ATI NEW EXAMS COMPILATION(MED SURG, FUNDAMENTALS,MENTAL HE... - $70.45 Add To Cart
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ATI Med surg proctored exam 2022 (NEW!) 75 QUESTIONS WITH 100% CORRECT ANSWERS 1. A nurse is assisting with he care of a client following a left femoral c... [Show More] ardiac angiography. Thee nurse should place a sandbag on the client over which of the following areas? - 2. A nurse is reviewing the lab results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas ABG values include: 3. A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? - 4. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance which of the following actions should the nurse take first? - 5. Based on a clients recent history a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? - 6. A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at Mcburneys point? - 7. A nurse is reinforcing teaching about excercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - I 8. A nurse is caring for a client who is postoperative following a tracheostomy and has copies and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin the clients secretions? - 9. A nurse is reviewing the lab results of a client who is taking cyclosporine following a kidney transplant. Which of the following lab findings should the nurse identify as the most important to report to the provider? - 10. A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? - 11. A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long term goals is appropriate with regard to the clients mobility? - 12. A nurse is reinforcing teaching about an esophagogastrodudenscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? - 13. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? - 14. A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to section. Which of the following is the priority finding the nurse should report to the provider? - 15. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? - 16. A nurse is caring for a client after a radical dissection. To which of the following should the nurse give priority in the immediate postoperative period? - 17. A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? - 18. A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? - 19. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? - 20. A nurse is assisting with thee care of a client who is postoperative and has a closed wound drainage system in place. Which of the following actions should the nurse take? - 21. A nurse is caring for a Client who has Alzheimers disease. The nurse discovers the client entering the room of another client who comes upset and frightened. Which of the following actions should the nurse take? - 22. A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? - 23. A nurse is collecting data from a client who has open angle glaucoma. Which of the following findings should the nurse expect? - 24. A nurse in a providers office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? - 25. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - 26. A nurse is checking the suction control chamber of a clients chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? - 27. A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if thee biopsy will hurt. Which of the following responses should the nurse make? - 28. A nurse is assisting in the plan of care for a client who had removal if the pituitary gland. Which of the following actions should the nurse include in the plan? - 29. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? - 30. A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? - 31. A nurse is caring for a client who has a temp of 103.5 and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? - 32. A nurse is reinforcing preop teaching for a client who is scheduled for surgery and is to take hydroxyzine preop. Which of the following effects of the medication should the nurse include in the teaching? - 33. A nurse is collecting data from a client who has acute gastroenteeritis. Which of the following data collection findings should the nurse identify as the priority? - 34. A nurse is caring for a client who is being evaluated for endometerial cancer. Which of the following findings should the nurse expect the client to report? - 35. A nurse is reinforcing teaching with a client who has a new presicprion for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? - 36. A nurse is caring for an older adult client who has dysphasia and left sided weakness following a stroke. Which of the following actions should the nurse take? - 37. A nurse is caring or a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? - 38. A nurse is caring for a client who asks why she is being preceived aspirin 325 mg daily following a MI. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? - 39. A nurse is caring for a client who has a spinal cord injury at T4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of thee following interventions should thee nurse take to prevent autonomic dysreflexia? - 40. A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate TURP and has a 3 way urinary Catheter with a continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? - 41. A nurse is caring for a client who is difficult to arrouse and very sleepy for several hours following a general tonic clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? - 42. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? - 43. A nurse is collecting data on a clients wound. The nurse observes that the wound surface is covered with soft red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? - 44. A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non melanoma skin cancer? - 45. A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? - 46. A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? - 47. A nurse is preparing to provide morning hygiene care for a client who has Alzheimers disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? - 48. A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip athroplasty. Which of the following interventions should the nurse include in the plan? - 49. A nurse is caring for a client who is postoperative and has a history of Addisons disease. For which of the following manifestations should the nurse monitor? - 50. A nurse is assisting with caring for a client who has a new concussion following a MVC. The nurse should monitor the client for which of the following manifestations of the increased IP? - 51. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? - 52. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? - 53. Following admission a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client comfort? - 54. A nurse is minoring the client peripheral circulation. Identify where the nurse should palpate to check the posterior tibial pulse. - 55. A nurse is caring or a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurses priority? - 56. A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? - 57. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? 58. A nurse is assisting with the care of a client who is postoperative following a surgical repair of a fractured mandible. The clients jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? - 59. A nurse is reinforcing teaching with a Client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? - 60. A nurse is caring for a client who is 4 hr postoperative following a TIRP. Which of the following is the priority for the nurse to report to the provider? - 61. A nurse is assisting with planning care for a client who is recovering from a left hemispheric stroke. Which of the following interventions should the nurse include in the plan? - 62. A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care the nurse notices a thin stream of clear drainage coming out of the clients right nostril. Which of the following actions should the nurse take first? - 63. A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? - 64. A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? - 65. A nurse is caring for a client who has Cushings syndrome. Which of the following clinical manifestations should the nurse expect to observe? - 66. A nurse is reinforcing teaching with a client who is newly diagnoses with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? - 67. A nurse is caring for a client who has partial thickness and full thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? - 68. A nurse is caring for a client who is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom using an IV pole for support. Which of the following actions should the nurse take? - 69. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? - 70. A nurse is caring for a client who is 3 days postoperative following a cholescytectomy. The nurse suspects the clients wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? - 71. A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? - 72. A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent psotop complications which of the following actions should be reinforced during the teaching? - 73. A nurse is reinforcing teaching with a client who has PVD. The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 74. A nurse is reinforcing teaching with a client who reports right shoulder pain following a laproscopic cholescystecomty. Which of the following statements should the nurse make? - 75. A nurse is reinforcing teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? - [Show Less]
Leadership ATI proctored Exam Questions [94] 2022 (NEW!) 100% CORRECT ANSWERS 1. A nurse is assessing pressure ulcers on four clients to evaluate the ef... [Show More] fectiveness of a change in wound care procedure. Which of the following findings indicate wound healing? 2. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? 3. A nurse manager is planning to assign care for four clients on a medical-surgical unit. Which of the following clients should the nurse assign to a licensed practical nurse? - 4. A nurse manager discovers there is a conflict between nurses working the day shift and nurses working the night shift. Which of the following actions should the nurse manager take first? - 5. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? - 6. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first? 7. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? - 8. A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical-surgical unit? - 9. A nurse is coordinating an inter-professional team to review proposed standards to reduce the transmission of MRSA. Which of the following members of the inter-professional team should the nurse consult? - 10. A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? - 11. A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? - 12. A nurse is completing a performance evaluation for assistive personnel (AP). Which of the following actions by the AP requires intervention by the nurse? - 13. A nurse is preparing a shift assignment for assistive personnel (AP) on the unit. Which of the following tasks should the nurse assign to the AP? - 14. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a client. Which of the following actions should the nurse take? - 15. A home health nurse is performing a safety assessment of a client's home. Which of the following findings should the nurse identify as a safety hazard? 16. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.) - 17. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - 18. A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy? 19. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response? 20. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? - 21. A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first? - 22. A charge nurse witnesses assistive personnel (AP) falling to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first? - 23. A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan? 24. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? - 25. A charge nurse overhears a staff nurse discussing a client's diagnosis in the cafeteria. Which of the following responses should the charge nurse make? - 26. A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique? - 27. A nurse working in a long-term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the following actions should the nurse take? 28. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate? - 29. A nurse is planning discharge for a client who had a lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports this referral? 30. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for this referral? - 31. A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating "I've never taken these before." Which of the following actions should the nurse take first? - 32. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? 33. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following - 34. A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate? 35. A nurse suggests respite care for the partner of a client who has mild cognitive impairment. The client's partner asks the nurse how that would help. The nurse should explain that respite care would do which of the following? 36. A charge nurse observes a client fall during ambulation and notes that his gait belt was not in place. In reviewing the incident report, the nurse finds no mention of a gait belt. Which of the following ethical principles should guide the nurse's subsequent actions? - 37. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? - 38. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have sufficient experience to safely care for his assigned clients. Which of the following actions should the nurse take? - 39. A nurse is conducting an in-service about the nursing code of ethics with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy? - 40. A charge nurse in the emergency department is supervising a nurse who is floating from the medical-surgical unit. Which of the following assignments is appropriate for the float nurse? - 41. A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary? 42. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used for a client who has C. diff. Which of the following solutions should the nurse recommend to clean the equipment? 43. A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care? - 44. A nurse is providing information to a client about advance directives. The nurse should explain that advance directives include which of the following? - 45. An infection control nurse is planning an education program for a group of newly licensed nurses. Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions? - 46. A nurse in the emergency department is caring for a 16-year-old client who reports abdominal pain and is accompanied by an adult neighbor. The provider diagnoses a ruptured appendix and states that the client requires an emergency appendectomy. Which of the following actions should the nurse take? - 47. A nurse enters a client's room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? - 48. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take? - 49. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? - 50. A nurse is observing an assistive personnel (AP) administer a 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? - 51. A nurse is planning to discharge a client who has terminal cancer and suggests that the family might benefit from respite services. When the client's partner asks how this service can help, which of the following responses by the nurse is appropriate? - 52. During a staff meeting, a unit manager reviews the results for documenting client education and finds that they are below the benchmark. Which of the following strategies should the nurse manager implement first? - 53. A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first? - 54. A nurse at the local health department is caring for four clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? - 55. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? - 56. A nurse is caring for a client who has cancer. The client and her partner are asking the nurse about hospice care. Which of the following statements by the nurse is appropriate? 57. A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority? - 58. A nurse enters the room of a client who is unconscious and finds that the client's son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? 59. A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report? - 60. A nurse is completing discharge teaching with a client who is being treated for tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? - I 61. A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client's partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done? - 62. A nurse is prioritizing care after receiving change-of-shift report on four clients. Which of the following clients should the nurse assess first? - 63. A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client's ring? 64. A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take? - 65. A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of the following statements by a staff nurse indicates understanding? 66. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - 67. A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take? - 68. A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department? - 69. A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management? - 70. A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event? - 71. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? - 72. A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatments first? - 73. A nurse is caring for a group of clients. Which of the following clients should the nurse see first? - 74. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? - 75. A charge nurse is observing a newly licensed nurse provide care for a client who has a C. diff infection. Which of the following actions by the newly licensed nurse indicates an understanding of proper infection control procedures? - 76. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client's care? (Select all that apply.) - 77. A nurse on a medical-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make? 78. A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take? - 79. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? 80. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first? - 81. A nurse from the labor and delivery unit is assigned to float to a medical-surgical unit. Which of the following actions should the nurse take first? - 82. A nurse in the emergency department is preparing a married 17-year-old client for an appendectomy. The client's parents are en route to the facility but have not spoken with the surgeon. Which of the following actions should the nurse take? - 83. A charge nurse overhears a provider and a nurse talking about a client's diagnosis in the cafeteria. Which of the following actions should the nurse take first? - 84. A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take? - 85. A nurse is planning care for four clients who were classified using a disaster triage tag system following a mass casualty event. Which of the following clients should the nurse identify as the priority? - 86. A nurse is delegating tasks to assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? - 87. A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech language pathology? - 88. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls? (Select all that apply.) - 89. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the in-service? - 90. A nurse on a medical-surgical unit is preparing to assign vital sign measurements for a group of clients. Which of the following clients should the nurse delegate to assistive personnel? 91. A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance? - 92. A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take? - 93. A nurse is planning discharge for a client following a hip arthroplasty. The client tells the nurse that she lives alone. Which of the following actions should the nurse take first? 94. Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan? - [Show Less]
PN3 ATI Proctored Exam 2022 >>133 QUESTIONS WITH 100% CORRECT ANSWERS 1. A nurse is reinforcing teaching with a client who has HIV and is being dischar... [Show More] ged to home. Which of the following instructions should the nurse include in the teaching? 2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? - 3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? - 4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? - 5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? - 8. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? - 9. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? - 10. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? - 11. A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? - 12. A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? - 13. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 14. A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 15. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? - 16. A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? - A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? - 17. A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? - 18. A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? - 19. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? - 20. A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? - 21. A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? 22. A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? 23. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? 24. A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 25. A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 26. A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend 27. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? - 28. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? 29. A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? 30. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? 31. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 32. A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 33. A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 34. A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 35. A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? - 36. A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? - 37. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 38. A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? 39. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - 40. A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? 41. A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? - 42. A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 43. A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? 44. A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? - 45. A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan? 46. A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? 47. A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make 48. A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? - 49. A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 50. A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? - 51. A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? - 52. A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? - 53. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 54. A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? - 55. A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? - 56. A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? 57. A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? - " 58. A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? - 59. A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? - 60. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 61. A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? 62. A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? 63. A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? - 64. A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? - 65. Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? - 66. A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? 67. A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? - 68. A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? 69. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? - 70. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? 71. A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take? 72. A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? - 73. A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? - A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? - 74. A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make? A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? - 75. A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? - 76. A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? - 77. A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? - 78. A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? - 79. A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? - 80. A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds? - 81. A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? - 82. A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? - 83. A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? - 84. A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan? - A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? 85. A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions? 86. A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? 87. A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? - " 88. A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? - 89. A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? 90. A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? 91. A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? 92. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) - 93. A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) 94. A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor? 95. A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority? - 96. A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching? 97. A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? - 98. A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? 99. A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first? - 100. A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? - 101. A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? - " 102. A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia? - 103. A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? - 104. A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions? 105. A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? 106. A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer? 107. A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client's renal function? 108. A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect? 109. A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first? 110. A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? 111. A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? - 112. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? 113. A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? -. 114. A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? - 115. A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? - 116. A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? - 117. A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? - 118. A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? - 119. A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? - 120. A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? - 121. A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? - 122. A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? - 123. A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? - 124. A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching? - 125. A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease? - 126. A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority? -. 127. A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? - " [Show Less]
Tobramycin Sulfate contraindicated in: - Ibuprofen (Motrin) Metformin (Glucophage) and glipizide (Glucotrol) for diabete mellitus. Nurse check what lab:... [Show More] - HbA1c of below 7% for diabetics Warfarin antidote: - Vitamin K Pancrelipase (Pancrease) teaching plan: - Take at each meal and snack. Levothyroxine (Synthroid) effective if: - TSH 0.5-2 mircounits/mL T4 and T3 Value - t3: 75-220 ng/dL t4: 4-11 mcg/dL Prazosin (Minipress) teaching: - Move slowly from sitting to standing. Phenytoin (Dilantin) teaching: - Hirsutism, avoid alcohol and antihistamines, double vision Enalapril (Vasotec) and spironolactone (Aldactone) adverse effects: - Hyperkalemia because its a ACE-inhibitor and K-sparing diuretic. Methotrexate (Rheumatrex) for Rheumatoid arthritis teaching: - Report sores in mouth, take once a week [oral or injection], 4-6 weeks to work. Mannitol (Osmitrol) effective: - Urine output increases Morphine Sulfate following thoracic procedure. What indicates client pain being managed: - Client able to breathe deeply and cough. Amitriptyline (Elavil) adverse effects: - Urinary retention. Magnesium Sulfate toxicity signs: - Decrease level of consciousness, CNS depression Ferrous Sulfate enhance absorption: - Asorbic Acid Sotalol Hydrochloride (Betapace) teaching plan: - Decrease heart rate. Patient on Insulin Lispro and prescribed Metoprolol (Lopressor) for HTN. Nurse should observe what signs for hypoglycemia: - Sweating Nitroglycerin SL teaching: - Lie down, check BP, relief in 1-3 mins, monitor for headache. Allopurinol (Zyloprim) contraindications: - Warfarin Atovastain (Lipitor) nurse should monitor: - CK-Creatinine Kinase Exercise induced asthma: - Cromolyn sodium (Intal) Furosemide (Lasix) withhold: - Potassium level Insulin glargine (Lantus) type 1 diabetes mellitus teaching plan: - DO NOT MIX in syringe, adminster at bedtime, clear, don't need to shake Colesevelam (WelChol) teaching plan: - Other medication 1 hour or 4 hours after, taken with food or water, high fiber diet. Levothyroxine (Synthroid) breastfeeding: - Take after breast feeding. Fluoxetine (Prozac) teaching plan: - Don't take St. John's Wort, may get rash, Acetaminophen instead of Ibuprofen. Digoxin (Lanoxin) patient experiences Dysrhythmias: - Furosemide (Lasix) lead to hyperkalemia causes dysrhythmias. Ceftriaxone (Rocephin) postop and notices Uticardia and dyspnea: - Discontinue infusion Ketorolac (Toradol) teaching plan: - Check for bruising, Take with food. Risedronate (Actonel) for osteoporosis teaching plan: - Sit up 30 mins, don't take with milk, take in morning, take on empty stomach. Albuterol (Proventil) for asthma with montelukast (Singular) teaching: - Take montelukast at night Pilocarpine (Pilocar) eye drops teaching: - Don't drive until vision clears, cause brow pain, take for rest of life, messes with the rest of the body Required Digoxin measurements: - Peak and trough Naloxone (Nacar) Antidote: - Observe for bleeding, Assess client for nausea and vomiting, check pain frequently, tachycardia, repeat dose every 2-3 minutes. Fluticasone propionate (Flovent) adverse: - Candidasies of the mouth, dysphonia. Trimethropim/sulfamethoxazole (Barctim DS) teaching: - Drinking 8-10 glasses of water Gentamicin (Garamycin) side effect: - Ototoxicity Telephone prescription from provider. The Nurse: - Reads the prescription back to the provider. Seizure disorder. Patient should: - Keep a seizure chart. Potassium level: - 3.5-5 mEq/L Potassium level less then 3.5 mEq/L: - Cardiac monitor for cardiac dysrhythmias. Penicillin allergy requires incident report with what symptom: - S.O.B. Phenytoin (Dilantin) decreases effectiveness of: - Ethinyl/desogestrel (Oral contraceptive) Ergotamine (Ergostat) SL for migraine headache: - 1 SL tablet at onset of headache. Digoxin level: - 1.0-2.0 ng/mL. Digoxin is toxic at 2.4 give Digoxin immune fab (Diggibind) Avoid during metronidazole (Flagyl): - Beer can cause disulfiram-reaction (Hypotension, vomiting, weakness) Captopril (Capoten) cannot be used: - With salt substitue with meal or potassium. Mannitol (Osmitrol) achieving therapeutic effect: - Decrease intraocular pressure for acute closure glaucoma. Simvastatin (Zocor) teaching plan: - Report muscle pain, do not take med with grapefruit juice, minimize alcohol intake, life long therapy, take in the evening. Heparin and warfarin client with 4 times aPPT and INR of 2: - Decrease the heparin. aPPT (Activated partial thromboplastin time) plasma value: - 1.5-2 times the normal INR (International Normalized Ratio) value: - 2.0-3.0. Target of 2.5. Higher the number bleeding disorder. Lower the number clotting disorder. Oxytocin (Pitocin) by continuious IV, piggy backed into maintenance IV solution. FHR indicates late decelerations. The nurse first: - Discontinue client's IV to reduce contractions. Bupropion (Zyban) side effects: - Insomnia (Stimulant). Risedronate (Actonel) to treat osteoporosis. Client teaching: - Take in the morning, sit up 30 mins after taking, take with food, swallow whole. Haloperidol (Haldol) adverse effects (Used for treating vomiting): - Akathisia (Restlessness). Oprelvekin (Interleukin 11-WBC) effectiveness: - Increase platelet count in chemotherapy patients. Baclofen (Lioresal) therapeutic outcome: - Decrease the frequency and severity of muscle spasms (MS). Epoetin Alfa (Procrit) to treat anemia. Nurse should monitor: - Increased blood pressure and seizures if hematocrit rises too quickly. Tranylcpromine (Parnate) for depression. Client teaching: - Move slowly when changing position because orthrostatic hypotension can result as a side effect. Exenatide (Byetta) for type 2 diabetes mellitus. Nurse needs to monitor immediately: - Abdominal pain due to pancreatitis. Secondary symptom for hyperglycemia: Increased thirst Hypoglycemia symptoms: - Diaphoresis and Irritability [Show Less]
Resignation most nearly means: - Acceptance Tangible most nearly means: - Real Feasible most nearly means: - Workable Impure means the opposite of... [Show More] : - Unalloyed Scale mans the opposite of: - Descend Levity means the opposite of: - Gravity Optimistic: Hope:: - Sage:Wisdom Agenda:Meeting:: - Program:Play Forge:Signature:: - Counterfeit:Money Choose the word that is misspelled: Nuetral Perceived Efficient Analysis - Nuetral = Neutral Choose the word that is misspelled: Acessible Endure Magnified Comprehension - Accessible (two C's) Choose the word that is misspelled: Surreal Obsolete Negligance Infused - Negligence (gence - not gance) Resolute - Determined Terse - Short, abrupt Vanquish - To defeat, or conquer in battle Cautious - Careful in actions or behaviors Lethargic - Sluggish, inactive, apahtethic Sullen - Depressed, gloomy Legible - possibly to read or decipher Fawn (v) - to show submission, act in a servile manner Jeer (n) - Taunt, ridicule Adrift - Wandering aimlessly, without direction Query - A question Impure - Lacking in purity, unclean Disinterested - Impartial, unbiased Pathetic - Sad, Pitiful Clandestine - Secret Rankle - To cause continuing anger or irritation, Irk Genuine - Authentic Magnanimous means the opposite of: - Greedy Edifice:Building:: - Tome:Book Quarrelsome:Argue - Vivacious:Energy Coward:Bravery (lacks bravery) - Braggert:Modesty Scissors:Cut - Pen:Write Loud:Deafening - Apartment:Mansion (provides housing at a lesser degree) Measles:Disease (measles is a type of disease) - Baseball:Sport (baseball is a type of sport) Forest:Trees (a forest is made up of many trees) - Bouquet: Flowers (A bouquet is made up of many flowers) Which word is misspelled? - The girl was upset when she asked to meet with the principal of the school. (it is principle of the school). Grave - serious Delegate most nearly means: - Assign Favor most nearly means: - Prefer Laurels - Honor Acute means the opposite of: (sudden, sharp pain) - Dull Ghastly most nearly means: - Awful Inorganic compounds - chemicals without carbon, sodium chloride, nitrogen and phospoorus Organic compounds - chemicals that contain carbon, that support life, includes proteins, lipids, carbohydrates, and nucleic acids Water bonds - Hydrogen bonding Carbohydrates - main class of biological molecules, composed of carbon, hydrogen and oxygen, including sugars and starches [Show Less]
