluids
Symptoms:
Fluid Volume Deficit - decrease weight, no edema, VS will be tachycardia, BP low, pulse thready, Urine output will be low/decreased, will have LOC changes/confusion, no lung sounds present/no crackles, no JVD present/will be normal
Fluid Volume Excess - weight will be increased, edema will be present, VS will be bounding pulse, and high BP, urine output will be increased, LOC is decreased (depends on age), lung sounds will be moist with crackles and dyspnea, JVD will be present with distention
96
Is the Change Significant
Yesterday: Potassium 4.8 (trended, watch), Sodium 139 (call provider), Creatinine 1.2
Today: Potassium 4.3 (trended, watch), Sodium 130 (all provider, assess), Creatinine 3.4 (something is wrong, something going on with kidney, do another test, drink water)
97
An older adult client is receiving IV fluids at 150 mL/hr and suddenly reports, "I feel like I am suffocating." Respirations are labored at 40/min and crackles are auscultated bilaterally. What action should the nurse take? SATA
A. Increase IV fluids
B. Administer oxygen
C. Assess jugular vein
D. Administer PRN dose of furosemide
E. Monitor HR and BP
F. Place in modified Trendelenburg position
B, C, D, E
98
Acid Base Imbalances (p. 84)
Hyperventilation - respiratory acidosis
99
A nurse admits a client with symptoms of tachycardia, hypotension, fever, and a history of severe diarrhea for the past 2 days. What ABG results should the nurse recognize as being consistent with the clients history and symptoms?
A. pH 7.24; PaCO2 83 mm/Hg; HCO3 42 mEq/L
B. pH 7.49; PaCO2 29; HCO3 22
C. pH 7.48; PaCO2 39; HCO3 32
D. pH 7.27; PaCO2 32; HCO3 16
A. is for respiratory acidosis
D is right answer
100
Pulmonary Embolus (p. 89-90)
S&S of PE - dyspnea/SOB, feelings of doom, chest pain, restlessness, anxiety, stridor/intense breathing, tachycardia, tachypnea, diaphoresis, hemoptysis
Will feel like MI
Interventions - sit pt. up, O2, pain medications, give clot buster/anticoagulants, respiratory assessment, pain management, anticoagulation or thrombolytic therapy, monitor for complications
101
A client has a PE. Initial treatment includes 40% oxygen via Venturi mask, IV heparin therapy and bed rest. What finding should indicate to the nurse therapy is effective?
A. PaO2 is 75 mm/Hg
B. aPTT 70 seconds
C. CT scan of chest positive for infiltrate
D. Calf edema and erythema are resolved
B. pt. is on heparin so should be 1.5-2x normal range which is 30-40)
102
Pneumothorax Nursing Interventions (p. 90-91)
O2
Sit pt. up/position
Anxiolytics/Anxious
Analgesics/In pain
Chest tubes in place
103
Chest Tubes
What is done if no bubbling is seen? (should be bubbling slightly) - make sure it is not kinked, pt. is laying on tubing, bed isn't rolled on tubing
What to do if drainage becomes purulent? - call provider, treat infection/antibiotics
If client has crackles? - not related to each other, will not affect inflation of lung, may need furosemide to get rid of excess fluid
104
Mechanical Ventilation (p. 92)
Interventions - check ABGs, pressure and placement, listen to lungs
Assist w/ ventilation, assess breath sounds, maintain position of ETT tube, suction PRN, manage the CLIENT not the ALARMS (look at your pt.)
105
A client has a water seal chest drainage system in place for the treatment of a pneumothorax. What action should the nurse perform when intermittent bubbling is observed in the water seal chamber?
A.
Expected finding
106
A nurse cares for a client who has a Chet tube and notices that the tidaling in the water seal chamber has stopped. What complication is most likely the cause?
A. Obstruction is present in the tubing
B. Crackles are heard upon auscultation
C. Water level in suction chamber is low
D. Air is into longer present in the pleural space
A. Should present on every breath
107
Client is receiving mechanical ventilation and the high-pressure alarm sounds. What action should the nurse implement?
A. Check for a leak or break in the ventilator system
B. Administer a sedative to decrease the clients anxiety
C. Assess the client to determine the need for suctioning
D. Check for air escaping around the cuff of the endotracheal tube
C.