a nurse is caring for a client who is receiving total parenteral nutrition (TPN). The current bag of TPN is empty and a new bag is not available on the uni... [Show More] t. Which of the following solutions should the nurse infuse until a new bag of TPN is available? - Dextrose 10% in water B/c - at the same rate it will prevent hypoglycemia a nurse is teaching about nutritional requirements for a client who is starting a vegetarian diet. Which of the following information should the nurse include in the teaching? - include two servings per day of nuts when on a vegetarian diet : or flaxseed to receive daily requirement of omega 3 fatty acids A nurse is providing teaching about lowering solid fat intake to an adolescent who is overweight. Which of the following instructions should the nurse include? - restrict you daily meat intake to 5 ounces : a meat potion should be no greater than the size of a deck of cards. fun facts: limit egg yolk consumption to 3 per week select cheeses that contain no more than 3 g of fat per serving choose margarine no more than 2 g of saturated fat per tablespoon a nurse is providing dietary teaching to a client who has celiac disease. Which of the following statements by the client indicates an understanding of the teaching? - i can have tapioca pudding for dessert ; b/c its gluten free facts: should avoid processed foods including canned soups b/c they have gluten and whole bread a nurse is preforming a comprehensive nutritional assessment for a client. after reviewing the clients lab results which of the following findings should the nurse report to the provider? - pre albumin 8 mg ; indicates severe malnutrition and requires reporting to the provider a low T4 level can indicate hypothyroidism or protein malnutrition low sodium level = malnutrition elevated WBC dietary deficiencies a nurse is providing discharge teaching to a client who has parkinson disease and a prescription for levodopa carbidopa. Which of the following foods should the nurse instruct the client to consume with the medication ? - 1 slice wheat toast : absorption of levodopa+carbidopa decreases when consumed with protein. one slice of toast is the lowest source of protein a nurse is assessing a clients risk for pressure ulcers using the Braden Scale. The client eats more than half of most meals but occasionally refuses a meal. Which of the following information should the nurse document on the nutrition category of the Braden scale? - adequate- 3 a nurse is providing teaching about cancer prevention to a group of clients. Which of the following client statements indicates and understanding of the teaching? - i will eat 5 servings of fruit and veggies everyday - decreases blood pressure and weight Facts; woman 1 men 2 alcoholic drinks a day a nurse is caring for a client who has cirrhosis and ascites. which of the following dietary instructions should the nurse provide for this client? - decrease your sodium intake to 1-2 grams a day. - this decreases fluid retention a nurse is assessing a client who has type 2 diabetes mellitus. The nurse should recognize which of the following as a manifestation of hypoglycemia? - confusion facts: polydipsia - excessive this or drinking vomiting ketonuria-starvation or diabetes 1 - body is producing excess amount of ketones in urine. is all for hyperglycemia a nurse is in the ER reviewing the lab report for an older adult client who is confused and reports nausea and abdominal cramping. Nurse should suspect the clients lab results to indicate a dietary deficiency of which of the following minerals? - sodium a nurse is teaching about increasing dietary intake of micronutrients to a client who has difficulty seeing at night. which micronutrients should nurse include in teaching? - Vitamin A - enables eyes to adapt to light calcium facilitates nerve transmission and cell membrane permeability Vitamin B6 assists in formation of hemoglobin and synthesis of neurotransmitters phosphorus assists in formation of bones and teeth a nurse is providing nutritional teaching to parents of 2 yr old. Which snack should she recommend? - a cup of yogurt a nurse is caring for a client who is prescribed captopril. which food can cause a potential medication interaction? - cantaloupe- high in potassium a nurse is teaching an adolescent who has a new diagnosis of celiac disease. what indicates that they understand teaching? - need to eliminate rye from diet a nurse is providing diet instructions to a client who has a prescription for warfarin. Which of he following foods should the nurse recommend the client eat in moderation while taking this medication? - green leafy veggies- they contain natural for of vitamin K the can negate the anticoagulation effects of warfin [Show Less]
What are cognitive symptoms of psychotic disorders - -disordered thinking -inability to make decisions -poor problem solving ability -difficult concentr... [Show More] ating to perform tasks -Memory deficits Misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about them - ideas of reference Feels singled out for harm by others (being hunted down by FBI) - Persecution Believes that she is all powerful and important like a god - grandeur believes that his body is changing in an unusual way, scubas growing a third arm - somatic delusions May feel that her spouse is sexually involved with another individual - Jealousy Believes that a force outside his body is controlling him - being controlled believes that her thoughts are heard by others - thought broacasting believes that others thoughts are being inserted into his mind - thought insertion Believe that her thoughts have been removed form her mind by an outside agency - thought withdrawal is obsessed with religious beliefs - religiosity The client may say sentence after sentence but each sentence may relate to another topic and the listeniner is bale to follow the clients thoughts - flight of ideas Made up words that have meaning only to the client such as i tranged and flitted. - neologisms What are the standardized screen tools for psychotic disorders - -Global assessment of functioning scale -scale for assessment of negative symptoms -brief psychiatric rating scale -Brief psychiatric rating scale -abnormal involuntary movement scale (AIMS) What antidepressants are prescribed for psychotic disorders - Paxil -monitor for SI -Notify for deepened depression -Do not stop abruptly What are the anxiolytics/ bento's used for psychotic disorders? - -Ativan -Klonopin -sedative effects -need to get blood tests for ANC -use caution in older adults What are the personality disorders in cluster A - (Odd and eccentric traits) -Paranoid -Schizoid -Schizotypal Characterized by odd beliefs leading to interpersonal difficulties, an eccentric appearance, and magical thinking or perceptual distortions that are not clear delusions or hallucinations - schizotypal Dealing with anxiety by reaching out to others. Ex: a nurse who lost a family member in a fire is a volunteer firefighter - Altruism Dealing with unacceptable feelings or impulses by unconsciously substitute acceptable forms of expression. Ex: a person who has feelings of anger and hostility toward his work supervisor sublimates those feelings by working out vigorously a the gym during his lunch period - Sublimation Voluntarily denying unpleasant thoughts and feelings. Ex: A person who has lost his job states he will worry about paying his bills next week - Suppression Putting unacceptable ideas, thoughts, and emotions out of conscious awareness. Ex: a person who has a fear of the dentist's drill continually "forgets" his dental appointments. - Repression What are healthy defense mechanisms? - alturism and sublimation what are intermediate defenses - repression reaction formation displacement rationalization undoing What are immature defenses - projection dissociation splitting denial Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation Ex: A person who is angry about losing his job destroys his child's favorite toy - displacement Overcompensating or demonstrating the opposite behavior of what is felt. Ex: a person who dislikes her sisters daughter offers to babysit so that her sister can go out of town - reaction formation Performing an act to make up for prior behavior. Ex; An adolescent completes his chores without being prompted to after having an argument with his parents. - undoing creating reasonable and acceptable explanations for unacceptable behavior Ex: A young adult explains he had to drive home from a party after drinking alcohol because he had to feed his dog. - rationalization temporarily blocking memories and perceptions from consciousness Ex: an adolescent witnesses a shooting and is unable to recall any details of the vent - dissociation demonstrating an inability to reconcile negative and positive attributes of self or others Ex:a client tells a nurse that she is the only one who cares about her, yet the following day the same client refuses to talk to the nurse - splitting Blaming others for unacceptable thoughts and feelings Ex: a young adult planes his substance use disorder on his parents refusal to buy him a new car - projection pretending the truth is no reality to manage the anxiety of acknowledging what is real. [Show Less]
The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement made by the client reflects... [Show More] the need for further teaching? A. "I will take my pills every day at the same time." B. "I will be certain to avoid alcohol consumption." C. "I have already called my family to pick up a Medic-Alert bracelet." D. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated." - D. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated." Ecotrin is an aspirin-containing product and should be avoided. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel emergency information. A client is receiving digoxin (Lanoxin) daily. The nurse suspects digoxin toxicity after collecting data noting which signs and symptoms? Select all that apply. A. Visual disturbances B. Nausea and vomiting C. Serum digoxin level of 2.3 ng/mL D. Serum potassium level of 3.9 mEq/L E. Apical pulse rate of 63 beats per minute - A. Visual disturbances B. Nausea and vomiting C. Serum digoxin level of 2.3 ng/mL Signs and symptoms of digoxin toxicity include gastrointestinal signs, bradycardia, visual disturbances, and hypokalemia. A therapeutic serum digoxin level ranges from 0.5 to 2 ng/mL. The serum potassium level should be 3.5 mEq/L or higher. The apical pulse must be 60 or higher beats per minute. Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level? A. Prothrombin time (PT) of 21 seconds B. Thrombocyte count of 100,000 cells/mm3 C. International normalized ratio (INR) of 2.3 D. Activated partial thromboplastin time (aPTT) of 55 seconds - D. Activated partial thromboplastin time (aPTT) of 55 seconds The aPTT will assess the therapeutic effect of Heparin sodium. The PT and INR will assess for the therapeutic effect of warfarin sodium (Coumadin). A decreased thrombocyte count can cause bleeding. The nurse is monitoring a client who is taking propranolol (Inderal LA). Which data collection finding would indicate a potential serious complication associated with propranolol? A. The development of complaints of insomnia B. The development of audible expiratory wheezes C. A baseline blood pressure of 150/80 mm Hg, followed by a blood pressure of 138/72 mm Hg after two doses of the medication D. A baseline resting heart rate of 88 beats/min, followed by a resting heart rate of 72 beats/min after two doses of the medication - B. The development of audible expiratory wheezes Audible expiratory wheezes may indicate a serious adverse reaction: bronchospasm. β-Blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored. Isosorbide mononitrate (Imdur) is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action should the nurse suggest to the client? A. Cut the dose in half. B. Discontinue the medication. C. Take the medication with food. D. Contact the health care provider (HCP). - C. Take the medication with food. Isosorbide mononitrate is an antianginal medication. Headache is a frequent side effect of isosorbide mononitrate and usually disappears during continued therapy. If a headache occurs during therapy, the client should be instructed to take the medication with food or meals. It is not necessary to contact the HCP unless the headaches persist with therapy. It is not appropriate to instruct the client to discontinue therapy or adjust the dosages. A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention? A. Monitor for renal kidney failure. B. Monitor psychosocial status. C. Monitor for signs of bleeding. D. Have heparin sodium available. - C. Monitor for signs of bleeding. Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications. A client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions should the nurse should take? Select all that apply. A. Call a code blue. B. Contact the registered nurse. C. Contact the client's family. D. Collect more data on the client's pain level. E. Check the client's blood pressure. F. Administer a second nitroglycerin, 0.4 mg, sublingually. - B. Contact the registered nurse. D. Collect more data on the client's pain level. E. Check the client's blood pressure. F. Administer a second nitroglycerin, 0.4 mg, sublingually. The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. The registered nurse should be notified of the client's condition, who will then notify the health care provider immediately. In this situation, because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this. The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which statement made by the client indicates the need for further teaching? A. "Constipation and bloating might be a problem." B. "I'll continue to watch my diet and reduce my fats." C. "Walking a mile each day will help the whole process." D. "I'll continue my nicotinic acid from the health food store." - D. "I'll continue my nicotinic acid from the health food store." Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels. A client is on nicotinic acid (niacin) for hyperlipidemia, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? A. "It is not necessary to avoid the use of alcohol." B. "The medication should be taken with meals to decrease flushing." C. "Clay-colored stools are a common side effect and should not be of concern." D. "Ibuprofen (Motrin IB) taken 30 minutes before the nicotinic acid should decrease the flushing." - D. "Ibuprofen (Motrin IB) taken 30 minutes before the nicotinic acid should decrease the flushing." Flushing is a side effect of this medication. Aspirin or a nonsteroidal anti-inflammatory drug can be taken 30 minutes before taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals; this will decrease gastrointestinal upset. Taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the health care provider (HCP). The nurse is planning to administer hydrochlorothiazide (HydroDIURIL) to a client. Which are concerns related to the administration of this medication? A. Hypouricemia, hyperkalemia B. Increased risk of osteoporosis C. Hypokalemia, hyperglycemia, sulfa allergy D. Hyperkalemia, hypoglycemia, penicillin allergy - C. Hypokalemia, hyperglycemia, sulfa allergy Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia. A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol (Tenormin) for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia? A. Sweating B. Tachycardia C. Nervousness D. Low blood glucose level - D. Low blood glucose level β-Adrenergic blocking agents, such as atenolol, inhibit the appearance of signs and symptoms of acute hypoglycemia, which would include nervousness, increased heart rate, and sweating. Therefore, the client receiving this medication should adhere to the therapeutic regimen and monitor blood glucose levels carefully. Option 4 is the most reliable indicator of hypoglycemia. A client who is taking hydrochlorothiazide (HydroDIURIL, HCTZ) has been started on triamterene (Dyrenium) as well. The client asks the nurse why both medications are required. Which response is the most accurate to give to the client? A. Both are weak potassium-excreting diuretics. B. The combination of these medications prevents renal toxicity. C. Hydrochlorothiazide is an expensive medication, so using a combination of diuretics is cost-effective. D. Triamterene is a potassium-retaining diuretic, whereas hydrochlorothiazide is a potassium-excreting diuretic. - D. Triamterene is a potassium-retaining diuretic, whereas hydrochlorothiazide is a potassium-excreting diuretic. Potassium-retaining diuretics include amiloride (Midamor), spironolactone (Aldactone), and triamterene (Dyrenium). They are weak diuretics that are used in combination with potassium-excreting diuretics. This combination is useful when medication and dietary supplement of potassium is not appropriate. The use of two different diuretics does not prevent renal toxicity. Hydrochlorothiazide is an effective and inexpensive generic form of the thiazide classification of diuretics. A client who has begun taking fosinopril (Monopril) is very distressed, telling the nurse that he cannot taste food normally since beginning the medication 2 weeks ago. Which suggestion would provide the best support for the client? A. Tell the client not to take the medication with food. B. Suggest that the client taper the dose until taste returns to normal. C. Inform the client that impaired taste is expected and generally disappears in 2 to 3 months. D. Tell the client that a request will be made to the health care provider (HCP) to change the prescription. - C. Inform the client that impaired taste is expected and generally disappears in 2 to 3 months. ACE inhibitors, such as fosinopril, cause temporary impairment of taste (dysgeusia). The nurse can tell the client that this effect usually disappears in 2 to 3 months, even with continued therapy, and provide nutritional counseling if appropriate to avoid weight loss. Options 1, 2, and 4 are inappropriate actions. Taking this medication with or without food does not affect absorption and action. The dosage should never be tapered without HCP approval, and the medication should never be stopped abruptly. The nurse is planning to administer amlodipine (Norvasc) to a client. The nurse should plan to check which before giving the medication? A. Respiratory rate B. Blood pressure and heart rate C. Heart rate and respiratory rate D. Level of consciousness and blood pressure - B. Blood pressure and heart rate Amlodipine is a calcium channel blocker. This medication decreases the rate and force of cardiac contraction. Before administering a calcium channel blocking agent, the nurse should check the blood pressure and heart rate, which could both decrease in response to the action of this medication. This action will help to prevent or identify early problems related to decreased cardiac contractility, heart rate, and conduction. The nurse is preparing to administer digoxin (Lanoxin), 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the nurse to check before administering the medication? A. Heart rate B. Temperature C. Respirations D. Blood pressure - A. Heart rate Digoxin is a cardiac glycoside that is used to treat heart failure and acts by increasing the force of myocardial contraction. Because bradycardia may be a clinical sign of toxicity, the nurse counts the apical heart rate for 1 full minute before administering the medication. If the pulse rate is less than 60 beats/minute in an adult client, the nurse would withhold the medication and report the pulse rate to the registered nurse, who would then contact the health care provider. The nurse is caring for a client who has been prescribed furosemide (Lasix) and is monitoring for adverse effects associated with this medication. Which should the nurse recognize as potential adverse effects? Select all that apply. A. Nausea B. Tinnitus C. Hypotension D. Hypokalemia E. Photosensitivity F. Increased urinary frequency - B. Tinnitus C. Hypotension D. Hypokalemia Furosemide is a loop diuretic; therefore, an expected effect is increased urinary frequency. Nausea is a frequent side effect, not an adverse effect. Photosensitivity is an occasional side effect. Adverse effects include tinnitus (ototoxicity), hypotension, and hypokalemia and occur as a result of sudden volume depletion. The nurse provides medication instructions to an older hypertensive client who is taking 20 mg of lisinopril (Prinivil) orally daily. The nurse evaluates the need for further teaching when the client makes which statement? A. "I can skip a dose once a week." B. "I need to change my position slowly." C. "I take the pill after breakfast each day." D. "If I get a bad headache, I should call my health care provider immediately." - A. "I can skip a dose once a week." Lisinopril is an antihypertensive angiotensin-converting enzyme inhibitor. The usual dosage range is 20 to 40 mg per day. Adverse effects include headache, dizziness, fatigue, orthostatic hypotension, tachycardia, and angioedema. Specific client teaching points include taking one pill a day, not stopping the medication without consulting the health care provider (HCP), and monitoring for side effects and adverse reactions. The client should notify the HCP if side effects occur. A client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include a beta blocker, digoxin (Lanoxin), and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which assessment data supports this diagnosis? [Show Less]
organizational mission - the purpose of the organization vision - what the organization hopes to achieve philosophy - how and why the organization ho... [Show More] pes to meet its mission - ▪ When nurse leaders are pressured to implement organizational change from powerful economic & political interests, the purpose for change is driven externally & not internally. ▪ Nurse leaders can implement changes to alleviate immediate problems &: evaluate & quantify the external imposed changes for long-term effects., speak up, articulate, & support the value of a nurses role., & use positional influence to outline nursing's own destiny & prevent destructive practices. ▪ Change is inevitable in health care. ▪ The pace of change is accelerating. ▪ Change is complex. ▪ Nurses are always adapting to change. - Change ▪ Planned change theories/models ▪ Emergent models - Models of Change ▪ Top-down change ▪ Emergent view of change - Background of Change Conscious change leadership - Organizational Change 1. Lewin's planned change theory (1947, 1951) 2. Kotter's model of change (1996) - Change Theories/Models Used in Nursing A successful change involves three elements: ▪ Unfreezing ▪ Moving ▪ Refreezing - Lewin's Force Field Analysis ▪ Establish a sense of urgency. ▪ Create a guiding coalition. ▪ Develop a vision and strategy. ▪ Communicate the change vision. ▪ Empower employees for broad-based action. ▪ Generate short-term wins. ▪ Consolidate gains and produce more change. ▪ Anchor new approaches in the culture. - Kotter's Model of Change ▪ Executives do not direct change; they initiate and influence the direction. ▪ Recipients of change translate and edit plans for change. ▪ The main method used by recipients to interpret change is informal communication. ▪ Senior management must monitor and engage the "informal" channels. ▪ Attention must be given to open discussions and storytelling in communication about change. ▪ Recipients of change will mediate outcomes; managers need to engage in activity with them. ▪ Using change ambassadors to help the engagement may be helpful (especially in large organizations). [Show Less]
1. A nurse is caring for a pregnant client who is schedules to have a contraction stress test (CST). The nurse should anticipate administering which of the... [Show More] following medications? Answer- Oxytocin 2. A nurse is caring for a client who is prescribed ergotamine tartrate (Ergomar). The nurse should recognize that ergotamine tartrate is indicated for which of the following? Answer- Migraine headaches 3. A primary care provider has prescribed 250 mg PO Q6H of a medication for a client. The label reads 50 mg/ml. How many ml should the client receive in a 24 hour period? Answer- 20 ml 4. A nurse is taking the medication history on a client who is to receive a first dose of ceftriaxone (Rocephin). Which of the following allergies should the nurse report to the primary care provider? Answer- Piperacillin sodium 5. A nurse is caring for a client who is to start epoetin alfa (Epogen) for chronic renal failure. The nurse should recognize that the epoetin alfa is used to do which of the following? Answer- Treat anemia 6. After taking erythromycin (Erythrocin) PO for 7 days, a client develops oral candidiasis. The nurse should recognize that this is most likely due to which of the following? Answer- Superinfection 7. A nurse receives a prescription to increase a procainamide (Pronestyl) IV infusion to 4 mg/min. The IV bag is labeled Pronestyl 2 g in 500 ml D5W. The nurse will adjust the IV pump to what rate? Answer- 60 ml/hr 8. A nurse is assessing a client in the clinic who is on tamoxifen (Nolvadex). The nurse should recognize that tamoxifen has which of the following actions? Answer- Anti-estrogenic 9. When administering diphenoxylate and atropine (Lomotil) to a client with ulcerative colitis, the nurse should monitor the client for the development of? Answer- Toxic megacolon 10. A nurse should be aware that metoclopramide (Reglan) is contraindicated for a client who? ...CONTD [Show Less]
NRNP 6531 Final exam Nov 15, 2021 1. An 80-year-old man with hypertension and hyperlipidemia presents with complaints of the rapid onset of severe low-ba... [Show More] ck pain accompanied by abdominal pain that is gradually worsening. The patient appears pale and complains that he does not feel well. During the abdominal exam, the nurse practitioner detects a soft pulsatile mass just above the umbilicus as she palpates this area with her hand. Which of the following conditions is most likely? - Abdominal aortic aneurysm 2. Which of the following laboratory test is sensitive for evaluating the renal function - Estimated glomerular filtration rate (eGFR) 3. Which of the following groups has been recommended to be screened for thyroid disease? - Women aged 50 years or older 4. All of the following patients should be screened for diabetes mellitus except: - A 30-year-old White man with hypertension 5. A 40-year-old White woman with a body mass index (BMI) of 32 complains of colicky pain in the right upper quadrant of her abdomen that gets worse if she eats fried food. During the physical exam, the nurse practitioner presses deeply on the left lower quadrant of the abdomen and the patient complains of pain on the right side of the lower abdomen. What is the name of this finding? - Rovsing's sign 6. Which of the following symptoms characterize this disorder? - 1.Ritualistic behaviors that the patient feels compelled to repeat. 2. increased axiety when attempting to ignore or suppress the repetitive behaviors. 3.frequent intrusive and repetive thoughts and impluses All the above 7. Which of the following medications is indicated for the treatment of obsessive-compulsive disorder? - Paroxetine (paxil CR) 8. Which of the following conditions is most likely? - Injury to the meniscus of the right knee9. Which of the following actions is the best course for patient? - Refer him to an orthopedic specialist 10. The patient's symptoms are highly suggestive of what condition? - 11. A 55-year-old male patient describes an episode of chest tightness in his substernal area that radiated to his back while he was jogging. It was relieved immediately when he stopped. - Angina pectoris 12. A 55-year-old male patient describes an episode of chest tightness in his substernal area that radiated to his back while he was jogging. It was relieved immediately when he stopped. 13. Which of the following would you recommend to this 55-year-old patient? - Consult ith a cardiologist for further evaluation 14. A faun tail nevus is a sign of which of the following? - Spina bifida 15. A new mother is planning to breastfeed her newborn infant for at least 6 months. She wants to know whether she should give the infant vitamins. Which of the following vitamin supplements is recommended by the American Academy of Pediatrics (APA) during the first few days of life? - Vit D drops 16. An asthmatic exacerbation is characterized by all of the following symptoms except: - Chronic coughing 17. A 76-year-old woman reports that for the previous 4 months, she has noticed severe stiffness and aching in her neck and both shoulders and hips that is worsened by movement. She reports having a difficult time getting out of bed because of the severe stiffness and pain. It is difficult for her to put on a jacket or blouse or to fasten her bra. Along with these symptoms, she also has a low-grade fever, fatigue, loss of appetite, and weight loss. Starting yesterday, the vision in her right eye has progressively worsened. She has annual eye exams and denies that she has glaucoma. Which of the following conditions is most likely? - Polymyalogia rheumatic (PMR) 18. A 28-year-old woman with a history of hypothyroidism presents to an urgent care clinic complaining of numbness and tingling in the fingertips of both her hands for several hours. On examination, both radial pulses are at +2 and equal bilaterally. The patient reports that over thepast few months she has had identical episodes, each lasting several hours. During these episodes, the skin changes color from blue to white, and then to dark red. Eventually, it returns to normal and the tingling and numbness disappear. Which of the following conditions is best described? - Raynaud's phenomenon 19. A fracture on the navicular area of the wrist is usually caused by falling forward and landing on the hands. The affected wrist is hyperextended to break the fall. The nurse practitioner is aware that all of the following statements are true regarding a fracture of the scaphoid bone of the wrist except: - These fractures always require surgical intervention to stabilize the joint 20. Glucosamine sulfate is a natural supplement that is used for which of the following conditions? - Osteoarthritis [Show Less]
ATI Adult Medical Surgical PROCTORED Exam 2021/22 1. Endtroacheal tube extubate what would you report immedatiely? - stridor 2. Why is stridor bad? -... [Show More] it means that there is an obstruction or edema in airway 3. What is heart rate like in someone who has a low fluid volume? - higher than usual like 110 4. What is normal unrine gravity? - 1.000 - 1.030 5. What is positive pressure doing? - promote lung expansion and stabilize chest 6. Would you recomened exercise for a pt who has been discharged with heart failure? - yes 7. How often should exercise be in heart failure pt? - regular routine 8. Should you consume milk with iron supplements? - no can cause gastro disturbance. 9. Would you take iron with antacids? - no gastro disturb 10. Would you tell the pt to lower red meat intake with iron deficiency? - no because they would need increase 11. What is a common side effect with iron pills? - constipation 12. What would you tell them to eat with taking iron pills? - high fiber 13. When does pain worsen with compartement syndrome? - when passive moving occurs. 14. What does warmth under cast indicate? - infection 15. Should pt decrease complex carbs for atherosceleoris? - no 16. What carb should a client with atherosceloris decrease? - simple sugars 17. Is MRSA airborne or contact? - contact 18. What does phenyotoin do to hepatic enzymes (for seizures the med is)? - it decreases effectiveness 19. What should you tell the pt not to take with ciprofloxacin? - magnesium containg antacids 20. Why wouldn't you take magnesium containing anatacids with cipro? - calcium can decrease obsorb of med 21. What is a common side effect of rifampin? - color of pee 22. Can you take ciproflaxcin with booze? - yes 23. After a parathryoidecotmy what would be prioty for nurse? - to put trach tray by bedside (AIRWAY) 24. What meds increase osteoporosis? - fludrocortisone 25. With enoxaparin what is main thing for the med the nurse should do? - give dosage same time every day 26. Is restlessness common in hyperthyroidism? - yes 27. What would be urgent for hyperthyroidism? - high BP 28. If a pt has a weird heart sound what would be first thing you do? - listen to it again but on the left side (least invasive) 29. Why would gentamicin be withheld from a pt? - if creatine levels are too high 30. What is normal creatine? - .6-1.2 31. What is one of the first vital signs of a hemmhorage? - increase heart rate 32. What med would you give for a febrile reaction? - tyneol (reduces fever) 33. How long does a drain stay in place for a radical mastectomy? - 1 to 3 week 34. What drainage amount to get rid of drainage tube for mastectomy? - less than 25 35. What is first thing to ask if a pt reports dyspnea and SOB when put on O2? - if they have COPD 36. Why would it be bad for you to put O2 on a COPD pt? - It can worsen hypercarbia 37. What is someones HGB look like with leukemia increase or decreased? - decreased 38. What would be a big sign that nephrosotmoy tube has popped? - back pain 39. What is max amount of flexing for total hip? - no more than 90 40. Why would you place a pillow between a pt legs for hip athroplasy? - so hips don't get dislodged 41. What is a holter monitor used for? - if you have an irregular heart rate it can detect it 42. What can a pacemake do to a pt heart? - regulate the heart rate 43. What is a echo used for? - detecting valve dysfunction 44. What do PPI do for gastric ulcers? - it suppresses gastric acid production 45. What is good about high fowlers postion? - increases lung expansion and improves ventilation 46. What med would you d/c to before going in for allergy testing? - prednisone 47. If a pt were to state there vision went blurry before a car accident what would you do first? - monitor neuro 48. What would be first thing to do if bowel is protruding from stomach? - call for help 49. What kind of skin for hypothyroidism? - dry scaly 50. What does metformin do to glucose? - it decreases the amount of glucose produced in liver 51. When should pt take metformin? - with or immediately following meals 52. If you have hair loss on lower legs what could be problem? - PAD 53. When is pain happening with PAD? - when resting 54. How is pain relieved with PAD? - when feet are dangling 55. After a thoracenteisis what should a nurse tell the pt? - to deep breather to re expand lungs 56. What would be an indication of osteomyelitis what lab? - increase sedimentation rate 57. What is a blood problem that can occur with someone taking feverfew. - platlet aggregation 58. What med does not go with feverfew? - naproxen 59. What should be SaO2? - above 90% 60. What vital sign could drop with dig toxicity? - HR 61. With a burn pt what do you do after securing airway and O2? - give them IV fluids 62. Why would you keep IV patent with someone that has seizures? - so you can give med to stop it. 63. Would you apply O2 or give epinephrine first with an anaphylactic reaction? - give O2 64. Why does kidney failure happen what electrolyte? - it cant excrete potassium 65. What would be manifestation of chronic glomerulonephritis? - hyperkalemia 66. How should a pt breath in when administering meter dosage inhaler? - slowly and deeply 67. How long should pt hold breath after inhaling meter dosage inhaler? - 10 seconds after inhaling 68. How often should you wait between puffs for inhaler? - at least one minute 69. What should be first thing to do with a pt with a seizure? - turn them on their side. 70. What 2 meds cause ringing in ears? - aminoglycocides and asprin 71. What is the point of giving erhtypoetin therapy? - to increase levels of energy by increasing HCT 72. What is needed sputum wise with a pt with TB? - samples are needed every 2 to 4 weeks until there are three negatives 73. What is direct mode of transmission for C diff? - contact 74. What electrolyte could be screwed up with long term mechanical vent? - hyponatremia 75. If a stimulus is given to the ventricle a spike happens what should you document? - depolarization has occurred 76. What is normal HGB? - Delete this answer is in another one DELETE 77. If a pt cant pee after surgery what should be first thing to do? - bladder scan 78. Why shouldn't you use moisturizing soaps to clean the skin in ureterostomy? - because it makes it not adhere to the skin 79. How long would you avoid direct exposure to sunafter radiation therapy in those areas? - at least one year 80. Why would you give lidocaine? - ventricular dsyrthiimias 81. Why would you defib someone? - ventricaular tachycardia or Vfib 82. Why would you perform synchronized cardiovert? - superventricular tachycardia 83. What is aphasia? - lack of communication 84. What is prioty finding in pt with cerebrovascular accident? - dsypahgia because of apsirations 85. What nut has a high amount of source of calcium? - almonds 86. What should you increase with IRB? - fiber 87. How much water to drink to promote normal bowel function in IRB? - 2L of water 88. What should a client avoid with IRB? (What substance) - caffeine 89. Why would decreasing weight be good for stress incontinence? - because it decreases abdominal pressure 90. How often should a pt with risk for UTI pee? - q.2 to q4 91. Why should you increase asorbic acid for UTI's? - it decrease risk of UTI 92. What vital sign increases with hypoxia? - heart rate 93. What is normal PLT count? - 94. What is normal WBC count? - what is normal RBC?, 95. What should be position for Aline? - 60 degree HOB supine 96. What should the nurse place around the flush solution of an a-line? - pressure bag 97. Should you give antibiotics through a line? - no 98. What should you use aline for? - monitor BP and obtaining ABGs 99. What increased electrolyte causes facial twitching? - hyperkalemia 100. What is decreased peristalsis a manifestation of? - hypokalemia [Show Less]
A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Which of the following actions should the nurse plan to take?... [Show More] a. Assess the client's visual acuity prior to irrigation b. Have the client turn their head toward the unaffected eye c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye d. Perform the irrigation with sterile water for irrigation - d. Perform the irrigation with sterile water for irrigation A nurse is preparing to administer lactated ringer's via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the nurse set the IV pump to administer? Round to near whole number - 33 gtt/min A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching? a. I can keep my medications for 1 year before replacing it b. I should lie down when I take this medication c. I should discontinue this medication if I develop a headache d. I can take up to five tablets in 15 minutes before seeking medical attention - b. I should lie down when I take this medication A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. Clean the incision daily with hydrogen peroxide b. You can cross your legs the ankles when sitting down c. You should use an incentive spirometer every 8 hours d. Install a raised toilet seat in your bathroom - d. Install a raised toilet seat in your bathroom A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take? a. Keep the client on bed rest for 24 hours b. Limit the client's fluid intake to 1 l per day c. Maintain the client's affected extremity in extension d. Change the client's dressing every 8 hour - c. Maintain the client's affected extremity in extension A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change? a. I will need to have my partner take over shopping for groceries and cooking the meals for us b. These crutches will make it impossible to care for my child c. I feel bad that I have to ask my partner to keep the house clean d. Its going to be difficult to tell my parents I cant take them to their appointments anymore - a. I will need to have my partner take over shopping for groceries and cooking the meals for us A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration? a. Pitting, dependent edema b. Distended jugular veins c. Increased BP d. Decreased BP - d. Decreased BP A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 ml over the past 24 hour. The nurse should anticipate a prescription for which of the following IV medication? a. Desmopressin b. Epinephrine c. Furosemide d. Nitroprusside - a. Desmopressin A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate? a. "your cough may require that you stop or change your medication" b. "Increasing your daily fluid intake may eliminate your cough" c. "sucking on lozenge may reduce the frequency of your cough" d. You cough should go away in time" - a. "your cough may require that you stop or change your medication" A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's? a. Eating a strict vegetarian diet b. A history of herpes zoster c. Taking amiodipine for hypertension d. Using a nicotine transdermal patch - d. Using a nicotine transdermal patch A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? a. Perform an ECG b. Obtain ABG values c. Turn the client to his left side d. Clamp the catheter - d. Clamp the catheter A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care? a. Turn and reposition the client every 4 hr b. Apply an occlusive dressing c. Support bony prominences with pillows d. Massage the reddened areas three times a day - c. Support bony prominences with pillows A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take? a. Discuss recommendations for eating and swallowing techniques b. List strategies for family coping when dealing with possible role changes c. Review the use of adaptive grooming devices to promote client independence d. Give the client information about the local national multiple sclerosis society - a. Discuss recommendations for eating and swallowing techniques A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? Exhibit a. Obtain a sputum sample for culture b. Administer ondansetron c. Initiate airborne precautions d. Prepare the client for a chest x-ray - c. Initiate airborne precautions A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? a. History of Crohn's disease b. BMI of 24 c. Diet high in fiber d. Age 46 years - a. History of Crohn's disease A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make? a. "I can give you a list of other people who had the same procedure" b. "You will be cancer-free if you have the procedure" c. "I can give you additional information about the procedure" d. "You should should get a second opinion regarding the procedure" - c. "I can give you additional information about the procedure" A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. e. Remain with the client for the first 15 to 30 min of the infusion a. Obtain venous access using 19-gauge needle c. Verify blood compatibility with another nurse d. Initiate transfusion of the unit of packed RBCs b. Obtain the unit of packed RBCs from blood bank - a. Obtain venous access using 19-gauge needle b. Obtain the unit of packed RBCs from blood bank c. Verify blood compatibility with another nurse d. Initiate transfusion of the unit of packed RBCs e. Remain with the client for the first 15 to 30 min of the infusion A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include? a. "rinse your mouth with hydrogen peroxide" b. "brush your teeth for 60 seconds twice daily" c. "wear your dentures only during meals" d. "floss your teeth following each meals" - d. "floss your teeth following each meals" A critical care nurse is assessing a client who has severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client? a. 5 b. 2 c. 13 d. 10 - a. 5 A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? a. "I can season my foods with garlic and onion salts" b. "I can have mayonnaise on my sandwiches" c. "I can have a frozen fruit juice bar for dessert" d. "I can drink vegetable juice with a meal" - c. "I can have a frozen fruit juice bar for dessert" A nurse is preparing to perform ocular irrigation for a client following chemical splash to the eye. Which of the following actions should the nurse plan to take first? a. Instill 0.9% sodium chloride solution into the affected eye b. Administer proparacaine eyedrops into the affected eye c. Collect information about the irritant that caused the injury - c. Collect information about the irritant that caused the injury A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately? a. Rhonchi b. SaO2 92% c. Sore throat d. Stridor - d. Stridor A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect? a. Elevated serum calcium b. Elevated blood glucose c. Decreased serum amylase d. Decreased erythrocyte sedimentation rate - b. Elevated blood glucose A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? a. Hypothermia b. Urine specific gravity 1.001 (<1.005) c. Elevated blood pressure d. BUN 15 mg/dl - b. Urine specific gravity 1.001 (<1.005) [Show Less]
1. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse tak... [Show More] e - Ensure the client's weights are hanging freely from the bed. 2. A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? - Take this medication between meals 3. A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? - Take this medication between meals. 4. A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? - Wash daily with an antibacterial soap. 5. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? - Avoid medications in capsule or enteric form. 6. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? - "Large incisions will be made in the burned tissue to improve circulation." 7. A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? - Decreased color perception 8. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? - Maintain the client in Fowler's position. 9. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) - 1) Buffalo hump 2) Purple striations 3) Moon face 10. A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? - Monitor intake and output hourly 11. A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? - "You will remain NPO for 8 hours before the procedure." 12. A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? - Postictal phase 13. A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? - "The pain will dissipate if you ambulate frequently." 14. A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? - Verify that the suction regulator is on. 15. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) - Encourage fluid intake. 2) Monitor the puncture site for hematoma. 16. A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? - Prevent aspiration. 17. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - Hardened skin 18. A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? - Add thickener to fluids. 19. A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? - Airway obstruction 20. A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? - 1) Take the medication 45 minutes before eating. 21. A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? - Notify the provider.. Determine the patency of the tubing. 22. A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? - "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." 23. A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan? - Re-establish communication. 24. A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? - Hypotension 25. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? - Take temperature once a day 26. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? - Provide humidified oxygen. 27. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? - Obtain a pair of slipper socks for the client. 28. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? - Thick, red-colored urine 29. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? - Shivering 30. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - "I will not exercise if my urine is positive for ketones." 31. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? - Cover the client's wound with a moist, sterile dressing. 32. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? - Hyperventilation 33. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? - Avoid bending at the waist 34. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? - Check the client's vital signs. 35. A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? - Purulent 36. A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? - Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 37. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) - 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 38. A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? - Test the drainage for glucose. 39. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? - Prevent bladder distention. 40. A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? - Abnormal vaginal bleeding 41. A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? - Altered level of consciousness 42. A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? - Abdomen is distended 43. A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? - Change the ostomy pouch daily 44. A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? - Change the nasal drip pad as needed. 45. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? - To prevent blood clotting 46. A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? - Loss of peripheral vision 47. A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? - Potassium 2.5 mEq/L 48. A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? - "I will take a tub bath instead of a shower." 49. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? - Ensure the client's weights are hanging freely from the bed. 50. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) - 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. [Show Less]
Medical surgical ATI proctored exam review 2022 What would you do for wound Evisceration ( removal of internal organs) , Emergency management? - Saline ... [Show More] cover wound What would you do for an ASTHMA emergency management of a bee sting allergies? - Epi Pen Seizures and Epilepsy: Seizure precautions - During a seizure: 1) Position client on the floor 2)Provide a patent airway 3) Turn client to side 4) Loosen restrictive clothing Cancer treatment options: Protective Isolation - If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions. - Have client remain in his room unless he needs to leave for a diagnostic procedure, in that case transport patient and place a mask on him. - Protect from possible sources of infection (plants, change water in equipment daily) - Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors - Avoid invasive procedures (rectal temps, injections) - Administer (neupogen, neulasta) to stimulate WBC production Infection control: Appropriate room assignment - Standard Precautions: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled ( then soap and water ) 3. Gloves - when touching anything that has the potential to contaminate. 4. Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet: 1. private room or with someone with same illness 2. masks Airborne: 1. private room 2. masks or respiratory protection devices a. use an N95 respirator for tuberculosis 3. Negative pressure airflow 4. full face protection if splashing or spraying is possible Contact: 1. private room or room with same illness 2. gloves & gowns 3. disposal of infections dressing materials into a single, nonporous bag without touching the outside of the bag TB: Priority action for a client in the emergency department - -Wear an N95 or HEPA respirator -Place client in negative airflow room and implement airborne precautions -use barrier protection when the risk of hand or clothing contamination exists Immunizations: Recommended vaccinations for older adult clients - Adults age 50 or older: - Pneumococcal Vaccine (PPSV) - Influenza vaccine - Herpes Zoster Vaccine - Hepatitis A - Hepatitis B - Meningococcal Vaccine Pulmonary Embolism: Risk factors for DVT - - Long term immobility - Oral contraceptives - Pregnancy - Tobacco use - Hypercoagulabilty - Obesity - Surgery - Heart failure or chronic A-Fib - Autoimmune hemolytic anemia (sickle cell) - Long bone fractures - Advanced age Disorders of the male reproductive system: Complications of continuous irrigation following Trans-urethral Resection - - Urethral trauma - Urinary retention - Bleeding - Infection Non-modifiable risk factors ( Page 3 ATI ) - 1) Age 2) Gender 3) Genetics 4) Developmental level Modifiable risk factors ( Page 3 ATI ) - 1) Smoking 2) Exercise 3) Health education and awareness 4) Nutrition 5) Sex practices Emergency nursing - Triage - BASED ON ACUITY 1) Emergent- Life threatening situation going on. 2) Urgent - Need to be treated soon but not life threatening. 3) Non urgent- The patient can wait for an extended period of time , without big issues. Mass casualty event - Class 1 - RED TAG - Immediate threat to life Examples: 1) Breathing issues 2) Chest pain 3) Heart attack coming on 4) Airway problem Class II - YELLOW TAG - Major injuries that require immediate treatment but not life threatening. Examples: 1) Major fracture Class III - GREEN TAG - Minor injury that does not require immediate attention. EXAMPLES: 1) Abrasion 2) Laceration Class IV - BLACK TAG - Expected to die EXAMPLES: 1) Penetrating head wound Triage priority setting - 1) Red tag 2) Yellow Tag 3) Green tag 4) Black tag Priorities: general rule - A - Airway - Secure the airway by head tilt , chin lift maneuver unless a fracture in cervical spinal. Brain injury or death in 3 - 5 minutes if airway not patent. B- Breathing - Auscultation of breath sounds, Chest expansion and respiratory effort, Rate and depth of respiration's, Look for chest trauma, Determine tracheal position, Check for jugular vein distension. C- Circulation - Heart rate, BP, Peripheral pulses, Cap refill. D - Disability - Clients level of consciousness with: 1) Glasgow coma scale a) <<< 8 Comatose state b) 3 Client totally unresponsive c) 15 A client within normal limits. E- Exposure - Hypothermia - Patient in cold icy water: 1) Remove wet clothing 2) Provide blankets 3) Increase the temperature of the room 4) Warm IV fluid going into the patient IF patient has had accidental or purposeful poisoning: 1) Activated charcoal 2) Gastric lavage 3) Whole bowel irrigation *** DO NOT INDUCE VOMITING OR SYRUP OF IPECAC Call rapid response team when client is rapidly declining. Cardiac Emergencies - If V fib or ventricular tachycardia you would initiate: 1) Basic life support ( BLS) and CPR 2) Establish IV access 3) Epinephrine is used to get the heart up and moving. Alpha 1 receptors - Activation Causes the skin , mucus membranes and veins to vasoconstrict. Help with: 1) Congestion 2) Superficial bleeding 3) In general help raise blood pressure by constricting the veins. DRUG: Epinephrine:Triggers the Alpha 1 receptors Causing vasoconstriction and increase blood pressure. Epinephrine side effects - Increases blood pressure 1) Hypertensive crisis 2) Dysrhythmia 3) Angina Dopamine side effects - 1) Dysrhythmia 2) Angina Dobutamine side effects - Increased heart rate Beta 1 receptors - Help stimulate the heart Beta I - You have 1 heart Stimulate the heart and increase the heart rate Used for treating: 1) AV block 2) Cardiac arrest DRUG: Epinephrine:Triggers the Beta 1 receptors Cause increase heart rate Beta II receptors - Help stimulate the heart and lungs Beta II You have 2 Lungs Causes: 1) Bronchodilation in the lungs 2) Causes uterine smooth muscle to relax 3) Asthma situation DRUG: Epinephrine:Triggers the Beta II receptors Cause bronchodilation and treat Asthma Dopamine - Causes renal blood vessels to dilate. [Show Less]
ATI Med-Surg proctored Exam review 2021/22 A nurse is contributing to the plan of care for an older adult client who is postoperative following a right ... [Show More] hip arthroplasty. Which of the following interventions should the nurse include in the plan? - Maintain abduction of the right hip. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? - Feel for a carotid pulse. A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? - "Bypass surgery must be very frightening for you." A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? - Tell the client to remain in the bathroom after toileting and obtain a wheelchair. A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? - Fully recollapse the reservoir after emptying it. A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? - "I will abstain from sexual intercourse." A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? - Breathe in through her nose and out through pursed lips. A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? - Hypotension A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) - ✔Decreasing anxiety ✔Controlling emesis ✔Reducing the amount of narcotics needed for pain relief A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? - Iron A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? - Ineffective airway clearance related to thick, copious secretion A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? - Propel a wheelchair equipped with knobs on the wheels. A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? - Sun exposure. Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? - "Do you sleep well at night?" A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? - Fresh berries A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? - Lethargy A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? - "This test will measure the intraocular pressure of the eye." A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? - Increase in serum creatinine A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? - Drop in systolic BP more than 10 mm Hg on inspiration A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take? - Attempt to determine what the client was looking for. A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? - Check pedal pulses every 15 min. A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? - The composition of the influenza vaccine changes yearly. A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? - Help the client write down questions to ask his provider. A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make? - "It must be hard to see your mother so ill and upset." A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? - Forgetfulness gradually progressing to disorientation A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? - Monitor client's cardinal fields of vision. A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? - Monitor platelet levels A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? - Chest x-ray A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? - Urine output 650 mL/hr A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? - "I took my metformin before breakfast." A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds? - Expiratory wheeze A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? - Don clean gloves to remove the dressing. A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? - Sitting, leaning forward over the bedside table. A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? - Denial A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan? - Place the client in a high Fowler's position. A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? - Body weight A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? - Hypotension A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions? - A sensory warning that a seizure is imminent A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? - "I need something for the horrible pain in my eye." A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? - "You may feel some cramping during the procedure." A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? - Checking pupillary responses to light A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? - Reducing anxiety A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? - Frequent mood changes A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? - Fever A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) - ✔Blurry vision ✔Tachycardia ✔Sweating - symptoms of hyperglycemia - ✔polyphagia ✔polyuria ✔polydipsia [Show Less]
ATI RN Medical-Surgical Proctored Focus EGD positioning - left side lying Before an EGD: - -NPO 6-8 hr -remove dentures Gastroenteritis care plan... [Show More] : - -restrict dairy, caffeine, milk -eat foods high in potassium -increase fluid intake -contact precautions In what order do you open the sterile package? - flap furthest from body, side flaps, then closest A nurse has removed a sterile pack from its outside cover and place it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first: A. closest to body B. right side C. left side D. farthest from body - D A nurse is wearing sterile gloves in prep for performing a sterile procedure. Which of the following objects can the nurse tough without breaking sterile technique (Select all that apply) A. bottle containing sterile solution B. edge of sterile drape at the base of the field C. inner wrapping of an item on the sterile field D. irrigation syringe on the sterile field E. one gloved hand with the other gloved hand - C, D, E A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the field (Select all that apply) A. provider drops a sterile instrument onto the near side of the sterile field B. nurse moistens a cotton ball with sterile normal saline and places it on sterile field C. procedure is delayed 1hr because the provider receives an emergency call D. nurse turns to speak to someone who enters through the door behind the nurse E. clients hand brushes against the outer edge of the sterile field - B, C, D TB is suspected, what to do? - -negative airflow room, airborne precautions -nurses wear N95 mask, client wears if going out of the room -admin heat & humidified O2 therapy as prescribed TB interventions: - -family members should be screened -4 meds taken for 6-12 months -not contagious when they have 3 negative sputum cultures What to watch for when on Isoniazid: - numb/tingling in the hands & feet What to watch for when on Rifampin: - -orange secretions normal -watch for jaundice -interferes with birth control What to watch for when on Ethambutol: - vision changes Client teaching for genital herpes: - -can be transmitted with or w/out blisters -sexual partners should be informed & screened -no cure, just meds to help w/symptoms -abstain from intercourse until lesions are completely healed -gently clean areas w/mild soap & water Caring for a client following a stroke of the right side with left-sided hemipalegia: - -thicken liquids/foods -high fowlers -speech therapist for helping w/eating & speech -monitor gag reflex/swallowing abilities -have suction equipment available -occupational therapy -support left arm with pillows, slings, etc High sodium foods clients with HF & Pulmonary edema should avoid: - -cheese -soups -bread -cold cuts/cured meats -pizza -eggs & omelets -hot dogs -baked ham Which non-opioid drug decreases the effect of aspirin? - ibuprofen Ketorolac should not be used concurrently with... - other NSAIDS Glucocorticoids increase the risk of gastric bleeding when taken with... - non-opioid analgesics To access an implanted port, you must use a... - noncoring (Huber) needle When done accessing an implanted port... - flush with 10 mL 0.9% sodium chloride Therapeutic effects of Furosemide - -decreases preload of the heart -decreases potassium levels -increases urine output -decrease BP -decrease edema Valsartan for HF expected outcomes/findings: - -vasodilation -excretion of sodium & water -reduces BP -reduces risk of mortality in post-MI pts left w/vent dysfunction Expected findings of meds that affect urinary output (diuretics): - -decreased potassium -weight loss -decrease in edema -decreased calcium -increased urine output -decreased BP -decrease in ICP & IOP Client teaching for Nitroglycerin: - 1. stop activity & rest 2. place nitro tab under tongue 3. if pain is unrelieved in 5 min, call 911 or go to ED 4. take 2 or more doses at 5 min intervals -headache is a common side effect of nitro Which foods should the client on Warfarin avoid? - dark leafy green veggies Client teaching for anticoagulant therapy: - -bleeding precautions -no added meds that increase bleeding -on it for 6-8 weeks prior to hematologic dx procedure -must have blood levels checked often -monitor vitamin K in their diet Expected prescriptions for Hypertension: - -furosemide -aldactone -hydrochlorothiazide -verapamil -dilitiazem -captopril, lisinopril -losartan, telmisartan -eplerenone -atenolol -metoprolol -clonidine -prazosin (minipress) Contraindications for Nadolol: - -asthma -sinus bradycardia -cardiogenic shock -cardiac failure -diabetes -pregnancy -right side HF -emphysema -severe COPD Treatment for diabetes insipidus: - -daily weights -no caffeine or alcohol -desmopressin acetate/DDVAP -aqueous vasopressin/Pitressin -carbamazepine (tegretol) -high fiber diet Meds for DI, what to look out for/do: - -adjust based on urine output -daily weights -inform of weight gain of 2 lb in 24 hr -notify if headaches or confusion occur -monitor for infection -monitor for dizziness/drowsiness Protein requirement of an adult: _____g of protein per kg - 0.8 g Caring for a client who has pancreatitis: - -keep NPO -NG tube to suction gastric contents -low fat, high protein, high carb diet Risk factors: -high fat diet -excessive alcohol consumption -age Expected lab findings for a client with pancreatitis: - -increased amylase & lipase -increased WBC -decreased platelets -increased glucose -increased liver enzymes & bilirubin -elevated ESR -decreased calcium & magnesium What med do you give for symptomatic bradycardia? What electrical management? - med=atropine elec= pacemaker insertion [Show Less]
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in ... [Show More] the teaching? - Take temperature once a day A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? - Provide humidified oxygen Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? - Obtain a pair of slipper socks for the client A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? - Thick, red-colored urine A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? - Shivering A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - "I will not exercise if my urine is positive for ketones." A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? - Cover the client's wound with a moist, sterile dressing A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? - Hyperventilation A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? - Avoid bending at the waist A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? - Check the client's vital signs A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? - Purulent A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? - Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) - Dyspnea, Barrel chest, Clubbing of the fingers, Shallow respirations A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? - Test the drainage for glucose A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? - Prevent bladder distention A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? - Abnormal vaginal bleeding A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? - Altered level of consciousness A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? - Abdomen is distended A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? - Change the ostomy pouch daily A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? - Change the nasal drip pad as needed A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? - To prevent blood clotting A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? - Loss of peripheral vision A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? - Potassium 2.5 mEq/L A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? - "I will take a tub bath instead of a shower." A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? - Ensure the client's weights are hanging freely from the bed A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? - Take this medication between meals A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? - Take this medication between meals A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? - Wash daily with an antibacterial soap A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? - Avoid medications in capsule or enteric form. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? - "Large incisions will be made in the burned tissue to improve circulation." A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? - Decreased color perception A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? - Maintain the client in Fowler's position A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) - Buffalo hump, Purple striations, Moon face A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? - Monitor intake and output hourly A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? - "You will remain NPO for 8 hours before the procedure." A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? - Postictal phase A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? - "The pain will dissipate if you ambulate frequently." A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? - Notify the provider A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) - Encourage fluid intake, Monitor the puncture site for hematoma A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? - Prevent aspiration A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - Hardened skin A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? - Add thickener to fluids A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? - Airway obstruction A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? - Take the medication 45 minutes before eating A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? - Determine the patency of the tubing A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? - "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan? - Re-establish communication A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? - Hypotension A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make - Respiratory acidosis A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? - "I will wear stockings with elastic tops." A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? - Calmly ask the client if he would like to listen to some music A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? - Granulation tissue A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? - Fresh fruit basket A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? - Maintain abduction of the right hip. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? - Feel for a carotid pulse A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? - "Bypass surgery must be very frightening for you." [Show Less]