108
Delegate or Do Not Delegate
PN to complete an assessment of a client just transferred from the ED to your unit? - NO
PN to validate the color and amount of gastric content upon insertion of a nasogastric tube? - NO
An AP to increase the oxygen flow rate from 2L to 4L on a client with a chronic respiratory illness? - NO
A PN in a community health clinic to discuss the need for a meningococcal vaccine with a parent of a 16 YO planning to go to summer camp? - NO
An AP to gather and document the amount of darning present in a NG tube suction container? - Yes (I&O's, documenting amount)
An AP to ambulate a client who had a laparoscopic appendectomy four hours ago? - Yes, within scope
A PN to resolve the care plan of a client ready for discharge from the unit? -No (RN will resolve/make sure everything has been done/signed off/everything is up to date)
A PN to provide care for a client returning from a cardiac catheterization?- No (Initial/New assessment & pt. will be unstable)
A novice RN orienting to the unit to complete a central line dressing change on a client while the preceptor is busy completing another task? - No (still on orientation)
A PN to administer albumin at 2ml/min over 4 hrs to a client? - No (blood product, PNs cannot give)
PN floated to the ED to care for a 26 YO female presenting with frequency, urgency, and burning on urination? - Yes (stable, expected outcomes)
A PN working in the ED to care for a 42 YO male presetting with chest pain, nausea, & diaphoresis? - No (unstable)
A PN to discontinue an IV for a client ready for discharge? - Yes
PN to verity client understanding of instructions following a teaching session with a Certified Diabetic Educator? - Yes (can reinforce teaching)
AP to insert an indwelling urinary catheter on a client who has urinary retention? - No (no invasive or sterile procedures)
PN to administer IM injection of Rhogam to a postpartum client- No (blood product, can give IM injections but is blood product)
AP to assist a client with ambulation who is 24-hours post following a bilateral mastectomy - Yes (been 24 hours)
RN floated to ICU from a medical surgical unit to care for a client requiring monitoring of CVP to guide IV fluid admin - No (if floated and there are procedures only part of that unit that require special skills/training then is above the nurse/RN float, is special to ICU so can't do)
PN to care for a client who has a tach and requires enteral feeds and g-tube med admin - Yes (can take care of trachs and give meds to g-tube)
PN in the ED to care for a toddler who presents with drooling, dysphagia, dyspnea - No (unstable)
PN to provide teaching for a client who is 32 weeks gestation and is scheduled for discharge from antepartum unit - No (can't provide discharge teaching)
RN floating form med-surf unit to the inpatient mental health unit to care for a client admitted with weight loss and insomnia related to depression - Yes
PN to administer the 2nd dose of Cefotaxime IV PB to a client with pneumonia - Yes (except in CA)
109
Endocrine
Hyper/Hypothyroidism
Symptoms & Type
Irritable & Emotional - Hyper
Poor Wound Healing - Hypo
Dry Coarse Hair - Hypo
Exophthalmos (eyes start bugging/bulging out of eyes, meds can stop this but won't go back to normal) - Hyper
Heat Intolerance - Hyper
Cold Intolerance - Hypo
Depression & Withdrawal - Hypo
Flushed Diaphoretic Skin - Hyper
Bradycardia & Hypotension - Hypo
Insomnia - Hyper
Lethargy - Hypo
110
A nurse plans care for a surgical client who has undergone a bowel resection. What action should the nurse implement to prevent circulatory complications?
A. Monitor bowel sounds in each quadrant
B. Apply pneumatic compression stockings
C. Assist pulmonary hygiene measuures
D. Maintain patent IV with isotonic solution
B. Nothing to do with surgery, to do with circulation
111
A client had a ventral hernia repair 4 days ago which action should the nurse take when providing suture line care?
A. Remove crusty excudate with sterile saline
B. Obtain culture and sensitive of drainage
C. Reinforce the dressing with saline soaked gauze
D. Maintain aseptic technique during dressing change
D.
Nothing stating we have an infection, won't be saline soaked cause too wet, do not remove crusty exudate
112
GI Disorders (p. 100-104)
GERD - Antacids, Proton pump inhibitors (PPIs), Histamine blockers, Prokinetic agents
Peptic Ulcer disease - Mucosal protectants, Histamine blocker, PPIs, Antacids, Prokinetic agents
Irritable bowel syndrome - Antidiarrheals, Bulk agents
Inflammatory bowel - Antibiotics, Antidiarrheals, Immune modulators, Steroids
Diverticular disease - Antibiotics, Bulk agents (diverticulitis will complain in LOQ)
113
Nasogastric Tubes (p. 97-98)
Purpose - unable to swallow, decompression, bowel obstruction
OD on oral medication - lavage, suction
How is placement verified - X-ray first time and then from then on use pH
Residual - can be obstruction or too much feeding/too fast
How are medications given - one at a time & flush between each medication
Can the client ambulate w/ tube - Yes!