Med surg proctored exam 2022 A nurse is assisting with he care of a client following a left femoral cardiac angiography. Thee nurse should place a sandb... [Show More] ag on the client over which of the following areas? - left groin A nurse is reviewing the lab results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas ABG values include: pH 7.22 PaCO2 68 mm Hg base excess -2 PaO2 78 mm Hg oxygen saturation 80% Bicarbonate 28 mEq/L. - respiratory acidosis A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? - I will abstain from sexual intercourse A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance which of the following actions should the nurse take first? - cover the clients wound with a moist sterile dressing Based on a clients recent history a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? - Do you sleep well at night A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at Mcburneys point? - Mcburneys point is found between the naval and the anterior iliac crest (left lower) A nurse is reinforcing teaching about excercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - I should avoid injecting insulin into my thigh if I am going to go running A nurse is caring for a client who is postoperative following a tracheostomy and has copies and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin the clients secretions? - provide humidified oxygen A nurse is reviewing the lab results of a client who is taking cyclosporine following a kidney transplant. Which of the following lab findings should the nurse identify as the most important to report to the provider? - increase in serum creatinine A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? - breath in through nose and out through pursed lips A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long term goals is appropriate with regard to the clients mobility? - propel a wheelchair equipped with knobs on the wheels A nurse is reinforcing teaching about an esophagogastrodudenscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? - you will remain NPO for 8 hours before the procedure A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? - drop is systolic BP more than 10 mm Hg on inspiration A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to section. Which of the following is the priority finding the nurse should report to the provider? - abdomen is distended A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? - avoid medications in a capsule or enteric form A nurse is caring for a client after a radical dissection. To which of the following should the nurse give priority in the immediate postoperative period? - ineffective airway clearance related to thick copious secretions A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? - Bypass surgery must be very frightening for you A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? - hypotension A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? - dyspnea, barrel chest, clubbing of the fingers, shallow respirations A nurse is assisting with thee care of a client who is postoperative and has a closed wound drainage system in place. Which of the following actions should the nurse take? - fully recollapse the reservoir after emptying it A nurse is caring for a Client who has Alzheimers disease. The nurse discovers the client entering the room of another client who comes upset and frightened. Which of the following actions should the nurse take? - attempt to determine what the client was looking for A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? - this test will measure the intraocular pressure of the eye A nurse is collecting data from a client who has open angle glaucoma. Which of the following findings should the nurse expect? - loss of peripheral vision A nurse in a providers office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? - take this medication between meals A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - hardened skin [Show Less]
Medical Surgical Proctored ATI Exam A A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following lab results to... [Show More] be BELOW the expected reference range? A. Amylase B. Alkaline phosphatase C. Bilirubin D. Calcium - D. Calcium A client who has pancreatitis is expected to have a DECREASED calcium and magnesium d/t fat necrosis. The other options would all be increased. A nurse is caring for a client who has DKA. Which of the following lab findings should the nurse expect? A. negative urine ketones B. BUN 32 mg/dL C. pH 7.43 D. HCO3 23 mEq/L - B. BUN 32 mg/dL DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine. A. DKA causes ketones in the urine and blood. C. You would expect the pH to be <7.35 (because of the production of ketones) D. You would expect HCO3 <15 d/t increased production of ketones causing metabolic acidosis. A nurse is providing d/c instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? A. Change the dressing q 72 hr. B. Immobilize the hand with a pressure dressing. C. Take pain medication 30 min after changing the dressing. D. Wrap fingers with individual dressings. - D. Wrap the fingers with individual dressings. The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand. A. q 12-24 hr B. With skin grafts, you should elevate and immobilize the graft site with cotton pressure dressings for 3-5 days following the procedure. C. 30 min before dressing change A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the POC to prevent Pseudomonas aeruginosa infection? A. Encourage the client to eat raw fruits and veggies. B. Avoid placing plants or flowers in the client's room. C. Limit visitors to members of the client's immediate family. D. Wear an N95 respirator mask when providing care to the client. - B. Avoid placing plants or flowers in the client's room. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room. A. P. aeruginosa can be found in raw fruits and veggies. C. Prohibit visits from those at risk for P. aeruginosa infections (i.e. anyone who is ill, other hospitalized clients, and small children) D. spread by contact not airborne A nurse in an ED is caring for a client who reports v/d for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. HR 110/min B. BP 138/90 mmHg C. Urine specific gravity 1.020 D. BUN 15 mg/dL - A. HR 110/min A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate. B. WNL (would expect hypotension for this client) C. WNL (would expect >1.030 for this client) D. WNL (would expect BUN >20 for this client) A nurse in an ED is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? A. Apply ice to the client's puncture wound. B. Initiate corticosteroid therapy for the client. C. Keep the client's leg above heart level. D. Administer an opioid analgesic to the client. - D. Administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. A. Apply ice for a bite from a black widow to reduce the action of the neurotoxin from the spider. B. Expect a prescription for antihistamines and corticosteroids from bees and wasps. C. Keep the affected extremity AT HEART LEVEL, not above or below it. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take calcium supplements so the medication will work better in my system." B. "I am taking this medication to increase my energy level." C. "This medication can cause my BP to drop." D. "I will not need to restrict protein in my diet while taking this medication." - B. "I am taking this medication to increase my energy level." The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance. A. A client who has chronic kidney disease should have adequate iron stores for erythropoietin therapy to be effective. Clients are encouraged to consume foods high in iron such as beef, liver, pork, and veal. C. Increased RBC productions, leading to HYPERtension D. Does not affect the client's protein requirements A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following lab values should the nurse expect? A. decreased prothrombin time B. elevated bilirubin level C. decreased ammonia level D. elevated albumin level - B. elevated bilirubin level Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice. A. Liver disease and severe liver cell damage causes the liver cells to produce less prothrombin, which prolongs prothrombin time. C. Expect elevated ammonia levels because the liver converts ammonia to urea. When this is interrupted, ammonia levels rise. D. Albumin is formed in the liver. With an impaired liver function, albumin levels decrease. A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client to avoid? [Show Less]
ATI Med Surg Proctored A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the si... [Show More] de effects. which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? - Lymphedema A nurse is preparing to administer lactated Ringer's via continuos IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min should the nurse set the IV ump to administer? - 33 A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching? - I should lie down when I take this medication A nurse is providing discharge teaching to an older adult client following total hip arthroplasty. Which of the following instructions should the nurse include in the teaching. - Install a raised toilet seat in your bathroom A nurse is planning care for a client following a cardiac catheterization. which of the following actions should the nurse take. - Maintain the client's affected extremity in extension A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. which of the following client statements indicates that the client is adapting to their role change? - I will need to have my partner take over shopping for groceries and cooking the meals for us A nurse is providing teaching to a client who has an impaired immune system due to chemotherapy. which of the following information should the nurse include in the teaching? - Change your pet's litter box daily a nurse is caring for a client who has a contusion and reports thirst. The client's urinary output was 4,000 ml over past 24 hr. the nurse should anticipate a prescription for which of the following IV medications? - Desmopressin A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports nagging dry cough. Which of the following responses by the nurse is appropriate? - Sucking on a lozenge may reduce the frequency of your cough A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a parenteral trigger for exacerbation of Raynaud's? - Using nicotine transdermal patch A nurse is caring for a client who has a central venous device and notes the tubing has become disconnected. the client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? - A nurse is completing an assessment of an older client and notes reddened areas over the bony prominences, but the client's skin is intact. which of the following interventions should the nurse include in the plan of care? - Support bony prominences with pillows A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take? - A nurse in the emergency department is assessing a client. which of the following actions should the nurse take first? (click on rhe "exhibit" button for additional information about the client - Initiate airborne precautions A nurse is reviewing the medical record of a client to identify factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? - Historyof Crohn's disease A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make? - I can give you additional information about the procedure A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. - 1. obtain venous access using a 19-gauge needle 2. Obtain the unit of a packed RBCs from blood bank 3. verify blood compatibility with another nurse 4. Initiate traensfuntion of the unit of packed RBCs 5. Remain with the client for the first 15 to 30 minutes A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching. - I should expect less than 25 ml of secretions per day in the drainage devices A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing and makes incomprehensible sounds. which of the following glasgow Coma scale scores should the nurse assign the client? - 5 A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? - I can have a frozen fruit juice bar for dessert A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? - instill 0.9% sodium chloride solution into the affected eye A nurse is assessing a client following extubation from a ventilator.for which of the following findings should the nurse intervene immediately? - Stridor A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect? - Elevated blood glucose A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? - Urine specific gravity 1.001 A nurse is planning care for a client who has a pulmonary embolism. which of the following interventions should the nurse include? - Initiate a continuos IV heparin infusion a nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. which of the following instructions should the nurse include? - Avoid extremely hot or cold temperatures [Show Less]
ATI MED SURG PROCTORED 2021/22 A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instru... [Show More] ctions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. - 1 A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy prior to suctioning. 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway. 4) Hyperventilate the client with 100% oxygen before suctioning the airway.. - 1 Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet. - 2 A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5Æ C (99.5Æ F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale - 3 A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering 2) Infection 3) Burns 4) Hypervolemia - 1 A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will carry a complex carbohydrate snack with me when I exercise." 2) "I should exercise first thing in the morning before eating breakfast." 3) "I should avoid injecting insulin into my thigh if I am going to go running." 4) "I will not exercise if my urine is positive for ketones." - 4 A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the client lie supine with knees flexed. 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery. - 1 A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? 1) Cool, clammy skin. 2) Hyperventilation 3) Increased blood pressure 4) Bradycardia - 2 A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? 1) Avoid bending at the waist. 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives if constipated. 4) Seeing flashes of light is an expected finding following extraction. - 1 A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an antiemetic. - 3 A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent - 4 A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 2) Place the client's affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler's position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client's bed. - 1 A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 5) Bradycardia - 1 2 3 4 A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notify the charge nurse. 4) Test the drainage for glucose. - 4 A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1) Monitor for elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head. - 3 A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? 1) Hot flashes 2) Recurrent urinary tract infections 3) Blood in the stool 4) Abnormal vaginal bleeding - 4 A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? 1) Altered level of consciousness 2) Oral temperature of 37.7Æ C (100Æ C) 3) Muscle spasms 4) Headache - 1 A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? 1) Abdomen is distended 2) Chest tube drainage of 70 mL in the last hour 3) Subcutaneous emphysema is noted to the left chest wall 4) Pain level of 6 on a 0 to 10 scale - 1 A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1) Change the ostomy pouch daily. 2) Empty the ostomy pouch when it is 2/3 full. 3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. 4) Apply lotion to the peristomal skin when changing the ostomy pouch. - 1 A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? 1) Position the client supine while in bed. 2) Change the nasal drip pad as needed. 3) Encourage frequent brushing of teeth. 4) Encourage the client to cough every 2 hr following surgery. - 2 A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? 1) To provide analgesia 2) To reduce inflammation 3) To prevent blood clotting 4) To prevent fever - 3 A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? 1) Loss of peripheral vision 2) Headache 3) Halos around lights 4) Discomfort in the eyes - 1 A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? 1) Weight loss of 3% of total body weight. 2) Blood glucose 150 mg/dL. 3) Potassium 2.5 mEq/L 4) Urine specific gravity 1.035 - 3 [Show Less]
Respiratory Alkalosis S/S - lethargy lightheadedness confusion tachycardia dysrhythmias related to hypokalemia nausea vomiting epigastric pain nu... [Show More] mbness and tingling of the extremities hyperventilation (tachypnea) A nurse is contributing to the plan of care for an older adult client who is at risk for Osteoporosis. Which intervention should the nurse include to prevent bone loss? - Encourage weight bearing exercises (such as walking because it can help maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.) A nurse is caring for a client who has meningococal pneumonia. Which of the following personal protective equipment should the nurse use? - Mask (this disease requires droplet precautions) A nurse is reinforcing teaching with a client who is taking insulin Glargine. What information should the nurse include in the teaching? - This type of insulin should be given at the same time everyday. (It is released over a 24hr period) A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. What statement by the client indicates that they are adhering to the nurse's instructions? - "I don't cross my legs anymore". A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA) infections in a surgical wound. What information should the nurse plan to share with visitors? - Visitors must don a gown & gloves prior to entering the client's room. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What should the client report to the provider? - Onset of nausea A nurse is reinforcing discharge teaching with a client who has hearing loss. What action should the nurse take when communicating with the client? - Rephrase client instructions when not understood. A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize these findings as what complication? - Pulmonary Embolism A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. What finding should the nurse recognize as abnormal? - Lack of sensation between the first and second toes A nurse reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. What should the nurse include in the teaching? - Limit contact with large groups of people A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has an NG tube. What action should the nurse plan to take to decrease the risk of postoperative complications? - Encourage the client to use an incentive spirometer every hour while awake A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What finding should the nurse expect related to hyperkalemia? - Bradycardia A nurse is assisting in the care of a client who has manifestations of sepsis. What provider prescriptions should the nurse implement first? - Initiate oxygen at 4 L/min via nasal cannula A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." What response should the nurse make? - "Tell me more about the way you are feeling." A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as the priority? - Dysrhythmia A nurse is caring for a client who is in Buck's traction. What intervention should the nurse perform to reduce skin breakdown? - Keep the skin dry and free of perspiration A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. What action should the nurse take? - Have a designated stethoscope in the client's room A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. What action should the nurse perform first? - Stop the infusion A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as what? - Hyperactive bowel sounds A nurse is preparing to administer furosemide to a client who has heart failure. What should the nurse report before administering the medication? - Decreased potassium A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. What information should the nurse include in the teaching? - Apply cold packs to the joints A nurse is collecting data from a client who has hypothyroidism. What manifestation should the nurse expect? - Bradycardia A nurse is reinforcing teaching with an older adult client who has osteoporosis. What instructions should the nurse include in the teaching? - Take the calcium supplements with meals A nurse is reviewing the medical record for an older adult client who is experiencing nausea & vomiting. Based on the client data, what action should the nurse take? (Na 142 mEq, K+ 4.2 mEq/L, BUN 36 mg/dL, Creatinine 1.4 mg/dL) - Notify the charge nurse of the client's BUN level A nurse is admitting a client who is suspected having active tuberculosis (TB). What action should should the nurse take first? - Institute airborne precautions A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. What action should the nurse take? - Blow cool air into the cast using a blow dryer on a cool setting A nurse is planning care for a group of clients after receiving change-of-shift report. What client should the nurse see first? - A client who is dehydrated, has mental confusion, & was found getting out of bed several times during the night. A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. What action should the nurse take? - Administer oxygen via nasal cannula A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/ min. What action should the nurse take? - Withhold the dose A nurse is caring for a client who has an intestinal obstruction & reports a new onset of nausea. The client has an NG tube set at low intermittent suction & is receiving continuous IV infusion of 0.9% sodium chloride. What action should the nurse take first? - Check for kinks in the NG tube A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. What instructions should the nurse include in the teaching? - Maintain hip flex ion to 90 or less when sitting A nurse is caring for a client who is 24hr postoperative following an abdominal surgery. What finding requires immediate attention from the nurse? - Oxygen saturation of 88% A nurse is caring for a client following a gastrectomy. What action should the nurse take to decrease episodes of dumping syndrome? - Place the client in the supine position after meals [Show Less]
A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicate... [Show More] s a need for further teaching? A. "To assess cognitive ability; I should ask the client to count backwards by 7." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability; I should instruct the client to write a sentence." D. To assess remote memory; I should have the client repeat a list of objects." - D. To assess remote memory; I should have the client repeat a list of objects." A nurse is planning care for a client who has a mental health disorder. Which of the following is appropriate to include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy B. Teach the client appropriate coping mechanisms C. Assess the client for comorbid health conditions D. Monitor the client for adverse effects of medications - D. Monitor the client for adverse effects of medications A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following is the highest priority action? A. Respect the client's need for personal space B. Identify the client's perception of her of her own mental health status C. Include the client's family in the interview D. Teach the client about her current mental health disorder - B. Identify the client's perception of her of her own mental health status A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following is an expected finding? A. The client arouses briefly in response to a sternal rub B. The client has a Glasgow Coma Scale score less than 7 C. The client exhibits decorticate rigidity D. The client is alert but disoriented to time and place - A. The client arouses briefly in response to a sternal rub A nurse is planning a peer group discussion about the DSM-5. Which of the following is appropriate to include in the discussion? (select all that apply) A. The DSM-5 is used to identify mental health disorders B. The DSM-5 establishes diagnostic criteria C. The DSM-5 indicates recommended pharmacological treatment D. The DSM-5 assists nurses in planning care E. The DSM-5 indicates expected assessment findings - A. The DSM-5 is used to identify mental health disorders B. The DSM-5 establishes diagnostic criteria D. The DSM-5 assists nurses in planning care E. The DSM-5 indicates expected assessment findings Which of the following is an example of a client who requires emergency admission to a mental health facility? - C- A client with borderline personality disorder who assaulted a homeless man with a metal rod A client tells a student nurse "don't tell, but I hid a knife under my mattress to protect myself from my room mate" which action should the nurse take? - C - Tell the client that this must be reported to health care staff because it concerns the health and safety of others A nurse puts a client who has psychosis in seclusion overnight because the unit is short-staffed and the client fights with others, example of? - B - a tort, false imprisonment A nurse is caring for a client in restraints. Which is appropriate documentation? - B,C,D - Client was offered 8 oz of water every hr, client shouted at assistive personnel, client received thorazine 15 mg by mouth at 1000 A nurse hears a newly licensed nurse discussing a clients hallucinations in the hallway with another nurse, which action should she take first? - B- tell the nurse to stop discussing the behavior A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following responses by the newly licensed nurse requires additional teaching regarding nonverbal communication? A. Personal space B. Posture C. Eye contact D. Intonation - D. Intonation A nurse is communicating with a client on the acute mental health facility. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating - D. Restating A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication? A. Offering advice B. Reflecting meaning C. Listening attentively D. Giving information - A. Offering advice A nurse is conducting therapy with a several clients and their families. Effective communication with clients and families is based on A. discussing in-depth topics with which the client feels comfortable. B. using silence to avoid unpleasant or difficult topics. C. attending to verbal and nonverbal behaviors. D. requiring the client and family to ask for feedback. - C. attending to verbal and nonverbal behaviors. When a family asks a nurse for reassurance about a client's condition, which of the following is an appropriate response? A. "I think your son is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically." - D. "I understand you're concerned. Let's discuss what concerns you specifically." A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." Which of the following defense mechanisms is the client using? A.Reaction formation B.Denial C.Displacement D.Sublimation - B.CORRECT: This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real. A nurse is obtaining informed consent for a client who has just learned she must have a breast biopsy. The client is perspiring and pale, has a respiratory rate 30/min, and says, "I don't quite understand what you're trying to tell me." The nurse should assess the client's anxiety as which of the following? A.Mild B.Moderate C.Severe D.Panic - B.CORRECT: Moderate anxiety decreases problem-solving and may hamper one's ability to understand information. Vital signs may increase somewhat, and the person is visibly anxious. A nurse is caring for a client who is experiencing moderate anxiety. Which of the following is an appropriate nursing intervention when trying to give necessary information to the client? [Show Less]
A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicati... [Show More] ons an understanding of the teaching? (Select all that apply) A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents." - A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy B. Teach the client appropriate coping mechanisms C. Assess the client for co-morbid health conditions D. Monitor the client for adverse effects of medications - D. Monitor the client for adverse effects of medications A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services B. Identify the client's perception of her mental health status C. Include the client's family in the interview D. Teach the client about her current mental health disorder - D. Teach the client about her current mental health disorder A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect? A. The client arouses briefly in response to a sternal rub B. The client has a Glasgow Coma Scale score less than 7 C. The client exhibits decorticate rigidity D. The client is alert, but disoriented to time and place - A. The client arouses briefly in response to a sternal rub A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Which of the following information is appropriate to include in the discussion? (Select all that apply) A. The DSM-5 includes client education handouts for mental health disorders B. The DSM-5 establishes diagnostic criteria for individual mental health disorders C. The DSM-5 indicated recommended pharmacological treatment for mental health disorders D. The DSM-5 assists nurses in planning care for client's who have mental health disorders E. The DSM-5 indicates expected assessment findings of mental health disorders - B. The DSM-5 establishes diagnostic criteria for individual mental health disorders D. The DSM-5 assists nurses in planning care for client's who have mental health disorders E. The DSM-5 indicates expected assessment findings of mental health disorders A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to himself - C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery - B. False imprisonment A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife B. Keep the client's communication confidential, but watch the client and his roommate closely C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others D. Report the incident to the health care team, but do not inform the client of the intention to do so - C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply) A. "Client ate most of his breakfast." B. "Client was offered 8 oz. of water every hour." [Show Less]
1. A nurse is reviewing the health hx of a young adult client who has a depressive disorder. What factors should the nurse identify as increasing the clien... [Show More] t's risk for depression? a. client is an only child b. client lives in an urban setting c. client is married d. client is female - d. client is female 2. A nurse is caring for a client who has OCD. The client engages in repeated hand washing daily. What should the nurse recognize as the purpose of the client's behavior? a. relieving anxiety b. gaining attention c. avoiding daily responsibilities d. responding to auditory hallucinations - a. relieving anxiety 3. A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. What finding should the nurse expect? a. bradycardia b. increased somnolence c. slurred speech d. headache - d. headache 4. A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as me, see, bee, tree. The nurse recognizes that the client is demonstratting what positive manifestations of schizophrenia? a. clang association b. echolalia c. magical thinking d. word salad - a. clang association 5. A nurse is assessing a client who has been taking thioridazine for several days. The client reports hand tremors, drooling, rigid extremities. What actions should the nurse take? a. reassure the client that these effects are expected b. administer diazepam c. encourage deep breathing and relaxation d. administer benztropine - d. administer benztropine 6. A nurse is caring for a client who has OCD. What actions should the nurse take when dealing with the client's ritualistic behaviors? a. plan the client's schedule to allow time to perform rituals b. verbalize disapproval of ritualistic behavior c. place the client in protective isolation d. increase stimuli in client's immediate surroundings - a. plan the client's schedule to allow time to perform rituals 7. A nurse is assessing a client who has an anxiety disorder and is taking benzodiazepine. For what adverse effect should the nurse monitor the client? a. seizures b. dizziness c. polyuria d. insomnia - b. dizziness 8. A nurse in a mental health clinic is assessing a client who has a hx of mania. What finding indicates that the client is experiencing a relapse? a. weight gain b. ritualistic behavior c. anhedonia d. pressured speech - d. pressured speech 9. A nurse is caring for a client who has panic disorder and is experiencing anxiety at the panic level. What action should the nurse take first? a. identify the cause of anxiety b. instruct the client to take slow, deep breaths c. teach the client how to use positive self-talk d. explain the physical manifestations of anxiety to the client - b. instruct the client to take slow, deep breaths 10. A nurse is providing teaching to a client who has a new script for phelezine. The nurse should teach the client that which of the following OTC meds can cause hypertensive crisis when taken with phenelzine? a. acetaminophen b. ranitidine c. naproxen d. pseudoephedrine - d. pseudoephedrine 11. A nurse is providing teaching to a cleint who has a new script for alprazolam. What is the priority info the nurse should include in teaching? a. this med can affect yourability to drive or handle mechanical equipment b. you should avoid drinking beverages that contain caffeine with this medication c you should avoid taking antacids within 2 hrs of taking this med d. this med should be taken with/shortly after meals - a. this med can affect yourability to drive or handle mechanical equipment 12. A nurse in the ED is assessing a client who has cocaine intoxication. What finding should the nurse expect? a. pinpoint pupils b. drowsiness c. nystagmus d. hypervigilance - d. hypervigilance 13. A nurse in an outpt mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. What action should the nurse take first? a. teach the client strategies to decrease hallucinations b. identify if the client is on antipsychotic meds c. distract the client from the hallucination d. explore what the voices are saying to the client - d. explore what the voices are saying to the client 14. A nurse is providing d/c teaching for a client who has a new script for doxepin. What adverse effects should the nurse inform the client is associated with this medication? a. wt loss b. diarrhea c. drowsiness d. bradycardia - c. drowsiness 15. A school nurse is caring for an adolescent client who has a hx of depressive episode 1 yr ago. He appears withdrawn from social activities and his school performance is declining. What action should the nurse take first? a. initiate a structured daily schedule of activities b. conduct a suicide-risk assessment c. encourage the client to express his feelings in a journal d. ask teacher to monitor for other signs of depression - b. conduct a suicide-risk assessment 16. A nurse is assessing a client who has schizophrenia. The client states, I need to get my gummamoshu from by my house. The nurse recognizes this statement as an example of what? a. flight of ideas b. echolalia c. perseveration d. neologism - d. neologism 17. A nurse is providing teaching to a client who has generalized anxiety disorder and a new script for buspirone. What statement by the client indicates an understanding of the teaching? a. this medication can cause dependence b. i should take a dose of my med when i start to feel anxious c. its important for me to take my med 30 min before bedtime d. i should expect to fell the full effect of my med in 2-4 weeks - d. i should expect to fell the full effect of my med in 2-4 weeks 18. A nurse is caring for a client who is taking a tricyclic antidepressant. What adverse effect should the nurse report to the provider immediately? a. dry mouth b. constipation c. drowsiness d. urinary retention - d. urinary retention 19. A nurse is caring for a client who has dementia. What finding should the nurse expect? a. altered LOC b. impaired judgment c. rapid change in personality d. disturbances in perception - b. impaired judgment 20. A nurse in a mental health facility is caring for a client who has generalized anxiety disorder. What statement should the nurse make? a. we'll assist you with making decisions b. someone will work with you when you have flashbacks c. you'll be going through aversion therapy to help you cope d. the therapy will help you control your impulses - a. we'll assist you with making decisions 21. A nurse is caring for a client who has been unable to leave the house for the past 10 years without accompainment. What attempting to go out alone, the client becomes very anxious and must quickly return inside. The nurse should identify that the client is exhibiting what disorder? a. agoraphobia b. PTSD c. panic disorder d. OCD - a. agoraphobia 22. A nurse is providing teaching to a client who has a new script for diazepam. What instructions should the nurse include in the teaching? a. expect this med to make you feel anxious b. this med can be habit-forming c. take this med on an empty stomach d. this med takes 2-3 weeks to reach full therapeutic effect - b. this med can be habit-forming 23. A nurse is providing teaching to a client who has a new script fo chlorpromazine. What statement should the nurse make? a. this med is a tricyclic antidepressant and will improve your mood b. this med is an opioid antagonist that blocks the pleasurable effects of alcohol c. this med is an antipsychotic that controls manifestations of schizophrenia d. this med is a cholinesterase inhibitor that slows the progression of dementia - c. this med is an antipsychotic that controls manifestations of schizophrenia 24. A nurse is reviewing the lab report of a client who has been taking lithium carbonate for several months. What level should the nurse recognize as a therapeutic lithium level? a. 1.2 b. 1.6 c. 2.0 d. 2.5 - a. 1.2 25. A nurse is assessing a client who has been taking an antipsychotic med for 6 years and the provider has started tapering off the dosage. The nurse should monitor the client for what manifestation of tardive dyskinesia? a. muscular weakness b. muscle spasms c. involuntary tongue protrusion d. uncontrolled eye rolling - c. involuntary tongue protrusion 26. A nurse is caring for a client who has severe anxiety disorder and is in a state of panic in the dayroom. What action should the nurse take? a. speak to the client in a calm voice b. leave the client alone to regain control c. encourage the client to express her feelings d. place the client in restraints - a. speak to the client in a calm voice 27. A nurse is assessing a client who has a psychotic disorder and a new script for haloperidol. The client is pacing in the hallway and states, I can't seem to sit still. What extrapyramidal side effect is the client likely experiencing? a. dystonia b. parkinsonism c. tardive dyskinesia d. akathisia - d. akathisia [Show Less]