114
Nurse should make the following assessments when caring for a client who has a NG tube to a low wall suction? SATA
A. Bowel control
B. Aspirate color
C. Throat comfort
D. Device stability
E. Oral cavity hydration
F. Nares mucosa condition
B, C, D, E, F
115
A nurse provides dietary instruction to a client who has Crohn's disease (lower GI/colon). What foods should included as a low fiber, low residue diet (ex; corn)? SATA
A. Fresh avocado
B. Cooked lentils
C. Cream of wheat
D. Puffed rice cereal
E. Whole grain pasta
F. Canned green beans
C, D, F
116
Bariatric Surgery (p. 105)
High Risk Client - complications/comorbidities
Activity - Yes
Diet - after surgery pt. will be eating and drinking clear liquids, started w/ sugar free crystal lite
Dumping syndrome - brought on by eating lots of carbs & processed sugars
Pt.s who have to eat small meals throughout the day should NOT be drinking fluids during meals (empty calories that fill up on)
117
A nurse provides discharge teaching to a client regarding colostomy care. What instructions should be included? SATA
A. Clip hair surrounding the peristomal site
B. Empty colostomy bag when one third full
C. Add cranberry juice and yogurt to your diet
D. Apply moisturizing soap to cleanse skin surrounding stoma
E. Avoid use of stoma powder, if peristomal skin becomes raw
A (don't shave anymore just clip), B, C
118
A client who has ulcerative colitis is scheduled for discharge following placement of a permanent ileostomy (RLQ, all stool is liquid). What instructions should the nurse include? SATA
A. Take enteric-coated medications
B. Notify the provider if no stool in 24 hrs
C. Avoid raw caviare, nuts, and popcorn
D. Change the entire pouch system every 3-7 days
E. Include an adequate amount of sodium and water in the diet
F. Assume knee-chest position if abdominal cramping occurs
C, D, E, F
Should have stool within 6 hrs
119
A client who has cirrhosis is admitted with an elevated ammonia level. Nurse should request nutritional consult if the client repots which dietary change?
A. Eliminating protein intake
B. Reducing salt consumption
C. Increasing carbohydrate foods
D. Including a moderate amount of fat
A.
All others are GOOD things
120
A nurse cares for a client who has pancreatitis. Total parental nutrition was started 24rs ago. What finding assessment indicates need for intervention?
A. WBC 9600 mm3
B. Albumin level of 3.4 g/dL
C. Urine specific gravity 1.042
D. Weight gain of 1 lb in 24 hrs
C. (pt. most likely wasn't eating or drinking for a long period of time)
Normal albumin is 3.5-5.0
TPN - runs at a slow rate 40-60/hr
121
Arthritis Nursing Interventions (p. 109-111)
Osteoarthritis & Rheumatoid
Gout - bed rest, avoid touch of crystals , increase fluids, NSAIDs, steroid injection, take daily allopurinol, for acute episode colchicine
122
The nurse cares for a client who has gouty arthritis. What food should be avoided?
A. Cheese omelet with mushrooms, coffee, strawberries
B. Liver & onions, cauliflower, spinach, creamed peas
C. Fried chicken, mashed potatoes & gravy, carrots
D. Cheese pizza with black olives and a soda
B. (seafood, shrimp, scallops, lobsters high in purines as well)
123
Complications of Fractures (p. 112)
Fat Emboli - confusion, tachypnea, tachycardia, petechiae
Compartment Syndrome - pain, pressure, pallor, paresthesia, paralysis, pulselessness
124
Skeletal Traction/Halo (p. 113)
Teach Client - limited movement, traction can be attached & pin care, will ooze some, report issues (6 P's)
Nursing actions - positioning, assessment (six P's), prevention
125
Endocrine
1. Gland Function
2. Hyposecretion occurring? Giving Meds?
3. Hypersecretion? Medications, radiations, removal of gland
126
Nurse cares for a client who has Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and a serum level of 116 mEq/L. What action should be implemented?
Initiate seizure precautions
Holding on because sodium is low
127
Nurse admits client who had Addisonian Crisis (adrenal gland). What prescription should be questioned?
A. Sodium polystyrene suspension 15 grams PO now
B. Hydrocortisone sodium succinate 200 mg IV bolus
C. Initiate dextrose 5% in water intravenous therapy at 30 mL per hr
D. Obtain electrocardiogram followed by continuous bedside telemetry
C. not going to keep up with urine output
Addisons do not have enough steroids so adding steroids back (B is OK)
128
Adrenal Gland Disorders
Addison Disease - add the hormone in
Cushing's Disease - been taking too many/too much
129
A nurse reviews results for a client diagnosed with hypoparathyroidism. What lab value should be expected?
Low calcium and phosphorus values
130
Common Complications of DM (p. 123)
Symptoms - poor wound healing, diabetic neuropathy, vision changes, high BP, retinopathy, skin ulcers, hypertension, proteinuria, heart attack, neurogenic pain
131
A client receives one unit of packed RBCs. What finding should the nurse expect?
A. Auscultation of lungs reveal bibasilar crackles
B BP increases from 110/62 to 135/79
C. Bilateral jucular venous distention in supine position
D. Potassium level decreases from 4.8 to 3.7
B. BP increases from 110/62 to 135/79
Potassium will increase when giving a unit of blood
132
A nurse receives report and prepares to assess which client first? A client who?
A. With hypertrophic cardiomyopathy who is reporting dyspnea
B. ho had a cardia cauterization and will be ambulating for the first time
C. Receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain
D. 2 days postoperative coronary artery bypass surgery surgery with a temperature of 37.2'C (99'F)
C. (chest pain will take priority a lot of time, and all cardiac pt.s)
133
Cardiovascular Labs (p. 128)
C-reactive protein- tells us inflammation
BNP- indicates HF
Cardiac Enzymes - gold standard for MI = troponin
134
The nurse cares for a client one hour post cardiac stent placement via left femoral artery. What assessment should be of most concern?
A. 1-2 premature ventricular contractions per minute
B. Discomfort in the left ground "7" using pain scale of 0-10
C. Pulse 120; BP 90/60; respirations 22
D. Left pedal pulse 1+ right pedal pulse 2+ left leg slightly cooler than right
C. possible hemorrhage possibility, body compensating
D. is expected outcome due to procedure access site
135
Vascular Problems (p. 132)
Valve Disorders - verrrrry slow to happen, will go into surgery
Aortic Aneurysm - starts slow w/ no s/s, will go into surgery
Hypertension - starts slow w/ pt. having no s/s
136
Venous or Arterial Insufficiency
Venous -
Painless ulcers
Lower leg edema
Hyperpigmentation
Arterial -
Claudication
Delayed CRT
Painful ulcers
Hair loss on legs
Cyanotic extremities
137
Early & Late Symptoms of Shock
Early -
Pallor
Tachypnea
Confusion (LOC changes are early sign of low oxygen)
Hypertension
Tachycardia
Late -
Cold moist skin
Weak thready pulse
Anuria
Hypotension
Metabolic acidosis
138
A nurse cares for an infant who has cystic fibrosis and is receiving pancrelipase powder. What finding is a desired effect of the med?
A. Clear lung breath sounds
B. Skin is free of salt crystals
C. Steady weight/height gain
D. Fewer respiratory infections
C. helps to improve digestion of food by replacing digestive enzymes. These enzymes are produced by the pancreas.
139
A nurse administers a prescribed excessive dose of IV gentamicin and the client experiences nephrotoxicity. Who should be accountable? SATA
A. The FDA who approved use of medication
B. Pharmacist who dispensed medication
C. The company who designed the medication label
D. The nurse who verified the prescription of medication
E. The health care provider who prescribed the medication
B, D, E
140
A fire is forcing evacuation of clients from a nursing unit. What client should be evacuated first? A client who...
A. is admitted with pancreatitis with nasogastric tube & PCA device
B. 48 hr post hip replacement whose son & daughter are visiting
C. receiving IV antibiotics every 6 hr via saline lock for right leg ulcerations
D. semi-comatose after a cerebrovascular accident with an indwelling urinary catheter
C.
141
A nurse cares for a client who has exacerbation of asthma. Place actions in selected order of performance.
1. Position in high Fowler's
2. Assess bilateral breath sounds
3. Administer albuterol nebulizer
4. Administer methylprednisolone IV
5. Administer montelukast PO now
142
A nurse admits a client who has sickle cell anemia. What lab values should be expected? SATA
Normal Labs: WBC - 5-10,000; Hct - 37-52%; Hcg - 12-18; Reticulocyte Count - 0.5-2%; Total Bilirubin - 0.1-1.0; RBC - 4,700,000-6,100,000
A. Hematocrit 25%
B. Bilirubin 1.6 mg/dL
C. Reticulocytes 2.8%
D. RBC 7,000,000/mm3
E. Hemoglobin 14 gm/dL
A, B, C
143
A nurse cares for a toddler who has glomerulonephritis (inflammation of the tiny filters in the kidneys). What intervention should be the priority?
A. Record I&Os q 2 hrs
B. Assess BP q 1 hr
C. Maintain diet with reduced sodium content
D. Plan activities to allow for frequent rest periods
B. it is very important to control your blood pressure since this may slow down kidney damage. Your doctor may tell you to eat less protein, increased risk of hypertension
144
A nurse receives report on a group of clients. What client should be assessed first?