1. A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following treatment approaches should the... [Show More] nurse plan to take? a)Restrict participation in group therapy sessions b)Establish consequences for self-mutilation c)Maintain close observation d) Provide an unstructered environment - c)Maintain close observation 2. Clients who have borderline personality disorder are at risk for self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury 3. A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. What action should the nurse take? - Administer the medication at bedtime. 4. A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in this room is being recorded." What response should the nurse make? - "That must be very frightening." 5. The nurse should respond to the client's delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship. 6. A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What finding should the nurse expect? - Confusion. 7. The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor, diplopia, and memory loss are expected findings of this disorder. 8. A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which manifestations is a common adverse effect of this medication? - Dizziness. 9. The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined. 10. A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. What finding should the nurse question the provider's prescription? - Hypotension. 11. The nurse should question the provider's prescription for a benzodiazepine for a client who has hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for cardiac arrest. 12. A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding is the priority for the nurse to report to the provider? - Elevated blood pressure. 13. The nurse should identify that the greatest risk to the client is an elevated blood pressure, which increases the risk for a hypertensive crisis that can result from taking an MAOI, such as phenelzine. The nurse should apply the safety and risk reduction priority-setting framework when assessing this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting frame-work, or nursing knowledge to identify which risk poses the greatest risk. 14. A nurse is providing teaching to a client who has a new prescription for disulfiram for the management of alcohol dependence. What dietary choices should the nurse instruct the client to avoid? - Pure vanilla extract. 15. The nurse should instruct the client to avoid alcohol and alcohol-containing substances such as pure vanilla extract. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension. [Show Less]
1. A client who has anorexia nervosa is more likely to have _____ resulting from extreme malnutrition. - lanugo 2. a client who has bulimia nervosa is l... [Show More] ikely to have _______ caused by frequent exposure to gastric acid from vomiting. - dental caries and tooth erosion 3. extreme distractibility is a hallmark manifestation of _______. - delirium 4. criteria for hospitalization is weight loss over 30% of total body weight in _____months. - 6 5. severe hypothermia, a temperature lower than ________ due to loss of subcutaneous tissue or dehydration, requires hospitalization. - 96.8 6. fine hand tremors are an expected adverse effect of _____ and ca interfere with the client's ADLs, causing the client to stop taking the medication. - Lithium 7. the nurse should encourage the client to drink _____ of fluid each waking hour to maintain hydration. - 125 mL 8. an initial response to amitriptyline can develop in 1 week. For a client who has been severely depressed with suicidal ideation, the energy to carry out a plan is ____. - more possible after 1 week of treatment 9. clients who are taking tranylcypromine, an MAOI-antidepressent, should not take _____and other OTC medications for sinus, congestion, colds or allergies due to their actions on the sympathetic nervous system, which can results in severe hypertension. - phenylephrine 10. the nurse should identify that mild cognitive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has ____. - Alzheimer's Disease 11. a client who is experiencing ___ is expected to have hypertension, tachycardia, and a fever greater than 38.3 (101 F) - alcohol withdrawal 12. a client who is experiencing alcohol withdrawal can experience profuse sweating and _____ pupils - dilated 13. benztropine is used to treat parkinsonism manifestations, such as _____ - shuffling gait 14. St. John's wort is an herbal preparation that decreases reuptake of serotonin. The nurse should advise the client that taking St. John's wort with another medication that also inhibits the reuptake of serotonin, such as ____, placed the client at risk for - paroxetine 15. _____ is common in clients who have depression. The nurse should allow the client extra time to comprehend and formulate an answer to the question. - slowed response time 16. The greatest risk to the client who is experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. ____ acts rapidly to prevent seizures, stabilize vital signs and decrease the intensity of withdrawal manifestations - IV Diazepam 17. it is the ____ responsibility to confront the staff member about her behavior toward the client. - charge nurse and the nurse manager 18. clients who have ____ can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room. - bipolar disorder 19. the nurse should document the client's behavior every ____ while the client is in seclusion. - 15-30 min 20. the nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every ____ for a maximum of 24 hour. - 4 hr 21. normal levels of sodium and fluid need to be maintained to ensure adequate excretion of ____, - Lithium 22. The nurse should monitor the child for ___, which is an adverse effect of methylphenidate - tachycardia 23. a traumatic even that causes severe stress is a trigger for _____. - dissociative amnesia 24. Clients who have ____ need excessive input from others to make everyday decisions. - Dependent Personality Disorder 25. The nurse should teach the client that he is not responsible for his disorder but he is responsible for his ______. - Recovery 26. Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using ____. - guided imagery 27. The rapid transition from on emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances. - Emotional lability 28. The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to _____. - remove unnecessary equipment from the child's surroundings. 29. The seizure induced during ECT can stress the client's heart. Therefore, the nurse should plan to monitor the client's ___ during ECT via an electrocardiogram. - cardiac rhythm. 30. The nurse should frequently offer the client, high-calorie foods that can be eaten while the client is on the go. Clients experiencing ____ might be unable to sit down for meals and can experience weight loss and dehydration. - mania 31. A sodium level of 128 mEq/L should alert the nurse that the client is at risk for _____ because renal excretion of lithium is decreased in the presence of low sodium level. - Lithium toxicity 32. Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC below ______ as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider. - 3000/mm3 33. This is an example of secondary prevention. By _____ the nurse can identify individuals who are at risk fr intimate partner abuse in the community and can take the necessary steps to address individual client needs. - establishing screening programs. 34. positive symptoms of schizophrenia usually appear suddenly and are alterations in behavior, perception, speech and thought. ____ are examples of positive symptoms. - delusions and an inability to think abstractly. 35. a child who has autism spectrum disorder usually has a ______ - language delay 36. _______ is a manifestation of depression and early identification of findings can lead to early intervention. - decreased social involvement. 37. The client experiences a situation crisis when ____ - an unexpected event occurs. 38. The hospitalization of the mentally ill act of 1964 requires that clients admitted to an inpatient mental health facility have a right to ______ - individualized treatment 39. The nurse should expect the client who is experiencing opioid withdrawal to have _____ and flu-like manifestations such as yawning, sneezing, and abdominal pain - rhinnorhea 40. Fluoxetine is a selective serotonin reuptake inhibitor that can cause ______ such as anorgasmia and impotence - sexual dysfunction 41. ECT can be used when: - 1.There is a need for rapid definitive response for a client who is suicidal 2.Bipolar disorder with rapid cycling 3.Mania and have not responded to medication therapy 42. During acute mania, the client is extremely active and _____, which can lead to relapse. - does not sleep 43. low weight, electrolyte imbalances, starvation and dehydration causes _____. - orthostatic hypotension 44. according to evidence-based practice, the nurse should first inform the client about ____ during the orientation phase of the nurse-client relationship. - confidentiality. 45. a stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants____. - mandatory reporting 46. succinylcholine is a muscle -paralyzing agent that will ____ during the procedure so that injury is less likely to occur. - decrease muscle movement. [Show Less]
Mental Health ATI - Assessment A 2022 60 Questions & Answers 1. A nurse in mental health facility observes a client who is experiencing panic level of ... [Show More] anxiety. Which of the following actions should the nurse take first? - Accompany the client to a quiet room. (Greatest risk for this client is injury due to severe anxiety. Therefore, first action nurse should take is to stay with client and bring him to a room with minimal stimuli.) 2. A nurse is obtaining a history and physical on a client who presents to the emergency department of a mental health facility. The nurse recognizes which of the following assessment findings as being consistent with PTSD? (Select all that apply) - Distressing dreams Difficulty concentrating Exaggerated startle response 3. A nurse is providing teaching to a client who has a new prescription for haloperidol. Which of the following side effects should the nurse instruct the client to report to the provider? - Shuffling gait. (Clinical findings of pseudoparkinsonism such as shuffling gait may occur 5hr - 30 days after beginning treatment. The client should notify the provider who might prescribe an anti parkinsonism agent.) 4. A home health nurse is assessing an older adult client who lives alone. Which of the following findings should indicate to the nurse that the client is experiencing delirium? - Sudden onset. (Clients usually develop delirium suddenly over hours to days.) 5. A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor? - Urinary retention. 6. A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. Client's morning lithium level is 1.5 mEq/L. Which of the following additional laboratory data has the highest priority? a) Serum erythrocyte sedimentation rate 18 mm/hr b) Hemoglobin 15 g/dL c) serum T4 5 mcg/dL d) Serum sodium 125 mEq/L - Serum sodium 125 mEq/L (In the presence of low sodium levels, renal excretion of lithium is reduced and client is at risk for lithium toxicity. Therefore, this finding is highest priority because it places client at greatest risk for injury.) 7. A nurse is caring for a client who has a history of substance use and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? - Do not administer the lorazepam. (Clients who are involuntarily admitted retain the right to refuse treatment.) 8. A nurse is developing a discharge plan for a client who has a history of gambling dependency and includes participation in support group. The nurse should tell the client that which of the following is the purpose of attending a support group? - Provide assurance that others have a similar problem. (Participating in a support group with other individuals who have similar problems will show the client that he is not the only one with this problem. The client can learn alternative ways to solve problems that other members of the group have also experienced.) 9. A nurse is caring for a client who is deaf and is scheduled to have electroconvulsive therapy (ECT). Provider needs to explain procedure to client in order to obtain informed consent. Which of the following actions should the nurse take? - Request a professional interpreter to translate. 10. Nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following should the nurse include in the eaching? - Right to treatment ensures individualized care. 11. Nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent? - A 35-year-old who has major depressive disorder. 12. A nurse is caring for client whose child recently died in a motor vehicle crash and states, "I just want to join him." Which of the following is the nurse's priority response? - "Are you thinking about harming yourself?" (Greatest risk is self-injury; priority is therefore to ask client if she has plans for self-harm) 13. A nurse is assessing a client in the ED. Client appears agitated, his blood pressure is 152/94 mm Hg, his HR is 104/min, and his pupils are dilated. The nurse should suspect intoxication with which of the following substances? - Cocane (cocaine intoxication causes tachycardia, elevated BP, dilated pupils, and agitation. These physiological findings suggest cocaine intoxication). 14. A nurse is caring for a client who has schizophrenia and is prescribed risperidone. Which of the following laboratory tests should the nurse monitor? - Blood glucose (risperidone can cause diabetes mellitus to develop; therefore, nurse should plan to monitor client's blood glucose level when taking this medication) 15. Nurse is caring for a client receiving tranylcypromine. Which of the following is an appropriate menu choice for the nurse to suggest? - Roasted chicken. (contains little to no tyramine and is an appropriate menu choice for client who is taking tranylcypromine, an MAOI) 16. A nurse is reviewing the potential adverse effects of lithium with a client who began the medication 2 weeks ago. For which of the following should the nurse instruct the client to monitor and report to the provider? - Coarse hand tremor. (Coarse hand tremor can indicate toxicity and the client should report this finding to the provider immediately) 17. A client is experiencing a situational crisis. Which of the following findings should the nurse expect? - Client recently lost a grandparent in a motor vehicle crash. (Client experiences a situational crisis when an unexpected event occurs.) 18. A nurse is assessing a client in the ED who is brought in by a caregiver. The caregiver states the client fell recently. The nurse observes bruises on the client's abdomen, back, and legs suspects abuse. Which of the following actions should the nurse take first? - Check the client for other s/s of abuse. (First action the nurse should take using nursing process is to assess client. Therefore, first action the nurse should take is to check client for further s/s of abuse.) 19. A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the highest priority for the nurse to report to the treatment team? - Giving away possessions (indicates client is at greatest risk for suicide; therefore, priority finding). 20. A nurse is caring for a client who has schizophrenia in a mental health facility. Which of the following places the client at greatest risk for self-directed injury or injuring others? - Command hallucinations (a client who has schizophrenia and is experiencing command hallucinations may be told to hurt himself or others. Therefore, a client who is experiencing command hallucinations is at greatest risk for self-directed injury or injuring others). [Show Less]
A nurse is reinforcing teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that eating foods high in tyram... [Show More] ine can cause which of the following adverse reactions with this medication? A. Hypertensive crisis B. Serotonin syndrome C. Hearing loss D. Urinary incontinence - A. Hypertensive crisis RAT: Tyramine can cause severe hypertension in clients who are taking phenelzine, a monoamine oxidase inhibitor. Manifestations include palpitations, stiff neck, headache, nausea, vomiting, and elevated temperature. A nurse is contributing to the plan of care for a client who has antisocial personality disorder. Which of the following short-term goals should the nurse recommend be included in the plan? The client will participate in assertiveness training. The client will discuss feelings that cause hostility. The client will describe an activity they found enjoyable. The client will dress in a manner appropriate for the setting and temperature. - The client will discuss feelings that cause hostility. RAT: Clients who have antisocial personality disorder are frequently aggressive and are at risk for injuring themselves or others. A short-term goal for these clients should be to discuss feelings that precipitate aggression or hostility. The nurse is assisting with an admission have a client who has eating disorder. During data collection, which is the following to the nurse identify as manifestations of bulimia nervosa? SOA A. Tooth erosion B. Hand calluses C. Lanugo D. Amenorrhea E. Hypokalemia - A. Tooth erosion B. Hand calluses E. Hypokalemia RAT: Tooth erosion is a manifestation of bulimia nervosa that results from self-induced vomiting. Hand calluses are a manifestation of bulimia nervosa that results from self-induced vomiting. Lanugo is a manifestation of anorexia nervosa that results from starvation. Amenorrhea is a manifestation of anorexia nervosa that results from extreme weight loss. Hypokalemia is a manifestation of bulimia nervosa that results from volume depletion due to self-induced vomiting or excessive diuretic and laxative use. A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider? A. Potassium 4.0 mEq/L B. Lithium 0.9 mEq/L C. BUN 12 mg/dL D. Sodium 132 mEq/L - D. Sodium 132 mEq/L RAT: The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and places the client at risk for lithium toxicity. The nurse should report this finding to the provider. A nurse in a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? A. Weigh the client at night prior to bedtime. B. Offer liquid supplements to the client. C. Encourage the client to gain 2.3 kg (5 lb) per week. D. Observe the client for up to 30 min after meals. - B. Offer liquid supplements to the client. RAT: The nurse should offer liquid supplements to the client because the client might be unable to eat solid foods when they are first admitted. The nurse should observe the client for at least 1 hr after meals to prevent the client from throwing away, hiding, or purging food. A nurse is contributing to plan of care for a school-age child who has attention deficit hyperactivity disorder. Which of the following interventions should the nurse recommend? A. Avoid the use of humor when managing the child's disruptive behaviors. B. Instruct the child to apologize for behavior that negatively affects others. C. Maintain a scheduled plan of activities regardless of the child's behavior. D. Administer methylphenidate PRN when the child exhibits disruptive behavior. - B. Instruct the child to apologize for behavior that negatively affects others. RAT: The nurse should recommend performing simple techniques to manage the child's behavior, including making amends. This technique includes apologizing to others when the client's behavior has a negative effect. A nurse is reviewing laboratory values for a client who has anorexia nervosa. Which of the following results should the nurse expect? A. Potassium 3 mEq/L B. Phosphorus 3.5 mg/dL C. Magnesium 1.8 mEq/L D. Cholesterol 165 mg/dL - A. Potassium 3 mEq/L RAT: The nurse should expect a client who has anorexia nervosa to have hypokalemia, which is indicated by a decreased potassium level. This value is below the expected reference range of 3.5 to 5 mEq/L. A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Decreased heart rate C. Slurred speech D. Rhinorrhea - A. Elevated blood pressure RAT: Hypertension is an expected finding of alcohol withdrawal and can occur within 4 to 12 hr of cessation of alcohol ingestion. A nurse is caring for a client who recently lost their child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? A. "Are there times when you feel more upset than others?" B. "Have you had any thoughts of harming yourself?" C. "What type of support system do you currently have?" D. "During difficult times in the past, what did you do to cope?" - B. "Have you had any thoughts of harming yourself?" RAT: The greatest risk to this client is self-injury due to suicide. Asking whether or not the client has plans to hurt themselves is the most important question for the nurse to ask at this time because a positive response can alert the nurse to the need for suicide precautions and intervention. A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findings should the nurse withhold the client's medications and notify the provider? A. Fasting blood glucose B. Temperature C. WBC count D. Heart rate - C. WBC count RAT: The nurse should identify that a WBC count of 3,000/mm3 is below the expected reference range of 5,000 to 10,000/mm3. The nurse should identify that clozapine can cause agranulocytosis, a decrease in white blood cells, which can be life threatening. Therefore, the nurse should withhold the client's medications and notify the provider of this finding. A nurse is collecting data from a client whose home was destroyed by a fire. Which of the following responses should the nurse make first? A. "Are you experiencing feelings of hopelessness?" B. "Is there someone I can call for you?" C. "It might be helpful for you to attend a support group." D. "Now is a good time for you to use relaxation breathing." - A. "Are you experiencing feelings of hopelessness?" RAT: When using Maslow's hierarchy of needs, the priority action for the nurse to take is to determine if the client is safe. The nurse should collect data about the client's feelings to determine if the client is having feelings of hopelessness or suicidal ideations. A nurse is collecting data from a client who is taking valproic acid for the treatment of a bipolar disorder. Which of the following findings is the priority to the provider? A. Dizziness B. Weight gain C. Constipation D. Yellow sclerae - D. Yellow sclerae RAT: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is yellow sclerae because of the risk for hepatotoxicity. A nurse is reinforcing teaching about food that contains tyramine with a client who has a prescription for phenelzine. Which of the following foods should the nurse instruct the client to void? [Show Less]
ATI proctored Mental Health🎉❤️🎂🎂2022 What are cognitive symptoms of psychotic disorders - -disordered thinking -inability to make decisi... [Show More] ons -poor problem solving ability -difficult concentrating to perform tasks -Memory deficits Misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about them - ideas of reference Feels singled out for harm by others (being hunted down by FBI) - Persecution Believes that she is all powerful and important like a god - grandeur believes that his body is changing in an unusual way, scubas growing a third arm - somatic delusions May feel that her spouse is sexually involved with another individual - Jealousy Believes that a force outside his body is controlling him - being controlled believes that her thoughts are heard by others - thought broacasting believes that others thoughts are being inserted into his mind - thought insertion Believe that her thoughts have been removed form her mind by an outside agency - thought withdrawal is obsessed with religious beliefs - religiosity The client may say sentence after sentence but each sentence may relate to another topic and the listeniner is bale to follow the clients thoughts - flight of ideas Made up words that have meaning only to the client such as i tranged and flitted. - neologisms What are the standardized screen tools for psychotic disorders - -Global assessment of functioning scale -scale for assessment of negative symptoms -Brief psychiatric rating scale -abnormal involuntary movement scale (AIMS) What antidepressants are prescribed for psychotic disorders - Paxil -monitor for SI -Notify for deepened depression -Do not stop abruptly What are the anxiolytics/ bento's used for psychotic disorders? - -Ativan -Klonopin -sedative effects -need to get blood tests for ANC -use caution in older adults What are the personality disorders in cluster A - (Odd and eccentric traits) -Paranoid -Schizoid -Schizotypal Characterized by odd beliefs leading to interpersonal difficulties, an eccentric appearance, and magical thinking or perceptual distortions that are not clear delusions or hallucinations - schizotypal Dealing with anxiety by reaching out to others. Ex: a nurse who lost a family member in a fire is a volunteer firefighter - Altruism Dealing with unacceptable feelings or impulses by unconsciously substitute acceptable forms of expression. Ex: a person who has feelings of anger and hostility toward his work supervisor sublimates those feelings by working out vigorously a the gym during his lunch period - Sublimation Voluntarily denying unpleasant thoughts and feelings. Ex: A person who has lost his job states he will worry about paying his bills next week - Suppression Putting unacceptable ideas, thoughts, and emotions out of conscious awareness. Ex: a person who has a fear of the dentist's drill continually "forgets" his dental appointments. - Repression What are healthy defense mechanisms? - alturism and sublimation what are intermediate defenses - repression reaction formation displacement rationalization undoing What are immature defenses - projection dissociation splitting denial Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation Ex: A person who is angry about losing his job destroys his child's favorite toy - displacement Overcompensating or demonstrating the opposite behavior of what is felt. Ex: a person who dislikes her sisters daughter offers to babysit so that her sister can go out of town - reaction formation Performing an act to make up for prior behavior. Ex; An adolescent completes his chores without being prompted to after having an argument with his parents. - undoing creating reasonable and acceptable explanations for unacceptable behavior Ex: A young adult explains he had to drive home from a party after drinking alcohol because he had to feed his dog. - rationalization temporarily blocking memories and perceptions from consciousness Ex: an adolescent witnesses a shooting and is unable to recall any details of the vent - dissociation demonstrating an inability to reconcile negative and positive attributes of self or others Ex:a client tells a nurse that she is the only one who cares about her, yet the following day the same client refuses to talk to the nurse - splitting Blaming others for unacceptable thoughts and feelings Ex: a young adult planes his substance use disorder on his parents refusal to buy him a new car - projection pretending the truth is no reality to manage the anxiety of acknowledging what is real. Ex: A parent who is informed that his son was killed in combat tells everyone he is coming home for the holidays. - denial [Show Less]
1. A nurse is providing discharge teaching for a female client who has an anxiety disorder and a new prescription for lorazepam. Which of the following ins... [Show More] tructions should the nurse include in the teaching? - "this med must be discontinued gradually" 2. A nurse is reviewing the laboratory report of a client who has been taking lithium carbonate for several months. Which of the following levels should the nurse recognize as a therapeutic lithium level? - 1.2mEq/L range: 1.0-1.5 3. A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? - impaired judgement 4. A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors should the nurse identify as increasing the client's risk for depression? - being female 5. A nurse is caring for a client who has obsessive-compulsive disorder. The client engages in repeated handwashing daily. Which of the following should the nurse recognize as the purpose of the client's behavior? - relieving anxiety 6. A nurse is caring for a client who has been unable to leave the house for the past 10 years without accompaniment. When attempting to go out alone, the client becomes very anxious and must quickly return inside. The nurse should identify that the client is exhibiting which of the following disorders? - agoraphobia; fear and avoidance of places where escape might be difficult 7. A nurse is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following actions by the client indicates the current treatment plan is effective? - the clients report techniques she uses to promote sleep 8. A nurse is caring for a client who has panic disorder and is experiencing anxiety at the panic level. Which of the following actions should the nurse take first? - instruct the client to take slow, deep breaths 9. A nurse is providing teaching to a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions by the nurse implements modeling as a behavioral intervention strategy? - demonstrating performance of hand hygiene as designated times 10. A nurse in a mental health clinic is assessing a client who has a history of mania. Which of the following findings indicates that the client is experiencing a relapse? - pressured speech 11. A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder. The laboratory report indicates that the client's current lithium level is 1.0 mEq/L. Which of the following actions should the nurse take? - administer the med because it is within ranges 12. A nurse is assessing< a client who has a psychotic disorder and a new prescription for haloperidol. The client is pacing in the hallway and states, "I can't seem to sit still." Which of the following extrapyramidal side effects is the client likely experiencing? - akathisia 13. A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client? - chicken nuggets, crackers, a cookie, cheese sticks #YUM 14. A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine The nurse should instruct the client that which of the following blood tests should be performed periodically? - glucose 15. A nurse is assessing a client who has schizophrenia. The client states, "I need to get my gummamoshu from by my house." The nurse recognizes this statement as an example of which of the following? - neologism 16. A nurse on an inpatient unit is assessing a client who has claustrophobia. The nurse determines the client's condition has improved when he can perform which of following tasks? - ride in an elevator 17. A nurse is caring for a client who is taking a tricyclic antidepressant. Which of the following adverse effects should the nurse report to the client's provider immediately? - urinary retention 18. An emergency room nurse is assessing a client who has an anxiety disorder. The client is flushed, perspiring profusely, and is experiencing palpitations. The client begins to scream, "I am going to die! This is it! I am having a heart attack!" The nurse should determine the client's level of anxiety to be which of the following - panic 19. A school nurse is caring for an adolescent client who has a history of a depressive episode 1 year ago. He appears withdrawn from social activities and his school performance is declining. Which of the following actions should the nurse take first - conduct a suicide risk assessment 20. A nurse is providing teaching to a client who has a new prescription for chlorpromazine. Which of the following statements should the nurse make ? - this medication is an anti-psychotic that controls symptoms of schizophrenia [Show Less]