A. An infant with an axillary temperature of 100.1'F (37.8'C) who is tugging at their left ear
B. A school-aged client with sore throat who is sitting upright in tripod position and drooling
C. A pre-school aged child with hard cough, expiratory wheezes, and mild intercostal retractions
D. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation 94% on room air
B. tripod - upper airway obstruction
145
A nurse assesses a toddler who has a 36-hr history of vomiting & diarrhea. What findings should the nurse report to the provider? SATA
A. Absence of tears
B. Skin cool, clammy
C. Heart rate 110/min
D. 6% loss of body weight
E. Capillary refill 2 seconds
F. Blood pressure 78/52 mm/Hg
A, B, D, F
C - normal HR for toddler
E- normal cap refill
146
A nurse administers lisinopril to a client who is allergic to amoxicillin, enalapril and latex. What action should the nurse take?
A. Obtain VS
B. Monitor for angioedema
C. Complete an occurrence/incident report
D. Assure the client lisinopril is not one of the stated allergies
E. Record dose, time and route in the medication administration record
A, B, C, E
D- is not correct, if allergic to enalapril will have reaction to lisinopril
ACE inhibitor - can cause dry cough, switch to ARBS, used to treat high BP and heart failure
147
A nurse provides discharge teaching to parents of a newborn who has a cleft lip. What feeding guidelines should be included? SATA
A. Provide special feeding devices
B. Place nipple toward the cleft lip
C. Feed in the upright, sitting position
D. Introduce solid foods after 12 moths
E. Feed slowly over a 20-30 minute period
F. Wait to burp until the feeding is complete
A, C, E
B - place nipple away from cleft lip to latch better, F - burp throughout
148
A nurse provides teaching to parents of an infant who has Tetralogy of Fallot. The nurse should identify these as triggers of hyper cyanotic spells. SATA
A. When resting
B. During feeding
C. Upon awakening
D. After a crying episode
E. During painful procedures
B, C, D, E
149
A nurse admits a client who sustained a burn injury to the entire left arm, left anterior leg, and left anterior surface of the torso. Using the Rule of Nines for an adult, the nurse should calculate the percentage of body surface area burned.
Entire left arm = 9%
Left anterior leg = 9% (whole leg = 18%)
Left side of anterior torso = 9% (whole anterior torso = 18%)
Total body surface burned = 27%
150
A nurse plans to teach a parenting class. What measure should be included to prevent the most common cause of death for infants and children?
A. Avoid unknown animals
B. Place infant on back during sleep
C. Secure a child in a restraint car seat
D. Apply a water safety jacket when near a body of water
C.
151
A nurse admits a toddler who is scheduled for surgery. What assessment is most important to document in the care plan?
A. The child's rituals and routines at home
B. The parents methods of reward and discipline
C. The Childs ability to separate from the parents
D. The parents understanding of the childs hospitalization
A.
152
A nurse provides teaching to a client who has systemic lupus erythematosus (SLE). What statement indicates a need for further instruction?
A. When gardening I will plan to wear a large brimmed hat.
B. Prescribed antimalarial medications should reduce joint pain.
C. Remaining on oral contraceptives will control exacerbations.
D. Alternating rest w/ activity should enhance my immune system.
c.
153
A nurse cares for a client who has a spinal cord injury. What actions should be implanted to prevent autonomic dysreflexia? SATA
A. Perform rectal digital stimulation daily
B. Instruct the client to wear medic alert bracelet
C. Observe for pattern of BP changes
D. Promote high fiber diet & use of stool softeners
E. Monitor patency of indwelling bladder catheter
D & E
A - only want with vagal mauevares and don't want that here
154
Quickly identifies type of cerebral vascular accident:
A. Cerebral Angiography
B. MRI
C. CT Scan
C.
155
Requires contrast dye
A. Cerebral Angiography
B. MRI
C. CT Scan
A.
Although all can use it
156
Unable to perform if client has a pacemaker:
A. Cerebral angiography
B. MRI
C. CT Scan
B.
157
A nurse cares for a client who has dysphagia following a cerebral vascular accident. What interventions should be implemented? SATA
A. Place client in upright position
B. Verify present of a cough reflex
C. Instruct to lift chin when swallowing
D. Provide liquids once meal is completed
E. Select foods from mechanical pureed diet
F. Place food at front of mouth on unaffected side
A, B, E
158
A nurse cares for a client with AIDS who is receiving antiviral combination therapy. Which finding indicates an effective response to therapy?
A. Improved mental status
B. Client reports a weight gain
C. No evidence of pulmonary infiltrates
D. Western Blot analysis converts to negative
C.
159
A nurse provides discharge teaching to a client receiving rifampin. What instructions should be included regarding the use of contact lenses?
A. Wait two weeks until you have established a medication level
B. It's inadvisable to wear plastic contact lenses during treatment
C. It might behest to wait until you have completed treatment
D. Avoid consuming alcohol while you are taking the medication
B.
160
A nurse cares for a client with a PCA. What synergistic effects of anesthetic agents and opioids should the nurse expect? SATA
A. SpO2 89%
B. BP 154/86
C. Pulse 82/min
D. Respirators 10/min
E. Temp 97.2'F
F. Urine output 100 mL/hr
A, D
161
A nurse considers the use of a wrist restraint for a client with a peripheral IV. What finding should be evaluated before applying the restraint?
A. The time required to restart the IV if the site is compromised
B. The current staffing level of the nursing unit
C. The presence of family members at the bedside
D. The reason the client may potentially pull out the IV
D.
162
A nurse assigns an Apgar score of 8 at one minute. Which actions should the nurse take net?
A. Begin cardiopulmonary resuscitation
B. Suction the nose then mouth via bulb syringe
C. Transfer to the neonatal intensive care unit
D. Implement routine newborn care
D.
B - always suction mouth then nose via bulb
Apgar of 8 is normal (7-10 is good)
163
A nurse cares for a client who is admitted for treatment of opioid addiction What manifestations of opioid withdrawal should the nurse expect? SATA
A. Fever
B. Euphoria
C. Somnolence
D. Diaphoresis
E. Irritability
F. Vomiting
A, D, E, F
164
A nurse provides teaching to a client who has a WBC of 1000/mm3. What instructions should be included? SATA
A. Rinse toothbrush in bleach solution at least weekly
B. Wash dishes in hot, soapy water or dishwasher
C. Increase intake of fresh fruits and vegetables
D. Report fever greater than 100.0'F (37.8'C) immediately
E. Avoid fluids that have been unrefrigerated more than 1 hour
A, B, D, E
165
A nurse cares for a client who has been admitted for detoxification of CNS stimulant addiction. What finding should be expected eight hours after admission?
A. Tachycardia
B. Increased appetite
C. Tonic-clonic seizures
D. Paranoia w/ delusions
B.
166
The axillary temperature of a newborn client is 35.8'C (96.4'F). What finding should indicate to the nurse the presence of cold stress?
A. Apical heart rate of 160/min with shivering
B. Moist skin with vernix cases in skin folds
C. Cool, cyanotic extremities with warm trunk
D. Respirations 35/min with sternal retractions
C.
D - said resps were normal for newborn
A - newborns can't shiver
167
Electrocardiogram Monitoring
Hypokalemia
Hypocalcemia
Hypercalcemia
Hyperkalemia
Flattened T Waves
Prolonged Q-T Intervals
Shortened Q-T Intervals
Elongated QRS Complexes
168
A client has a water seal chest drainage system in place for the treatment of a pneumothorax. What action should the nurse perform when intermittent bubbling is observed in the water seal chamber?
A. Clamp the tube
B. Notify the provider
C. Document the finding
D. Obtain a bottle of sterile water
C.
169
A client who is at 18 weeks of gestation is scheduled for a test to detect fetal neural tube defects. What procedure should the nurse expect?
A. Non-stress test
B. Chorionic villus sampling
C. Fetal scalp blood sampling
D. Maternal serum alpha-fetoprotein
D.
170
A nurse cares for a client who has Rh negative blood and delivered a newborn with Rh positive blood. What maternal lab should be monitored to determine RhoGAM administration?
A. Platelets
B. Hemoglobin
C. Direct Coombs'
D. Indirect Coombs'
D. Done when Rh - mom delivers Rh + baby naturally, if any crossing of blood occurs can cause lysing of RBCs (more important to know that it's a Coombs' test than direct vs. indirect Eldon said)
171
A nurse provides dietary teaching to a client during the initial prenatal visit. What food should be identified as a source of vitamin B12? SATA
A. Liver
B. Lentils
C. Yogurt
D. Papaya
E. Asparagus
A & C
Also high in B12- kidneys, clams, sardines, beef, fortified cereal, tuna, trout, salmon, milk & dairy products, eggs
172
A nurse cares for a client who is admitted with Stage 2 (Moderate) Alzheimer's disease. What signs and symptoms should be expected? SATA
A. Cannot balance a checkbook
B. Leaves the stove on after cooking
C. Decline in daily basic hygiene needs
D. Does not recognize family members
E. Is unable to grocery shop independently
F. Experiences incontinence of bowel/bladder
A, B, C, E
173
A nurse teaches a client about breast feeding. What observation indicates a need for further instruction?
A. Feeds until breast tissue softens
B. Gives a bottle during the night
C. Infant nurses every 3 hr during the day
D. Keeps infant to each breast for 15 mins
B.
174
A nurse provides teaching to a client who has dentures. What information should be discussed? SATA
A. Store dentures in a closed, labeled cup
B. Brush dentures daily using short strokes
C. Wear dentures throughout the night
D. Remove dentures and wrap in a soft tissue
E. Soak dentures in mouthwash when not in use
A & B
175
A nurse admits a client with anorexia nervosa who has had a 14 lb weight loss in the past two weeks. What action should be the priority?