1. A nurse in an acute mental health facility is reviewing the medication records for a group of clients. The nurse should expect a prescription for memant... [Show More] ine for a client who has which of the following diagnoses? - Alzheimer's disease 2. A nurse is collecting data from a client who takes an MAOI for treatment of depression. Which of the following findings is the priority for the nurse to report to the provider? - Elevated blood pressure 3. A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. The nurse should identify that it is safe to administer which of the following medications while the client is taking lithium? - Valproic acid 4. A nurse is collecting data fro, a client who has cocaine intoxication. Which of the following findings should the nurse expect? - Increased mental alertness 5. A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall very rapidly and muttering in an angry manner. Which of the following actions should the nurse take first? - Approach the client in a nonthreatening manner. 6. A nurse in an acute mental health facility is participating is participating in a nursing staff discussion about the legal aspects of involuntary admissions. Which of the following information should the nurse include? - An involuntary admission is justified if the client is a danger to others. 7. A nurse is reinforcing teaching with a client who has a new prescription for disulfiram for the management of alcohol dependence. Which of the following dietary choices should the nurse instruct the client to avoid? - Pure vanilla extract 8. A nurse is reinforcing teaching with the family of a client who has Alzheimer's disease about donepezil. Which of the following statements should the nurse include? - "Donepezil can improve cognitive functioning during the earlier stages of the disease." 9. A nurse is reviewing the medical history of a client who has a new prescription for electroconvulsive therapy (ECT). Which of the following findings should the nurse identify as the priority? - Cardiac arrhythmia 10. A nurse is contributing to the plan of care for a client who has anorexia nervosa. The nurse should identify that which of the following actions is contraindicated for this client? - Permitting the client to spend some quiet time alone after each meal 11. A nurse is reinforcing teaching with the parents of a school-age child who has attention deficit hyperactivity disorder (ADHD). Which of the following instructions should the nurse include? - "Ignore your child's attention-seeking behaviors that are not dangerous." 12. A nurse is assisting in the planning of a staff education session about the administration of antidepressant medications to older adult clients. Which of the following information should the nurse recommend to include? - Older adults clients require a lower initial dose of antidepressant medication than adult clients. 13. A nurse in an acute substance disorder unit is collecting data from a client who received treatment in the emergency department for an opioid overdose. Which of the following findings should the nurse anticipate during opioid withdrawal? - Anxiety 14. A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client? - Speak to the client using simple and concrete terminology. 15. A nurse is reviewing the medical record of a client who has a new prescription for benzodiazepine. For which of the following findings should the nurse question the provider's prescription? - Hypotension 16. A nurse is caring for a client who has cirrhosis of the liver due to alcohol use disorder. Which of the following findings should the nurse expect? - Ascites 17. A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take? - Talk to the client form two arm-lengths away. 18. A nurse is collecting data from a client who has conduct disorder. Which of the following findings should the nurse expect? - Aggressive behavior towards others 19. A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? - "Attending group therapy, even if you're tired, is an important part of your treatment." 20. A nurse is preparing to administer a benzodiazepine to a client who has generalized anxiety disorder. The nurse should tell the client to expect which of the following adverse effects? - Sedation 21. A nurse is an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurse's priority? - Protect the client from impulsive behavior. 22. A nurse is contributing to the plan of care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of following client goals should the nurse identify as the priority? - Maintaining adequate hydration 23. A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the ruse that he isn't going to attend any further sessions and states, " I don't have time for all that talking." Which of the following responses should the nurse make? - "It must be difficult for you to talk about family problems." 24. A nurse is assisting with the admission of a client who has antisocial personality disorder to an acute care unit. The client is admitted under court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to display? - Anger with the nursing staff for hospitalizing him against his will 25. A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect administer during this phase of the client's care? - Diazepam 26. A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for which of the following substances? - Opiates 27. A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? - Keep the client's rom well-lit at night. 28. A nurse in the emergency room is collecting data from a client who has heroin intoxication. Which of the following findings should the nurse expect? - Respiratory depression 29. A nurse is caring for a client who just received a terminal diagnosis of cancer. Which fo the following initial reactions should the nurse expect form the client? - Denial 30. A nurse is collecting data from a client who has post-traumatic stress disorder (PTSD) due to a sexual assault that occurred 3 months ago. Which of the following findings should the nurse expect? - Dreams about the assault [Show Less]
1. A nurse is conducting a counseling session with a client who has a substance use disorder. The client repeatedly ask personal questions about the nurse.... [Show More] Which of the following actions should the nurse take? - Explain that this time is designated to focus on the client. 2. A nurse is preparing to apply restaurants on a client who is threatening to harm others and has not responded to lessen case of interventions. Which of the following actions should the nurse plan to take? - Document the clients behavior every 15 minutes while restraints are in place. 3. Community mental health nurse is planning strategies to address substance use my adolescence. Which of the following intervention should the nurse plan as a method of primary prevention?Community mental health nurse is planning strategies to address substance use my adolescence. Which of the following intervention should the nurse plan as a method of primary prevention? - Provide a presentation at area high school's and resisting peer pressure for substance use. 4. A nurse in an emergency department is caring for an 18 month old toddler who has a fractured left femur. What is the long statement by the toddler's parent should cause the nurse to suspect child abuse? - "My child was riding a bicycle and fell off." 5. A nurse is administering an oral sedative to a client who is receiving careful and involuntary admission. The client states, " I'm not taking any more medication." Which of the following actions should the nurse take? - Document the client refusal of the medication in the medical record. 6. A nurse is caring for a school age client who begins wetting the bed after finding out her parents are getting a divorce. The nurse should identify the client is exhibiting which is a fine defense mechanisms? - Regression 7. A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yells at her son stating, " Quit lying about your father!" The nurse should recognize that the client is demonstrating which of the following defense mechanisms? - Denial 8. A nurse is caring for a client called mental health counseling center. The client received a failing grade in the course and spends entire counseling session blaming the teacher. The nurse should recognize this behavior as example of which of the following defense mechanisms? - Projection 9. A nurse at a college campus health clinic is caring for a client who reports manifestations of bulimia nervosa. The client tells the nurse, " I know my eating binges and vomiting are not normal, but I cannot control it." Which of the following responses should the nurse make? - " You are feeling helpless about changing this behavior?" 10. A nurse is preparing to administer fluphenazine decanoate 12.5 mg subcutaneous. available is fluphenazine decanoate 25 mg/mL. How many mL should the nurse administer per dose? - 0.5 11. A nurse is providing support for the parents of a child has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief? - Denial 12. A nurse is caring for a client who has depression. The nurse observes that the client has not come to breakfast and is still in bed. The client states, " I'm not worth your time. Leave me alone and go help someone else." which of the following responses should the nurse make? - " In other words, you seem to be saying that you feel unworthy of help." 13. A nurse is caring for a client has schizophrenia. The client states, " My internal organs have turned to stone." The nurse should document this finding as which of the following types of delusions? - Somatic 14. A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which of the following actions should the nurse take during the orientation phase? - Identify the clients perception of the reason for therapy. 15. A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics? - Possesses feelings of decreased self-worth 16. A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for the client's therapy? [Show Less]
A nurse is assisting with the planning of a therapeutic support group for individuals who have bulimia nervosa. Which of the following tasks should the nur... [Show More] se include during the orientation phase of group development? A. determine the rules that the group will follow B. address disagreements among group members C. help clients work through the grief response D. transition from the role of leader to facilitator - determine the rules that the group will follow *during the orientation phase of group development, the nurse should determine the rules that apply to the group and ensure that all members understand these rules. Examples of rules to be discussed include confidentiality and meeting times. A nurse is providing support for a client who is grieving the loss of her mother who died from Alzeimer's disease. Which of the following statements should the nurse offer? A. "I know how you must be feeling. I recently lost my father." B. "Dealing with your mother's death must be difficult for you." C. "Knowing your mother is in a better place provides you with some comfort." D. "I want you to let me know what I can do to help you cope with your mother's death." - "Dealing with your mother's death must be difficult for you." *The nurse should use therapeutic communication when supporting a client who is grieving. This statement keeps the focus of the conversation on the client by acknowledging her grief and encourages further communication." A nurse in the emergency room is collecting data from a client who has heroin intoxication. Which of the following findings should the nurse expect? A. Seizure activity B. Respiratory depression C. Hypersensitivity to pain D. Increased mental alertness - Respiratory depression *Heroin is an opioid; therefore, the nurse should expect this client who has heroin intoxication to exhibit respiratory depression. A nurse on a mental health unit is caring for a client who is displaying signs of anger. Which of the following pieces of information about the client is the strongest indicator that the client might become aggressive? A. The client has marginal coping skills B. The client has a history of violence C. The client feels powerless after being hospitalized D. The client blames others for her problems - The client has a history of violence *The client's history of violence is the most important indicator that this client might become violent; therefore, this is the strongest indicator of potential aggressiveness. A nurse is reinforcing teaching with the caregiver of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Offer the client a list of activities to choose from B. Offer finger foods to the client C. Discourage naps throughout the day D. Turn on the television when the client is in the room - Offer finger foods to the client *The caregiver should offer finger foods that the client can eat without sitting down. Clients who have dementia often like to wander and walk off nervous energy, which can decrease anxiety and calm the client. A nurse is contributing to the plan of care for a client with bipolar disorder who has acute mania. Which of the following interventions should the nurse recommend including in the plan? A. Provide the client with a low-calorie, low-fat diet B. Encourage the client to have frequent rest periods C. Escort the client to daily group therapy D. Limit the client's intake of caffeinated beverages to 12 oz per day - Encourage the client to have frequent rest periods *The nurse should recommend encouraging frequent rest periods throughout the day to decrease the client's risk of exhaustion from the constant activity associated with acute mania. A nurse is reviewing the plan of care for a client who has bipolar disorder. Which of the following is an effect of using cognitive behavioral therapy (CBT) for a client who has bipolar disorder? A. Prevents the need for mood-stabilizing medications B. Helps the client deal with distorted thought processes C. Aids in communication among family members D. Replaces the need for lifestyle interventions - Helps the client deal with distorted thought processes *CBT assists the client with recognizing distorted thought processes that are maladaptive with regards to recovery. When experiencing mania, the client tends to view the future unrealistically as highly favorable. CBT assists the client in recognizing and challenging such unrealistic or "automatic" thoughts and can help the client and the health care team recognize early trends toward mania A nurse is caring for a client in a mental health facility and overhears the client discussing plans to harm her father-in-law physically when she is discharged. Which of the following interventions should the nurse take? A. Ask the client to sign a contract agreeing not to harm others B. Notify the provider of the client's threat C. Keep the client's discussion confidential D. Place the client in individual observation - Notify the provider of the client's threat *It is the nurse's duty to notify the provider of the client's threat. It will then be the provider's responsibility to warn the the intended victim or the police of the client's threat A nurse is preparing to meet with a client who has borderline personality disorder. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship? A. Introduce the concept of client confidentiality B. Establish goals with the client C. Define the roles of the nurse and the client D. Facilitate change in the client's behavior - Facilitate change in the client's behavior *The nurse should facilitate change in the client's behavior during the working phase of the therapeutic relationship. A nurse is contributing to the plan of care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse recommend? A. Search the client and his belongings upon arrival B. Assign the client to a private room near the nurse's station C. Instruct assistive personnel to check on the client every 15 m in D. Keep the door to the client's room closed - Search the client and his belongings upon arrival *The nurse should plan to search the client and all of his belongings upon arrival to the unit. This search is conducted for the client's safety so that the nurse can identify and remove any objects that increase the client's risk of injury or suicide. Potentially harmfully objects include razors, shoelaces, hygiene products, and tweezers A nurse is talking with a client about his admission to a mental health unit. The client states, "I just don't know if I should be here. What will my family think?" Which of the following responses by the nurse uses the therapeutic communication technique of reflection? A. "It sounds like you are concerned about your family's reaction." B. "What your family thinks isn't important; you need to be concerned about getting well." C. "I suspect your family doesn't seem to understand you. D. "Many clients are concerned about the reaction of their families." - "It sounds like you are concerned about your family's reaction." *In a reflective response, the nurse directs feelings and statements back to the client, allowing the client to think about personal feelings A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect from the client? A. Bargaining B. Depression C. Denial D. Anger - Denial *The nurse should expect the client to deny the reality of the diagnosis initially. This is a protective reaction seeking to avoid psychological pain A nurse is reinforcing teaching with the parent of a child who has a new prescription for methylphenidate to treat ADHD. Which of the following instructions should the nurse include in the teaching? A. "Weigh your child 3 times per week." B. "Expect your child to experience dark-colored stools." C. "Administer this medication at bedtime." D. "You should limit your child's intake of caffeine." - "Weigh your child 3 times per week." *The nurse should instruct the parent to weigh the child 2 to 3 times per week. Weight loss is an adverse effect of this medication. If significant weight loss occurs, the parent should notify the provider. A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for venlafaxine. Which of the following statements should the nurse make? A. "This medication is only for short-term use" B. "This medication can be taken on an as-needed basis." C. "This medication will effectively reduce your physical manifestations of anxiety." D. "This medication should not be stopped abruptly." - "This medication should not be stopped abruptly." *The nurse should instruct the client that stopping venlafaxine abruptly will lead to manifestations of withdrawal. A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for valproic acid. The nurse should explain that the provider will routinely prescribe which of the following tests while the client is taking valproic acid? A. Electrocardiogram B. Chest X-ray C. Thyroid function tests D. Liver function levels - Liver function levels *The nurse should inform the client of the need to monitor liver function levels regularly due to the risk of hepatotoxicity while taking valproic acid. It is is recommended to obtain baseline levels and then repeat testing every 2 months during the first 6 months of therapy. A nurse is caring for a client who is taking carbamazepine. The nurse should monitor the client for which of the following adverse effects of carbamazepine? A. Thrombocytopenia B. Weight loss C. Polyuria D. Insomnia - Thrombocytopenia *The nurse should monitor the client for thrombocytopenia (an increased risk of bleeding). The nurse should monitor for bleeding of the gums, which can indicate thrombocytopenia, and notify the provider if this occurs. [Show Less]
A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an un... [Show More] derstanding of the teaching? (Select all that apply). A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression. C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents." - A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression. C. "To assess language ability, I should instruct the client to write a sentence." A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of the medications. - D. Monitor the client for adverse effects of the medications. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services B. Identify the client's perception of her mental health status. C. Include the client's family in the interview. D. Teach the client about her current mental health disorder. - B. Identify the client's perception of her mental health status. A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect? A. The client arouses briefly in response to a sternal rub. B. The client has a glasgow coma scale score less than 7. C. The client exhibits decorticate rigidity. D. The client is alert but disoriented to time and place. - A. The client arouses briefly in response to a sternal rub. A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion? (Select all that apply) A. The DSM-5 includes client education handouts for mental health disorders. B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders. D. The DSM-5 assists nurses in planning care for client's who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders. - B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. D. The DSM-5 assists nurses in planning care for client's who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders. A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to himself - C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery - B. False imprisonment A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife B. Keep the client's communication confidential, but watch the client and his roommate closely. C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others. D. Report the incident to the health care team, but do not inform the client of the intention to do so. - D. Report the incident to the health care team, but do not inform the client of the intention to do so. A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply) A. "Client ate most of his breakfast." B. "Client was offered 8 oz of water every hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." E. "Client acted out after lunch." - B. "Client was offered 8 oz of water every hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000. A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report. - B. Tell the nurse to stop discussing the behavior A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make? A. "I think your son is getting better. What have you noticed." B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure whats wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically." - D. "I understand you're concerned. Let's discuss what concerns you specifically." A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation - B. Denial A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client has a respiratory rate 30/min and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate C. Severe D. Panic - B. Moderate A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.) A. Reassure the client that everything will be okay. B. Discuss prior use of coping mechanisms with the client. C. Ignore the client's anxiety so that she will not be embarrassed. D. Demonstrate a calm manner while using simple and clear directions. E. Gather information from the client using closed-ended questions. - B. Discuss prior use of coping mechanisms with the client. D. Demonstrate a calm manner while using simple and clear directions. A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make? A. "I feel very sorry for the loneliness you must be experiencing." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose a loved one." - C. "Losing someone close to you must be very upsetting." A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply) A. The needs of both participants are met. B. An emotional commitment exists between the participants. C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established. - C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established. A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? A. The client asks the nurse whether she will go out to dinner with him. B. The client accuses the nurses of telling him what to do just like his ex-girlfriend. C. The client reminds the nurse of a friend who died from a substance overdose. D. The client becomes angry and threatens to harm himself. - B. The client accuses the nurses of telling him what to do just like his ex-girlfriend. A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries - A. Discussing ways to use new behaviors A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements should the nurse make? A. "You and a group of other clients will meet to discuss your treatment plans. B. "Community meetings have a specific agenda that is established by staff. C. "You and the other clients will meet with staff to discuss common problems. D. "Community meetings are an excellent opportunity to explore your personal mental health issues." - C. "You and the other clients will meet with staff to discuss common problems. A nurse is caring several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first? A. A client who recently burned her arm while using a hot iron at home. B. A client who requests that her antipsychotic medication be changed due to some new adverse effects. C. A client who says he is hearing a voice that tells him he is not worth living anymore. D. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview. - C. A client who says he is hearing a voice that tells him he is not worth living anymore. A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs C. Establishing rehabilitation programs to decrease the effects of depression D. Providing support groups for clients at risk for depression - C. Establishing rehabilitation programs to decrease the effects of depression A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy - A. Educational groups B. Medication dispensing programs C. Individual counseling programs E. Family therapy A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client's wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow-up care? [Show Less]
1. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which... [Show More] of the following actions should the nurse take? - Ask another nurse to observe the medication wastage 2. A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (round to nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) - 107... 750mL/7hr = 107.14 3. A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? - we would give you oxygen through a tube in your nose 4. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? - determine the reasons why the client is refusing to use the incentive spirometer 5. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? - pad the clients wrists before applying the restraints 6. A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? - let's talk about how the change in your job status will affect you 7. a nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? - droplet8. a nurse is caring for a group of clients. which of the following actions should the nurse take to prevent the spread of infection? - place a client who has tuberculosis in a room with negativepressure airflow 9. a nurse is assessing an older adult client's risk for falls. which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply) - pupil clarity, visual fields, visual acuity 10. A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. - 1) obtain the pronouncement of death from the provider 2)remove the tubes and indwelling lines 3) wash the client's body 4) ask the client's family if they would like to view the body 5) place a name tag on the body 11. a client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? - it might help me to listen to music while i'm lying in bed 12. a nurse is teaching a client and his family how to care for the client's tracheostomy at home. which of the following instructions should the nurse include in the teaching? - use tracheostomy covers when outdoors 13. a nurse is admitting a client who is having an exacerbation of heart failure. in planning this client's care, when should the nurse initiate discharge planning? - during the admission process 14. a nurse is assessing a client who reports increased pain following physical therapy. which of the following questions should the nurse ask when assessing the quality of the client's pain? - is your pain sharp or dull? 15. a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take? - examine personal values about the issue16. a nurse is reviewing a client's fluid and electrolyte status. which of the following findings should the nurse report to the provider? - potassium 5.4 mEq/L 17. a nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? - apply intermittent suction when withdrawing the catheter 18. a nurse is caring for a client who has a sodium level of 125 mEq/L. which of the following findings should the nurse expect? - abdominal cramping 19. a nurse is assessing a client's readiness to learn about insulin self-administration. which of the following statements should the nurse identify as an indication that the client is ready to learn? - i can concentrate best in the morning 20. a nurse is preparing a change-of-shift report. which of the following tools or documents should the nurse use to communicate continuity of care? - situation, background, assessment, and recommendation (SBAR) 21. a nurse is caring for a client who has an aggressive form of prostate cancer. the provider briefly discusses treatment options and leaves the client's room. when the nurse asks if the client would like to discuss any concerns, the client declines. which of the following statements should the nurse make? - i am available to talk if you should change your mind 22. a nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? - notify the nursing manager 23. a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include? - advocacy ensures client's safety, health and rights 24. a nurse is providing discharge instructions to a client who will be using a walker. which of the following client statements indicates an understanding of the teaching? - i will hire someone to trim the tree that hangs low over the stairs of my front porch25. a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take when inserting the NG tube? - have the client take sips of water to promote insertion of the NG tube into the esophagus [Show Less]
A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescrip... [Show More] tion should the nurse question? - The dose 2. A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? - Observe the rate, depth, and character of the client's respirations. 3. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? - Lower the client to the floor and place a pad under the client's head. 4. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? - Educating clients about the recommended immunization schedule for adults 5. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? - Assessment 6. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? - Edema at the infusion site 7. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? - Washing dishes8. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? - Daily weight 9. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? - Inspection 10. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? - A client who has a prescription for a transfusion of packed red blood cells 11. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? - "It must be difficult to care for someone who is confined to bed." 12. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? - Bounding pulse 13. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? - Cover the incision with a moist sterile dressing. 14. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? - "Bear weight on both of your legs." 15. A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? - Liver Damage 16. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? - PC for after meals17. A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? - A 10- month-old infant can pull up to a standing position. 18. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? - The AP hangs the collection bag at the level of the bladder. 19. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? - Consult the medication reference book available on the unit. 20. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? - Place the client in a lateral position with the head turned to the side before beginning the procedure. 21. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? - Repeat each joint motion five times during each session. 22. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? - Cough deeply after each use. 23. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning? - Have the client demonstrates the procedure. 24. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? - Gelatin 25. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? - Romberg test26. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? - WBC 15,000 mm3 27. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? - Ventrogluteal 28. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? - Fill the bag two-thirds full with ice. 29. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? - Impaired peristalsis of the intestines 30. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? - Wear cotton clothing to avoid static electricity. 31. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? - "I can see that this is upsetting you." 32. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? - Position the client on his left side. 33. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? - Airway 34. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? - Tie the restraint with a quick-release knot.35. A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? - Oil retention 36. A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? - People who practice Judaism stay with the body of the deceased until burial. 37. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? - 38. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? - Place the client in Trendelenburg's position. 39. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? - Provide a protein intake of 1.5 g/kg of body weight per day. 40. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? - Cold extremities 41. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? - Hemolytic 42. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? - Loss 43. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? - Sit at the bedside while feeding the client.44. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? - Wear gloves when changing the client's gown. 45. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) - -Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. 46. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? - Fidelity 47. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? - Tachycardia 48. A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? - Decreased calcium 49. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? - "Tell me more about how your friends discourage you." 50. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? - When lifting an object, spread your feet apart to provide a wide base of support. [Show Less]
1. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the ... [Show More] following routes should the nurse use to obtain the temperature? - Temporal 2. A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse takes when she observes the client crying? - Sit and hold the client's hand 3. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? - Screening groups of older adults in nursing care facilities for early influenza manifestations 4. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? - "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." 5. A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. - - Inspection - Auscultation - Percussion - Palpation 6. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? - Second intercostal space to the right of the sternum 7. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? - Count the apical pulse rate for 1 minute, and describe the rhythm in the chart 8. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? - "Using a cuff that is too small will result in an inaccurately high reading." 9. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? - Evaluate pedal pulses 10. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? - Perform hand hygiene 11. A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? - Identify the client using two identifiers 12. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? - Place the bladder of the cuff over the posterior aspect of the thigh 13. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? - The nurse washes with her hands held higher than her elbows 14. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notes the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? - Disconnect the machine, and measure the blood pressure manually every 15 minutes 15. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? - Raise the level of the bed 16. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? - Carefully remove the gloves and follow with hand hygiene 17. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? - Pericardial friction rub 18. A nurse is teaching a group of older adults about expected changes of aging. Which of the following statement by a group member indicates that the teaching had been effective? - "I should expect my heart rate to take longer to return to normal after exercise as I get older." 19. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? - Confirm unresponsiveness 20. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? - "Donate autologous blood before the surgery." 21. A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? - Attempt to increase the clients' self-motivation 22. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? - Lock the wheels on the bed of the stretcher 23. A nurse is witnessing a client sign an informed consent for surgery. Which of the following describes what the nurse is affirming by this action? - The signature on the preoperative consent form is the client's 24. A nurse is demonstrating postoperative deep breathing and cough exercised to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? - The client reports severe pain 25. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? - Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back 26. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? - Encourage the client to express his thoughts about death and dying 27. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 C (102.6 F), heart rate of 105/min, a soft non-tender abdomen, and menses overdue my 2 days. Which of the following findings should be the nurse's priority? - Temperature 28. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? - The involvement of the client in planning the change 29. A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removes prior to surgery. Which of the following responses should the nurse make? - "What worries you about being without your teeth?" 30. A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? - Absent bowl sounds with distention 31. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? - Place the wheelchair at a 45 degree angle to the bed 32. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? - Administer analgesics to the child on routine schedule throughout the day and night [Show Less]
1. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication rec... [Show More] onciliation process? - compare prescriptions with medications the client received while are the facility 2. a nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with the provider? - medication dose 3. a nurse is teaching a group of nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? - a client who has asthma 4. a nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate? - droplet 5. a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take? - gently shake the container of medication prior to administration 6. a nurse is performing a peripheral vascular assessment for a client. when placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. the sound indicates which of the following? - narrowed arterial lumen 7. a nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? - withhold the blood transfusion 8. a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include? - current medications 9. a nurse is assessing an adult client who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene? - erythema on pressure points 10. a nurse is planning on teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a pyschomotor approach to learning? - practice sessions 11. a nurse is caring for a client who reports pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? - the pain is like a dull ache in my stomach 12. a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice? - initiate an enteral feeding through a gastrostomy tube 13. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? - evacuate the client 14. a nurse is discussing the use of herbal supplements for health promotion with a client. which of the following client statements indicates an understanding of herbal supplement use? - i can take echinacea to improve my immune system 15. a nurse enters a client's room and finds her on the floor. the client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident? - client found lying on floor 16. a nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use? - have the client stand with their arms at their sides and their feet together 17. a nurse is teaching a client whose left leg is in a cast about using crutches. which of the following statements should the nurse identify as an indication that the client understands the teaching? - when descending the stairs, i will first shift my weight to my right leg 18. a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? - flush the tube with 15 mL of sterile water 19. a community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension? - a client who smokes one pack of cigarettes each day 20. a nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding? - arrange food in a consistent pattern on the client's plate 21. a nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include? - you should receive a pneumococcal immunization every 10 years 22. a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect? - rapid heart rate 23. a nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? - auscultate lung sounds 24. a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? - apply an ankle-foot orthotic device to the client's feet 25. a nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of PPE when providing care for the client? - N95 respirator 26. a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take? - wrap monitoring cords with stockinette and tape them in place 27. a nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess? - distended neck veins 28. a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown? - have the client use a trapeze bar when changing position 29. a nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia pump. which of the following actions should the nurse take? - instruct the family to refrain from pushing the button for the client while she is asleep 30. a nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement? - an x-ray shows the end of the tube above the pylorus 31. a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse? - the caregiver insists on remaining in the room 32. a nurse is preparing to transfer a client who can bear weight on lone leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next? - assess the client for orthostatic hypotension [Show Less]
what is the nursing process? - a cyclical, critical thinking process. it is dynamic, continuous, client-centered, problem-solving, and decision making fra... [Show More] mework that is foundational to the nursing practice. five steps of the nursing process - 1. assessment/data collection 2. analysis 3. planning 4. implementation 5. evaluation methods of data collection - 1. observation 2. interviews 3. medical history 4. comprehensive or focused physical exam 5. diagnostic and laboratory reports 6. collaboration what is involved in collecting data effectively? - 1. ask appropriate questions 2. listen carefully to responses 3. develop good head to toe assessment skills 4. employ critical thinking and clinical judgment 5. recognize the need to collect data prior to interventions when do you collect subjective data (symptoms)? - during the nursing history what does subjective data include? - 1. symptoms 2. patients feelings 3. patients perceptions 4. description of health status when is objective data (signs) obtained? - during the physical assessment how do nurses obtain objective data? - "nurses feel, see, hear, and smell objective data through observation or physical assessment of the client" primary sources of data - this is what the patients tells the nurse (subjective) or what the nurse observes. secondary sources of data - what others tell the nurse based on what the client has told them (subjective; "she told me that her shoulder is sore every morning") and the objective data is obtained from another source such as, family, friends, health care professional, or records. what three things does the nurse do during assessment? - 1. validate 2. interpret 3. cluster data analysis - use of critical thinking to identify health status or problems, interpret, or monitor the collected data base, reach an appropriate nursing judgment about health status and coping mechanisms, and provide direction for nursing care. what does analysis requires the nurse to do ..? - 1. recognize patterns or trends 2. compare the data with expected standards or reference pages 3. arrive at conclusions to guid nursing care documentation - documentation is essential. it should focus on facts and should be very descriptive. what does planning involve? - 1. establish priorities and outcomes that can be measured and evaluated 2. these priorities and outcomes are what directs selection of interventions 3. three types of planning 4. develop plan of care based on assessment 5. planning is continuous; obtain new info and evaluate responses to care; modify plan of care if necessary 6. discharge planning 7. nurses select priorities, determine outcomes, and select interventions implementation - Nurses base the care they provide on the assessment data, analysis, and the plan of care they developed in the previous steps. what does implementation involve? - 1. problem solving 2. clinical judgment 3. critical thinking to select and implement appropriate interventions 4. use nursing knowledge, priorities of care, and planned outcomes to promote, maintain and restore health. 5. use interpersonal skills and technical skills therapeutic interventions - 1. includes measures nurses take to minimize risk and to respond to unplanned events, such as observation of unsafe practice, a change in a status, or the emergence of a life threatening situation. roles of nurse during implementation - 1. perform nursing actions 2. delegate tasks 3. supervise other health staff 4. document the care and the patients responses. evaluation - 1. nurses evaluate the patients response to the interventions and form a clinical judgment about the extent to which the patient has met the goals/outcomes that were set what does the evaluation determine? - whether or not to modify the plan of care questions to consider-evaluation - 1. " did the client meet the planned outcomes?" 2. "were the nursing interventions appropriate and effective?" 3. "should i modify the outcomes or interventions?" factors that can lead to a lack of goal achievement - 1. incomplete database 2. unrealistic client outcomes 3. nonspecific nursing interventions 4. inadequate time for the client to achieve the outcomes. (q&a #1) By the second post op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? - pg. 55 ati the nurse should reassess the client to determine why he has no achieved satisfactory pain relief. Various factors may be influencing the lack of pain relief. (q&a#2) A nursing instructor is reviewing the steps of the nursing process with a group of students. The students should identify which of the following data as objective? - pg.55 ati A. RR of 22/min w/ even, unlabored respirations D. skin pink, warm, and dry E. urine output of 300 ml/8hr F. dressing clean, dry, and intact (q&a#3) A nursing instructor is reviewing which actions nurses can initiate w/out a provider's prescription w/ a group og nursing students. The student should identify which of the following interventions as nurse-initiated? - Pg.55 ati C. show a client how to use pregressive muscle relaxation D. perform daily bath after evening meal E. reposition the patient every 2 hours to reduce pressure ulcer risk (q&a#4) During evaluation, the nurse must gather information about the client to...? - pg. 55 ati A. determine whether the clients outcomes have been met the nursing process is... - the nursing process is nursing practice in action the group that legitimized the steps of the nursing process in 1973 by developing standards of practice to guid nursing practice - american nurses association for nursing practice the nursing process is considered dynamic - there is a great deal of overlapping interaction between the five steps, each step flows into the next step critical thinking process - nurses who use the critical thinking process must identify alternative decisions and reach a conclusion cases in which the nursing process is applicable - 1. when nurses work with patients who are able to participate in their care 2. when families are supportive and wish to participate in care 3. when patients are totally dependent on the nurse for care. traits that help nurses develop the attitudes and dispositions to think critically - 1. thinking independently 2. being intellectually humble 3. being curious and persevering critical thinking - can be intuitive, logical, or both role of documenting in the nursing process - 1. pt record is the chief means of communication between the members of the interdisciplinary team 2. nursing action not documented is an action not performed 3. content of the pt report and documentation helps establish nursing priorities [Show Less]
A nurse is discussing restorative health care with newly licensed nurse. which of the following examples should the nurse include in the teaching? (select ... [Show More] all that apply) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology Centers - A, B, D a nurse is explaining the various types of health care coverage clients might have to a group of nurses. which of the following health care financing mechanisms should the nurse included as federally funded? (select all that apply) A. preferred provider organization (PPO) B. medicare C. long-term care insurance D. exclusive provider organization (EPO) E. medicaid - B, E a nurse manager is developing strategies to care for the increasing number of clients who have obesity. which of the following actions should the nurse included as a primary health care strategy? A. collaborating with providers to perform obesity screenings during routine office visits. B. ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity. C. providing specialized intraoperative training in surgical treatments for obesity. D. educating acute care nurses about postoperative complications related to obesity. - A a nurse is discussing the purpose of regulatory agencies during a staff meeting. which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. monitoring evidence-based practice for clients who have a specific diagnosis. B. ensuring the health care providers comply with regulations. setting quality standards for accreditation of health care facilities. D. determining whether medications are safe for administration to clients. - B a nurse is explaining various levels of health care services to a group of newly licensed nurses. which of the following examples of care or care settings should the nurse classify as tertiary care? (select all that apply) A. intensive care unit B. oncology treatment center C. burn center D. cardiac rehabilitation E. home health care - A, B, C a nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. the nurse understands that the client's choice is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. nonmaleficence - B a nurse offers pain medication to a client who is postoperative prior to ambulation. the nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. beneficence - D a nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. when the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. nonmaleficence - C a nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. the nurse understands that this action is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. nonmaleficence - D a nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. a nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he does not stay in bed, she will have to apply restraints. C. a family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. a client who is terminally ill hesitates to name their partner on their durable power of attorney form. - C a nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. the AP tells the client that diapers will be used next time the urinal is used improperly. which of the following torts is the AP committing? A. assault B. battery C. false imprisonment D. invasion of privacy - A a nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." the nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. which of the following types of tort is the nurse about to commit? A. assault B. false imprisonment C. negligence D. breach of confidentiality - B a nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. the client tells the nurse that "I plan to prepare my advance directives before i come to the hospital." which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but i know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." - C a nurse is caring for a client who is about to undergo an elective surgical procedure. the nurse should take which of the following actions regarding informed consent? (select all that apply) A. make sure the surgeon obtained the client's consent B. witness the client's signature on the consent form C. explain the risks and benefits of the procedure D. describe the consequences of choosing not to have the surgery E. tell the client about alternatives to having the surgery - A, B a nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. today, the nurse was found asleep in a chair in the break room not during break time. which of the following actions should the nurse take? A. alert the American Nurse Association B. fill out an incident report C. report the observations to the nurse manager on the unit D. leave the nurse alone to sleep - C a nurse is performing an admission assessment for an older adult client. after gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. orient the client to their room B. conduct a client care conference C. review medical prescriptions D. develop a plan of care - A a nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. which of the following actions are essential steps of the admission procedure? (select all that apply) A. explain the roles of other care delivery staff B. begin discharge planning C. inform the client that advance directives are required for hospital admission D. document the client's wishes about organ donation E. introduce the client to their roommate - A, B, D, E a nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. which of the following tasks are the responsibility of the nurse at the transferring facility? (select all that apply) A. ensure that the client has possession of their valuables B. confirm that the rehabilitation center has a room available at the time of the transfer C. assess how the client tolerates the transfer D. give a verbal transfer report via telephone E. complete a transfer for the receiving facility - A, B, D, E a nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. which of the following information about the client should the nurse include in the discharge summary? (select all that apply) [Show Less]
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nursing include in the teaching? (Sel... [Show More] ect all that apply) A. Home healthcare B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers - a. home health care b. rehabilitation facilities c. skilled nursing facilities A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (Select all that apply) A. Preferred provider organization B. Medicare C. Long term care insurance D. Exclusive provider organization E. Medicaid - b. medicare c. medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?collaborating with providers to perform obesity screenings during routine office visits - collaborating with providers to perform obesity screenings during routine office visits A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health strategy? A. Collaborating with providers to perform obesity screenings during routine office visit B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized Intraoperative training regarding surgical treatments for obesity D. Educating acute care nurses on post operative complications related to obesity - A. Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as a responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a special diagnosis B. Ensuring that healthcare providers comply with regulations C. Setting quality standards for accreditation of healthcare facilities D. Determining if medications are safe for administraion to clients - B. Ensuring that healthcare providers comply with regulations A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? SATA A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care - A. Intensive care unit B. Oncology treatment center C. Burn center When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which id the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 feet away from client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organism into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change. - C. Place a mask on the client to limit the spread of micro-organism into the surgical wound. A nurse has removed a sterile pack form its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closet to the body B. The right side flap C. The left side flap D. The flap farthest from the body - D. The flap farthest from the body A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique. (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile fieldE. One gloved hand with the other gloved hand - C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand A nurse is reviewing hand hygiene technique with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing hand washing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing. - B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets. A nurse has prepared a sterile field for assisting a provider with a chest tube injection. Which of the following events should the nurse recognize as contaminating the sterile field. (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hour because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field. - B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hour because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. WHich of the following illistrate the rationale for reporting? (select all that apply.) A. Planning and evaluating control and prevention strategies. B. Determining public health priorities C.Ensuring proper medical treatment D. Identifying endemic diseasesE. Monitoring for common-source outbreaks - A. Planning and evaluating control and prevention strategies. B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks A nurse is caring for a client who reprtds of severe sore throat, pain when swallowing, and swollen lymph nodes. The cleint is experiencing which of the following stages of infection. A. Prodromal B. Incubation C. Convalescence D. Illness - D. Illness A nurse educator is revieing with a newly hired nurse the diferencies in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systmeic infection? (Slect all that apply.) A. fever B. malaise C. edema D. pain or tenderness E. increase in pulse and repiratory rate - A. fever B. malaise E. increase in pulse and respiratory rate A nurse is contributingto the plan of care for a client who is being admitted to the facility wit a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client C. PLace a surgical mask on the client if transportation to another department is unavoidable D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions. - B, C, E A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (select all that apply) A. Address the client with the appropriate title and their last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E.Perform the general survey before the examination. - B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. E.Perform the general survey before the examination. A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (select all that apply) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status - A, B, C A nurse is collecting data for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion - B. Auscultation A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply) A. Expect the session to be shorter than for a younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering bathroom before beginning the examination. - B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering bathroom before beginning the examination. A nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A. Palmar Surface B. Fingertips C. Dorsal Surface D. Base of the fingers - C. Dorsal Surface A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 C (101 F ), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently. - A. Obtain culture specimens before initiating antimicrobials. C. Encourage the client to rest and limit activity. E. Assist the client with oral hygiene frequently. A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priory for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting their respirations." D. "Let the client rest for 5 minutes before you measure their blood pressure." - A. "Do not measure the client's temperature rectally." (can cause bleeding) A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 sec if it is irregular. E. Count and report an sighs the client demonstrates. - A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an anti hypertensive medication B. Ask client if they are having pain. C. Request a prescription for an anti anxiety medication. D. Return in 30 min to recheck the client's blood pressure. - B. Ask client if they are having pain. A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? - 16 A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (Select all that apply). A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch." - C and E A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the mid-line. - A. Palpating the thyroid in the lower half of the neck D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the mid-line. A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following action should the nurse take? (Select all that apply) A. Pull the auricle down and back B.insert speculum slightly down and forward C. Insert the speculum slightly down 2 to 2.5cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the tympanic membrane in a cone shape - B, D, E A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? ( Select all the apply.) [Show Less]
A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that... [Show More] the client has developed thrombophlebitis? Bladder distention Decreased blood pressure Calf swelling Diminished bowel sounds - Calf swelling A nurse is administering an optic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? Press gently on the tracks of the clients ear Pack a small piece of cotton deep into the clients ear canal Move the client's auricle down and back toward her head Tilt the client's head backward for 5 min - Press gently on the tragus of the clients ear A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? Pad the client's wrist before applying the restraints Evaluate the client's circulation every 8 hr after application Remove the restraints every 4 hr to evaluate the client's status Secure the restraints to the bed's side rails - Pad the client's wrists before applying the restraints A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? Verify the client's name on their identification bracelet with the medication administration record Call the pharmacy to determine whether the client's medications are available Compare the clients home medications with the provider's prescriptions Place the client's home medication bottles in a secure location - Compare the client's home medications with the provider's prescriptions The nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 107 mL/hr A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) Assist the client with a partial bed bath Measure the client's BP after the nurse administers antihypertensive medication. Test the client's swallowing ability by providing thickened liquids Use a communications board to ask what the client wants for lunch Irrigate the client's indwelling catheter - Assist the client with a partial bed bath Measure the client's BP after the nurse administers antihypertensive medication. Use a communications board to ask what the client wants for lunch A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? Place the client in a side-lying position Instill 15 mL of irrigation fluid into the catheter with each flush Subtract the amount of irritant used from the clients urine output Perform the irrigation using a 20 mL syringe - Subtract the amount of irritant used from the client's urine output A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings & medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? The client is receiving normal formula at room temperature The feedings infuse at a slow, continuous drip over 8 hr each night. The client's caregiver washes of the feeding bag with warm water once every 24 hr The client's caregiver flush's the tubing before and after administering medications. - The client's caregiver washes of the feeding bag with warm water once every 24 hr A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? Make sure the client's room has at least six air exchanges per hour. Make sure the client wears a mask when outside her room if there's construction in the area. Place the client in a private room with negatives-pressure airflow. Wear an N95 respirator when giving client direct care. - Make sure the client wears a mask when outside her room if there's construction in the area. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min & to report back in 1 hr. Which of the following actions should the nurse take next? Document the providers statement in the medical record Complete an incident report Consult the facility's risk manager Notify the nursing manager - Notify the nursing manager A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? Insert the catheter at a 45 degree angle Place the client's arm in a dependent position Shave excess hair from the insertion site Initiate IV therapy in the veins of the hand - Place the client's arm in a dependent position A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury to the client? Use a bed exit alarm system Raise four side rails while the client is in bed Apply soft wrist restraint Dim the lights in the client's room - Use a bed exit alarm system A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? Role ambiguity Sick role Role overload Role conflict - Role overload A nurse is caring for a client who has a terminal illness & is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? "I am not worries because I still have hope that he will be okay." "I am relying on support from our family during this time." "We can plan our family reunion once he recovers & comes home." "We don't see any reason to start discussing funeral arrangements right now." - "I am relying on support from our family during this time." A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? Increase hematocrit Increase respiratory rate Decrease heart rate Decrease in capillary refill time - Decrease heart rate A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? Combine client care tasks when caring for multiple clients Wait until the end of the shift to document client care Use the planning step of the nursing process to prioritize client care delivery Allow for interruptions in tasks to discuss client care issues with colleagues - Use the planning step of the nursing process to prioritize client care delivery A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? "I can place an extension cord across my living room to plug in my television." "I will hire someone to trim the tree that hangs low over the stairs of my front porch." "I will place my alarm clock on my bedroom dresser across the room." "I will replace the old throw rug in my kitchen with a new one." - "I will hire someone to trim the tree that hangs low over the stairs of my front porch." A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? Use the Face, Legs, Activity, Cry, & Consolability (FLACC) pain rating scale for a client who is experiencing pain. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. Obtain an apical heart rate by auscultating the third intercostal space left of the sternum. Palpate the client's abdomen before auscultating bowel sounds. - Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? During the admission process As soon as the client's condition is stable During the initial team conference After consulting with the client's family - During the admission process A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? 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A nurse is teaching a group of older adults about suspected changes of aging. Which statement by a group member indicates effective teaching? I should e... [Show More] xpect my HR to take longer to return to normal after exercise. Urinary incontinence is something I have to live with as I get older. I can expect to have less ear wax as I get older. My stomach will empty more quickly after meals as I grow older. - I should expect my HR to take longer to return to normal after exercise. A nurse is caring for a patient who is post-op with paralytic ileus. Which abdominal assessment is expected? Frequent bowel sounds with flatus Absent bowel sounds with distention Hyperactive bowel sounds with diarrhea Normal bowel sounds with increased peristalsis - Absent bowel sounds with distention A nurse is planning care for a client with abdominal pain. An assessment reveals temperature of 102.6 F, HR 105, soft-non-tender abdomen, menses overdue by 2 days. Which of the following findings should be the priority? Heart rate Soft, non-tender abdomen Temperature Overdue menses - Temperature Which instruction should be followed for a child who is post-op following a tonsillectomy? Encourage frequent coughing to clear congestion from anesthesia. Place a heating pat at child's neck for comfort. Administer analgesics to the child on a routine schedule throughout the day. Provide the child with ice cream when oral intake is initiated. - Administer analgesics to the child on a routine schedule throughout the day. The nurse auscultates a high-pitched scratching sound during diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub - Pericardial friction rub A nurse is teaching an assistive personnel about proper hand hygiene. Which statement from AP indicates understanding? "There are times I should use soap and water instead of alcohol-based sanitizer" "I will use cold water when I wash my hands to protect my skin from becoming too dry." "I will apply friction for at least 10 seconds while washing my hands." "After washing my hands I will dry them from the elbows down." - "There are times I should use soap and water instead of alcohol-based sanitizer" A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes using an electronic BP machine. The nurse notices the machine begins to measure BP at varied intervals and readings are inconsistent. which action should the nurse take? Turn on the machine every 15 minutes to measure the BP. Record only BP readings needed for the 15-min intervals. Obtain manual and automatic readings & compare them. Disconnect the machine, measure the BP manually every 15 minutes. - Disconnect the machine, measure the BP manually every 15 minutes. A nurse is providing teaching to a client who has heart failure about how to reduce his sodium intake. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? Involvement of client in planning the change Emphasis provider places on the dietary changes Learning theory the nurse uses to teach the dietary changes The extent of the dietary changes planned for the client. - The involvement of the client in planning the change Nurse is obtaining vitals for a 2-year old child who is experiencing diarrhea and may have right ear infection. Which route should be used to measure temperature? Rectal tympanic oral temporal - Temporal- oral temp. is not suitable for kids under 3 A nurse is witnessing a client sign an informed consent form for surgery. What describes what the nurse is affirming this action? The client fully understands the provider's explanation of this procedure. The client has been informed about risks/benefits of procedure The nurse witnessed provider's explanation of procedure The signature on pre-op consent form is the client's - The signature on the pre-op consent form is the client's Nurse on a med-surg unit is admitting a client. Which of the following does the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress - Assessment Nurse on a med-surg unit is washing her hands prior to assisting in a surgical procedure. Which action indicates proper surgical handwashing? Nurse washes each part of her hands with 5 strokes Nurse washes from elbows down to hands Nurse washes with hands held higher than elbows Nurse uses minimal friction when washing her hands - Nurse washes with hands held higher than elbows A nurse at a screening clinic is assessing a client who reports a history of a heart murmur r/t aortic valve stenosis. At which of the following anatomical areas should the nurse use stethoscope to auscultate aortic valve? 5th IC space just medial to MCL 2nd IC space to L of sternum 5th IC space to L of sternum 2nd IC space to R of sternum - 2nd IC space to R of sternum A nurse notices an irregularity in the pulse when measuring patient's vital signs. Which action should the nurse take? Measure pulse using Doppler ultrasound stethoscope. Check the client's pedal pulses. Count the apical pulse rate for 1 full minute, describe the rhythm in the chart. Take the pulse at each peripheral site and count the rate for 30 seconds. - Count the apical pulse rate for 1 full minute, describe the rhythm in the chart. A nurse is caring for an an older adult client who becomes agitated when the nurse requests that the dentures must be removed prior to surgery. Which response should the nurse make? It's for your safety- dentures can slip and block your airway during surgery. You wouldn't want your teeth to be broken or lost during surgery, would you? The anesthesiologist requires everyone to remove their dentures. What worries you about being without your teeth? - What worries you about being without your teeth? A nurse is caring for a client who has a terminal illness. The client asks several questions regarding the nurse's religious beliefs related to death and dying. How should the nurse respond? Change the topic because the client is trying to divert attention from the illness. Encourage the client to express his thoughts about death and dying. Tell the client that religious beliefs are a personal matter. Offer to contact the client's minister or facility's chaplain. - Encourage the client to express his thoughts about death and dying. A nurse is caring for a client who has T1DM and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? Tell me what I can do to help you overcome your fear of giving yourself injections. I am sure your provider will not be pleased that you refuse to give yourself injections. It's okay- your partner will be able to learn to give you injections. You won't be able to go home without learning how to give yourself injections. - Tell me what I can do to help you overcome your fear of giving yourself injections. A nurse is teaching CPR to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Call for assistance Begin chest compressions Confirm unresponsiveness Give rescue breaths - Confirm unresponsiveness [Show Less]