A. Explore clients feelings
B. Remain with client after meals
C. Foster a therapeutic relationship
D. Initiate IV fluid therapy as prescribed
D. most important due to the significant weight loss
176
A nurse cares for an older client who has unexplained weight loss and extensive bruising. What action should be the priority?
A. Use short, simple sentences
B. Refer client to medical social worker
C. Maintain client's self-esteem and dignity
D. Collect physical data and communicate findings to charge nurse
D.
177
A nurse cares for a newborn delivered at 41 weeks gestation who is jittery with a weak cry. What action should be first?
A. Send a specimen for a serum glucose
B. Perform a heel-stick for glucose levels
C. Request provider to order a drug screen
D. Administer soy based formula to newborn
B. hyperglycemia, full term so likely not on drugs
178
During a routine home visit which situations would require a nurse to provide additional education to the client about fire safety? SATA
A. Electrical cord under the rug
B. Oxygen tanks stored in the kitchen
C. "Stop, drop and roll" diagram posted
D. "No smoking" sign visible at each entry
E. Fire extinguisher placed in bedroom closet
A, B, E
179
A client has a Glasgow Coma Scale of 5 and is receiving mechanical ventilation. What actions should the nurse implement to maintain skin integrity? SATA
A. Reposition client every 2 hrs
B. Inspect bony prominences every 4 hrs
C. Provide a high intake of protein and vitamin C
D. Insert an indwelling urinary catheter if incontinent
E. Clean the perineal area with hot soapy water after bowel movements
A & C
B- incorrect, should be done every 2 hrs with repositioning
D- indwelling catheters should not be used unless absolutely necessary to prevent CAUTIs
E- never use HOT water, use warm/room temp
180
A nurse provides education to family members regarding home safety. What factors, if present, pose a risk for injury? SATA
A. Developmental stage
B. Delayed cognitive ability
C. Impaired sensory response
D. Altered communication skills
E. Earned General Equivalency Diploma (GED)
A, B, C, D
181
A client receives one unit of packed RBCs. What finding should the nurse expect?
A. Auscultation of lungs reveal bibasilar crackles
B. BP increased from 110/61 mmHg to 135/79 mmHg
C. Bilateral jugular venous distention in supine position
D. Potassium level decreases from 4.8 mEq/L to 3.7 mEq/L
B. delivering a foreign substance into body, hypertension can occur to compensate fluid changes, etc.
182
A nurse cares for a client following a below-the-knee-amputation. The client states "I can't look where my leg used to be." What response by the nurse is therapeutic?
A. I would have a hard time too
B. You are struggling with looking at your body?
C. Let me show you some range of motion exercises
D. I can come back later if you are not ready for your assessment
B.
183
A nurse provides dietary teaching to a client who has recently been diagnosed with acute cholecystitis. What instruction should the nurse include?
A. Eat balanced meals with complete protein
B. Consume low fat diet rich in HDL food sources
C. Avoid eating snacks within two hours of bedtime
D. Ingest small frequent meals, omitting liquids with meals
B.
Cholecystitis - swelling (inflammation) of the gallbladder. It is a potentially serious condition that usually needs to be treated in hospital.
184
A nurse provides teaching to a client following a left eye cataract removal with lens implant procedure. What statements indicate effective instruction? SATA
A. I will have 20/20 vision without glasses
B. My vision will be unchanged for several weeks
C. I should contact my surgeon if I experience pain
D. I will wear a patch on the left eye until my checkup
E. My eyelid swelling and bruising will be managed with ice packs
C & D
A- involves lasix surgery
B- should be immediate
E- cataract surgery does not have to do with eyelid, should be no swelling or bruising in this area
185
A client who is in the transitional phase of labor reports lightheadedness and tingling hands. What should be the initial action by the nurse?
A. Apply oxygen via nasal cannula
B. Obtain vital signs and pulse oximetry
C. Instruct client to breath into her cupped hands
D. Support client to decrease rate and depth of breathing
C. helps increase CO2, by collecting CO2 in hands and re-breathing to restore balance of oxygen and CO2
186
A client who is prescribed clozapine prepares for discharge. The nurse evaluates teaching as effective when the client makes which statements? SATA
A. Monthly injections will be required
B. Orange juice will increase the absorption
C. I should stand up slowly to prevent dizziness
D. The medication should be stopped if I have a headache
E. If flu like symptoms occur I will call the provider immediately
C & E
Side effects- dizziness, lightheadedness, fainting when standing up
Antipsychotic First gen
187
A nurse cares for a client who is prescribed olanzapine. What client statement indicates a need for further instruction?
A. I can eat whatever I want while taking the medication
B. I will continue taking olanzapine even when I have no delusions
C. It may take up to 1 month before symptoms are managed
D. I will go to the lab frequently to monitor WBC level during the first 2 months
A
Avoid grapefruit juice
188
A nurse cares for a client who is newly diagnosed with Autism Spectrum Disorder. What actions should the nurse implement? SATA
A. Introduce new activities slowly
B. Monitor level of attention span
C. Decrease environmental stimuli
D. Administer stimulant medication
E. Promote positive reinforcement
A, C, E
B- for ADHD child
189
A nurse cares for a client who is receiving magnesium sulfate IV for preeclampsia. Assessment findings include: absent deep tendon reflexes and respiratory rate of 10/min. What action should be implemented first?
A. Administer calcium gluconate IV
B. Place client in high-Fowler's position
C. Stop magnesium sulfate infusion
D. Decrease magnesium sulfate infusion
C.
190
A nurse cares for a client who is receiving peritoneal dialysis. What action should the nurse implement after one half to the total dialysate solution is returned?
A. Provide additional dialysate solution
B. Reposition client by turning side to side
C. Advance catheter further into abdomen
D. Milk catheter using thumb and index finger
B. turning to try to gather more fluid
C- can get stuck on something if advance too much
D- no longer an acceptable form of practice
191
A client who is 1 hr postpartum presses the call light and reports "a lot of blood and clots are coming from my vagina." What should the nurse do first?
A. Check time and mount of last void
B. Determine uterine firmness and location
C. Assess for orthostatic changes in vital signs
D. Examine the episiotomy for signs of bleeding
B.
192
A client who is diagnosed with schizophrenia states, "I am gesticulated and the confrazzlement of the issues warrants you to leave the room." How should the nurse interpret this information? The client is...
A. unable to use abstract reasoning
B. demonstrating grandiose delusions
C. incapable of accurately associating concepts
D. exhibiting a disruption in thought processes
D.
193
A nurse cares for a client who is prescribed lithium carbonate therapy. What findings should the nurse recognize as early signs of toxicity? SATA
A. Lethargy
B. Mild thirst
C. Dehydration
D. Blurred vision
E. Slurred speech
A, C, E
Normal range - 0.6-1.2mEq/L
194
A nurse cars for a client who has PTSD. What action should the nurse implement? SATA
A. Reinforce behavioral therapy
B. Allow expression of traumatic event
C. Administer haloperidol orally PRN
D. Encourage family participation in therapy
E. Approach client in calm, reassuring manner
B, D, E
C- antipsychotic medication
195
A nurse cares for a client who is prescribed paroxetine. What client statement should be reported immediately?
A. I can cut back on my coffee intake
B. When I feel better, I can be more social
C. This should help my St. John's wort work better
D. I will remember to take another pill at bedtime
C.
SSRI- increases serotonin (depression, anxiety)
196
A nurse plans discharge for a client who has dependent personality disorder. What findings indicate a desired response to therapy? SATA. The client...
A. demonstrates empathy for others
B. creates a daily list of short-term goals
C. gathers information before decision-making
D. self-administers diazepam to control anger
E. manages delusions of grandiosity with quetiapine
B & C
D- has nothing to do with dependent personality disorder, for anger management
197
A nurse is preparing a client who is in active labor for epidural anesthesia. What action should be implemented at this time?
A. Infuse an isotonic IV bolus
B. Place indwelling bladder catheter
C. Assist client in left side-lying position
D. Measure bilateral deep tendon reflexes
A. fluid!
198
A nurse cares for a client who is receiving oxytocin an has uterine contractions with a duration of 120 seconds. The fetal HR is 85 bpm. What action should be the priority?
A. Place client in supine positon
B. Discontinue oxytocin infusion
C. Apply 100% oxygen via face mask
D. Notify health care provider immediately
B.
199
A nurse cares for a client 24 hrs postpartum who has developed endometritis. What interventions should the nurse anticipate? SATA
A. Lochia assessment
B. Sitz baths as needed
C. Cephalosporin IV therapy
D. Perineal pads changed ever 6 hrs
E. Abdominal binder when ambulating
A, B, C
D- will be more frequent than that 2-4 hrs
E- did not mention c-section so no abdominal binder or order necessary
Endometritis- causes inflammation to the lining of your uterus. It's caused by bacterial infections after surgical procedures, childbirth or from sexually transmitted infections
200
A nurse cares for a client who has acute pyelonephritis. What finding should the nurse recognize as an effective response to therapy?
A. 24 hr urine collection of 1550 mL
B. Clank pain decreased since initial treatment
C. Clear liquids tolerated without nausea or vomiting
D. WBC changed form 18,000/mm3 to 13,000/mm3
D. higher WBC=worse the infection