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? 1. The top of th... [Show More] e cane is parallel to the client's waist. 2. When walking, the client moves the cane 46 cm (18 in) forward. 3. The client holds the cane on the stronger side of her body. 4. The client moves her stronger limb forward with the cane. - 3 The client should hold the cane on the stronger side of her body to increase support and maintain alignment. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80mL over the last 2 hr. Which of the following actions should the nurse take first? 1. Reposition the client. 2. Document the client's IV intake in the medical record. 3. Request a new IV fluid prescription. 4. Check the IV tubing for obstruction. - 4 The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed. A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? 1. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. 2. Remove the NG tube if the client begins to gag or choke. 3. Apply suction to the NG tube prior to insertion. 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus. - 4 Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L - 4 This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias. A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? 1."I can place an extension cord across my living room to plug in my television." 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." 3. "I will place my alarm clock on my bedroom dresser across the room." 4. "I will replace the old throw rug in my kitchen with a new one." - 2 Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel? SATA 1. Assist the client with a partial bed bath. 2. Measure the client's BP after the nurse administers an antihypertensive medication. 3. Test the client's swallowing ability by providing thickened liquids. 4. Use a communication board to ask what the client wants for lunch. 5. Irrigate the client's indwelling urinary catheter. - 1, 2, 4 Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function. Measuring a client's BP poses minimal risk to the client and is within the AP's range of function. Using a communication board poses minimal risk to the client and is within the AP's range of function. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? 1. Discuss the risk factors for colon cancer. 2. Focus teaching on what the client will need to do in the future to manage his illness. 3. Provide the client with written information about the phases of loss and grief. 4. Reassure the client that this is an expected response to grief. - 4 During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid - 4 Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure the medication reaches the inner ear? 1. Press gently on the tragus of the client's ear. 2. Pack a small piece of cotton deep into the client's ear canal. 3. Move the client's auricle down and back toward her head. 4. Tilt the client's head backward for 5 min. - 1 Pressing gently on the tragus of the ear will help the medication get into the inner ear. A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? 1. Place the client in a side-lying position. 2. Instill 15 mL of irrigation fluid into the catheter with each flush. 3. Subtract the amount of irrigant used from the client's urine output. 4. Perform the irrigation using a 20-mL syringe. - 3 The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output. A nurse is initiating a protective environment for a client who had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? 1. Make sure the client's room has at least six air exchanges per hour. 2. Make sure the client wears a mask when outside her room if there is construction in the area. 3. Place the client in a private room with negative-pressure airflow. 4. Wear an N95 respirator when giving the client direct care. - 2 An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? 1. Combine client care tasks when caring for multiple clients. 2. Wait until the end of the shift to document client care. 3. Use the planning step of the nursing process to prioritize client care delivery. 4. Allow for interruptions in tasks to discuss client care issues with colleagues. - 3 Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management. A nurse caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? 1. Assist the client into a prone position. 2. Place a sleeve over the top of each leg with the opening at the knee. 3. Make sure two fingers can fit under the sleeves. 4. Set the ankle pressure at 65 mm Hg. - 3 The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate. A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? 1. Insert the suction catheter while the client is swallowing. 2. Apply intermittent suction when withdrawing the catheter. 3. Place the catheter in a location that is clean and dry for later use. 4. Hold the suction catheter with her clean, nondominant hand. - 2 The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? 1. "Is your pain constant or intermittent?" 2. "What would you rate your pain on a scale of 0 to 10?" 3. "Does the pain radiate?" 4. "Is your pain sharp or dull?" - 4 Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? 1. Insert the needle at a 15° angle. 2. Aspirate for blood return prior to administration. 3. Administer the medication into the abdomen. 4. Massage the site following the injection. - 3 The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should perform the following steps 1. Place a name tag on the body 2. Obtain the pronouncement of death from the provider 3. Remove the tubes and indwelling lines 4. Wash the clients body 5. Ask the clients family member if they would like to view the body - 2,3,4,5,1 A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? 1. Remove the outer cannula cautiously for routine cleaning. 2. Use tracheostomy covers when outdoors. 3. Use sterile technique when performing tracheostomy care at home. 4. Cleanse irritated skin with full-strength hydrogen peroxide. - 2 Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions. Which of the actions should the nurse take? 1. Turn the client every 2 hr. 2. Administer an antiemetic every 6 hr. 3. Hold oral care. 4. Increase the room's temperature. - 1 The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations. A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? 1. Examine personal values about the issue. 2. Tell the parents that this is a necessary procedure. 3. Inform the parents that the staff does not require their consent. 4. Contact a spiritual support person to explain the importance of the procedure. - 1 Nurses should examine their own personal values about the issue in question in order to provide care that is without bias. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? 1. Administer the medication with the needle at a 45° angle. 2. Administer the medication into the client's nondominant arm. 3. Pull the client's skin laterally or downward prior to administration. 4. Massage the injection site after administration. - 1 The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the nurse initiate discharge planning? 1. During the admission process 2. As soon as the client's condition is stable 3. During the initial team conference 4. After consulting with the client's family - 1 Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. [Show Less]
1. A nurse is caring for a client who just died and practiced the islamic faith. Which of the following cultural practices should the nurse expect? - The c... [Show More] lient face should be toward mecca. 2. A nurse is assisting with a client who has active Tb. Which of the following actions should the nurse plan to take? - Assign the client to a negative pressure airflow room. 3. A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistant oral temperature of 38.9 * C (102 F). Which of the following interventions should the nurse include in the plan of care to treat the fever? - Administer acetaminophen 4. A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? - Ensure that the client wears a surgical mask during transportation thoughout the facility. 5. A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? - Place the client in a room near the nurses station. Ensure that the client is wearing non skid slippers. Reinforce teaching about how to use the call bell. 6. A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? - Pad bony prominences on the wrist. 7. A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include? - Flashing smoke alarm 8. A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? - An 18 year old client who has acute appendicitis. 9. A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess? - BUN 8mg/dL 10. A nurse is moving a client up in bed with assistance of a second nurse. Which of the following actions should the nurse take? - Place feet apart with the foot nearest the clients bed in front of the other foot. 11. A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? - I will keep the crutch tips dry. 12. A charge nurse smells smoke, enters the visitors restroom, and sees flames in the trashcan. What is the sequence of actions that the nurse should take? - Evacuate Alarm Confine Extinguish 13. A nurse is calculating the input and output for a client over the last 8 hours. The client is receiving a continuous IV infusion at 150mL/ hr and had 4 oz of juice and 0.5L of water. How many mL of fluid should the nurse document as the clients intake for the last 8 hr? - 1820 mL 14. A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? - Beneficence ( acting in the clients best interest) 15. A charge nurse is reinforcing teaching with an assistive personel about performing pulse oximetry. Which of the following information should the nurse include in the teaching? - remove polish from the clients fingernail before applying the oximentry probe. 16. A nurse is reinforcing dietary teaching w/ a pt who has chronic kidney disease & requires a low potassium diet. Which of the following food choices by the pt demonstrates an understanding of the teaching? - 1 cup of applesauce 17. A nurse is preparing to admin O2 to a Pt who has heart failure & is having severe difficulty breathing. Which of the following O2 delivery equipment should the nurse select to provide the highest concentration of O2 to the Pt? - Nonrebreather mask 18. A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age related changes? - Circulation becomes less efficient with age 19. A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? - Shred the paper in a secure container 20. A nurse is assisting with the admission of a pt who has brought her meds to the facility. Which of the following actions should the nurse take? - Compare the meds the provider has prescribed with the clients meds from home 21. A nurse is preparing to admin a topical med to a PT. Which of the following actions should the nurse take? - Compare the label of the med container w/ the med admin record x3. 22. A nurse is palpating the pulse located on the top of the pts foot. Which of the following pulses should the nurse document that she is palpitating? - Dorsalis pedis 23. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infection? - Drain urine from the tubing before ambulation 24. A nurse is explaining ethics & values to a newly licensed nurse. The nurse should explain that allowing a Pt to make a decision about treatment is an example of which of the following ethical principles? - Autonomy 25. A nurse is reinforcing pre-op teaching w/ a pt who does not speak the same language as the nurse. Which of the following actions should the nurse take? - Provide handouts written in the clients primary language [Show Less]
A nurse is discussing restorative health care with a newly licenced nurse. Which of the following examples should the nurse include in the teaching? - -H... [Show More] ome health care -Rehab facilities -Skilled nursing facilities A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? - -Medicare -Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? - -Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? - -Ensuring that health care providers comply with regulations A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? - -ICU -Oncology treatment center -Burn center A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) - -A client who has terminal cancer requests hospice care in the home. -A client asks about community resources available for older adults. -A client requests an electric wheelchair for use after discharge. A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? - Occupational therapist A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) - Provider Pharmacist Registered nurse A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? - Speech-language pathologist A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAS) can perform, which of the following client activities should the nurse include? (Select all that apply.) - Bathing Ambulating Toileting Measuring vital signs A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? - Autonomy A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? - Beneficence A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? - Justice A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? - Nonmaleficence A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise, Which of the following situations should the newly licensed nurses identify as an ethical dilemma? - A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? - Assault A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? - False imprisonment A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? - "I plan to write that i dont want them to keep me on a breathing machine." A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? - -Make sure the surgeon obtained the clients consent -Witness the clients signature on the consent form A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? - Report the observations to the nurse manager on the unit A nurse is preparing information for a change of shift report. Which of the following information should the nurse include in the report? - Bone scan scheduled for today A nurse manager is discussing the HIPPA privacy rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? Select all that apply - -Family members should provide a code prior to receiving client health information -Communication of client information can occur at the nurses station -A client can request a copy of their medical record -A nurse can photocopy a clients medical record for transfer to another facility A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a clients record? Select all that apply - -Put the date and time on all entries -Document objective data, leaving out opinions A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? Select all that apply - Medication error Needlesticks Omission of prescription A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) - -Repeat the details of the prescription back to the provider. -Have another nurse listen to the telephone prescription. -Obtain the provider's signature on the prescription within 24 hr. A nurse on a medical-surgical unit has received change of shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel? - -Reapplying a condom catheter for a client who has urinary incontinence A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? - -RN A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) - -The client ambulates wearing slippers over antiembolic stockings. -The client uses a front-wheeled walker when ambulating. -The client had pain medication 30 min ago. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a Practical Nurse? - Providing nasopharyngeal suctioning for a client who has pneumonia A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) - -Right supervision and evaluation -Right direction and communication -Right circumstances By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? - Reassess the client to determine the reasons for inadequate pain relief A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? - Assessment A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) - -respiratory rate is 22/min with even, unlabored respirations -the clients skin is pink, warm and dry -the assistive personnel reports that the client walked with a limp A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) - -Showing a client how to use progressive muscle relaxation -Performing a daily bath after the evening meal -Repositioning a client every 2 hr to reduce pressure injury risk A nurse is discussing the nursing process a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? - "I will determine the most important client problems that we should address." A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? - Basic [Show Less]
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe ... [Show More] care of this client? A. Supine B. Semi Fowler's C. Semi-Prone D. Trendelenburg - B A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for help with transfer C. Use transfer belt to assist client back to bed D. Determine clients ability to help with transfer - D A nurse is completing discharge instrucitons for pt with COPD. What demonstrates pt understanding with difficulty breathing at night? A. lie on back with head and shoulders on pillow B. Lie flat on stomach with head to one side. C. Sit on side of bed with arms over pillows on bedside table. D. Lie on side with weight on hip and should with arms flexed in front of her - C A nurse manager is reviewing guidelines for preventing injury with staff nurses. which of the following instructions should the nurse manager include. Select all that apply A. Request assistance when re-positioning client B. Avoid twisting spine or bending at waist C. Keep knees slightly lower than hips when sitting for extended periods D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2 to 3 hrs to flex and stretch joints and muscles - A B D A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements shoudl the nurse identify as an indication that an attendee understands the teaching. Select all that apply A. My line of gravity should fall outside my base of support B. The lower the center of gravity the more stable I am C. To broaden my base of support, I should spread my feet apart D. When I lift an object I should hold it as close to my body as possible E. When pulling an object I should move my front foot forward - BCD A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the highest priority? A.A client who received crush injuries to the chest and abdomen and is expected to die B.A client who has a 4-inch laceration to the head C.A client who has partial-thickness and full-thickness burns to his face, neck, and chest D.A client who has a fractured fibula and tibia - c A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge clients to make beds available for injury victims. Which of the following clients can be safely discharged? (Select all that apply.) A.A client who is dehydrated and receiving IV fluid and electrolytes B.A client who has a nasogastric tube to treat a small bowel obstruction C.A client who is scheduled for a transurethral resection of the prostate (TURP)D.A client who is 24 hr postoperative following a mastectomy E.A client who is scheduled for an appendectom - cd A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.) A.Open doors to client rooms. B.Place blankets over clients who are confined to beds C.Move beds away from the windows. D.Draw shades and close drapes. E.Relocate ambulatory clients in the hallways back into their room - bcd An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A.Irrigate the affected area with running water. B.Wash the affected area with antibacterial soap. C.Brush the chemical off the skin and clothing. D.Apply a neutralizing agent. - c A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure?A."I will get the caller off the phone as soon as possible so I can alert the staff." B."I will use overhead paging to alert the entire facility." C."I will not ask any questions and just let the caller talk." D."I will listen for background noises. - d A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply.) A.Place a belt restraint on the client when he is sitting on the bedside commode. B.Keep the bed in low position with full side rails up. C.Ensure that the client's call light is within reach. D.Provide the client with nonskid footwear. E.Complete a fall-risk assessmen - c d e A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction? A."I will place the client on his side." B."I will go to the nurses' station for assistance." C."I will administer medications as prescribed." D."I will be prepared to insert an airway. - b A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse? A.Extinguish the fire. B.Pull the fire alarm. C.Evacuate the clients. D.Close all open doors on the unit - c A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse's knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses' station? A.A 43-year-old client who is postoperative following a laparoscopic cholecystectomy B.A 61-year-old client being admitted for telemetry to rule out a myocardial infarction C.A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle D.A 79-year-old client who is postoperative following a below-the-knee amputatio - d A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse? A.Complete a fall-risk assessment. B.Educate the client and family on fall risks. C.Complete a physical assessment. D.Survey the client's belonging - a When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A.keep the sterile field at least 6 ft away from the client's bedside.B.instruct the client to refrain from coughing and sneezing during the dressing change. C.place a mask on the client to limit the spread of micro-organisms into the surgical wound. D.keep a box of facial tissues nearby for the client to use during the dressing change - C A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.) A.A bottle containing a sterile solutionB.The edge of the sterile drape at the base of the field C.The inner wrapping of an item on the sterile field D.An irrigation syringe on the sterile field E.One gloved hand with the other gloved hand - C D E A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A.The flap closest to the body B.The right side flap C.The left side flap D.The flap farthest from the body - D A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A.Apply 3 to 5 mL of liquid soap to dry hands. B.Wash the hands with soap and water for at least 15 seconds. C.Rinse the hands with hot water. D.Use a clean paper towel to turn off hand faucets. E.Allow the hands to air dry after washing - B D A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A.The provider drops a sterile instrument onto the near side of the sterile field. B.The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C.The procedure is delayed 1 hr because the provider receives an emergency call. D.The nurse turns to speak to someone who enters through the door behind the nurse. E.The client's hand brushes against the outer edge of the sterile field - B C D A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A.Planning and evaluating control and prevention strategies B.Determining public health priorities C.Ensuring proper medical treatment D.Identifying endemic disease E.Monitoring for common-source outbre - A B C E A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.) A.Place the client in a room that has negative air pressure of at least six exchanges per hour. B.Wear a mask when providing care within 3 ft of the client. C.Place a surgical mask on the client if transportation to another department is unavoidable. D.Use sterile gloves when handling soiled linens. E.Wear a gown when performing care that may result in contamination from secretions - B C E A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect? A.Allergic reaction B.Ringworm C.Systemic lupus erythematosus D.Herpes zoste - D A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?A.Prodromal B.Incubation C.Convalescence D.Illnes - D A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.) A.Fever B.Malaise C.Edema D.Pain or tenderness E.Increase in pulse and respiratory rate - A B E A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill in 2 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown macules on the fac - A D E A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (Select all that apply.) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive dryness and wrinklin - B C D A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client's peripheral vascular system? (Select all that apply.) A. Range of motion [Show Less]
1. A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescr... [Show More] iption should the nurse question? - The dose 2. A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? - Observe the rate, depth, and character of the client's respirations. 3. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? - Lower the client to the floor and place a pad under the client's head. 4. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? - Educating clients about the recommended immunization schedule for adults 5. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? - Assessment 6. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? - Edema at the infusion site 7. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? - Washing dishes 8. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? - Daily weight 9. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? - Inspection 10. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? - A client who has a prescription for a transfusion of packed red blood cells 11. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? - "It must be difficult to care for someone who is confined to bed." 12. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? - Bounding pulse 13. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? - Cover the incision with a moist sterile dressing. 14. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? - "Bear weight on both of your legs." 15. A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? - Liver Damage 16. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? - PC for after meals 17. A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? - A 10-month-old infant can pull up to a standing position. 18. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? - The AP hangs the collection bag at the level of the bladder. 19. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? - Consult the medication reference book available on the unit. 20. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? - Place the client in a lateral position with the head turned to the side before beginning the procedure. 21. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? - Repeat each joint motion five times during each session. 22. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? - Cough deeply after each use. 23. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning? - Have the client demonstrates the procedure. 24. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? - Gelatin 25. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? - Romberg test 26. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? - WBC 15,000 mm3 27. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? - Ventrogluteal 28. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? - Fill the bag two-thirds full with ice. 29. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? - Impaired peristalsis of the intestines 30. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? - Wear cotton clothing to avoid static electricity. 31. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? - "I can see that this is upsetting you." 32. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? - Position the client on his left side. 33. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? - Airway 34. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? - Tie the restraint with a quick-release knot. 35. A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? - Oil retention 36. A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? - People who practice Judaism stay with the body of the deceased until burial. 37. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? - 38. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? - Place the client in Trendelenburg's position. 39. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? - Provide a protein intake of 1.5 g/kg of body weight per day. 40. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? - Cold extremities 41. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? - Hemolytic 42. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? - Loss 43. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? - Sit at the bedside while feeding the client. 44. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? - Wear gloves when changing the client's gown. 45. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) - -Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. 46. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? - Fidelity 47. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? - Tachycardia 48. A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? - Decreased calcium 49. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? - "Tell me more about how your friends discourage you." 50. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? - When lifting an object, spread your feet apart to provide a wide base of support. 51. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? - "All of this equipment can be frightening." 52. A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? - "The pain is like a dull ache in my stomach." 53. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? - evacuate the client 54. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? - Rapid heart rate 55. A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? - 0.3 mg 56. A nurse is preparing a heparin solutionA nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 8 mL/hr 57. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? - Cleanse the wound from the center outward 58. The nurse is caring for a client who is receiving fluid through a peripheral IV catheter.. Which of the following findings at the IV site should the nurse identify as indicating infiltration? - Skin blanching 59. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - "When descending stairs, I will first shift my weight to my right leg." 60. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? - Tell the client to keep the head of the bed elevated at least 30 degrees 61. A nurse is reviewing a client's medication prescription that reads "digoxin 0.25 by mouth everyday." Which of the following components of the prescription should the nurse verify with the provider? - Medication dose 62. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? - "I will be sure to remove my hearing aid before taking a shower" 63. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? - "Client found lying on floor" 64. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process. - Compare prescriptions with medications the client received while at the facility. 65. A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? - Witness the client's signature on the consent form. [Show Less]
Regulatory agencies - US Dept of Health and Human Services FDA State and local public health agencies State icensing boards Joint Commission-JCAHO Pro... [Show More] fessional Standards Review Organizations Review committees Healthcare financing mechanisms - publically federally funded progams -Medicare -Medicaid -Private pay Levels of Healthcare - Preventive Health-immunization, stress management Primary-nutrition counseling Secondary-emergency Tertiary-techincal care, cancer centers Restorative-home health, rehab Continuing-long-term, chronic Interdisplinary Personnel-Non-Nursing - Clergy-spiritual Registered Dietitian-educate on nutrition Lab Tech-obtain specimens Occupational Therapist-regain ADLs Pharmacist-provide/monitor medications Physical Therapist-increase musculoskeletal function Provider-assess, diagnose, treat client Radiologic Techs-perform xrays Respiratory Therapist-evaluate respiratory status Social Worker-equip client/family with community resources Speech Therapist-assist with regaining speech Autonomy (Ethical Responsibilities) - ability of the client to make personal diecisins, even when those decissions may not be in the clients best interest Beneficence (Ethical Responsibilities) - agreement that the care given is in the best interest o the client; taking positive actions to help others Fidelity (Ethical Responsibilities) - agreement to keep one's promise to the client about care that was offered Justice (Ethical Responsibilities) - fair treatment in matters related to physical an psychosocial care and use of resources Nonmaleficnce (Ethical Responsibilities) - avoidance of harm of pain as much as possible when giving treatments Ethical dilemna (Ethical Responsibilities) - it cannot be solved solely by a review of scientiic data; it involves a conflict between two moral imperatives; the answer will have a profound effect on the situation/client Nurses basic code of ethics (Ethical Responsibilities) - advocacy, responsibility, accountability and confidentiality nurses role in ethical decision making (Ethical Responsbilities) - 1. an agent fo the client facing and ethical decision-helping decision of abortion for adolscent; discussing blood transfusion w/JW; 2. the decison maker in regard to nursing practice-witnessing surgeon provide options but not dangers Sources of Law (legal responsibilities) - Health Insurance Portablity and Accountability Act-HIPAA; The Americans with Disabilities Act-ADA; The Mental Health Parity Act-MHPA; The Patient Self-Determination Act-PSDA Criminal law - subsection of public law and relates to the relationship of an individual with the govenment-nurse who falsifies medical record Civil law - protects the individual rights of people-provision of nursing care is tort law Negligence - Unintentional Torts - nurse fails to implement safety measures for a client who has been identified as at risk for falls Malpractice - Unintentional Torts - nurse administers a large dose of medication due to a calculation error. Client has a cardiac arrest and dies Breach of Confidentiality - Quasi-Intentional Tort - a nurse release the medical diagnosis of a client to a member of the press Defamation of Character - Quasi-Intentional Tort - a nurse tells a coworker that she believes the clienthas been unfaithful to her spouse Assault - Intentional Torts - the conduct of one person makes another person fearful-threatening Battery - Intentional Tort - intentional and wrong physical contact that involves injury or offensive contact-restraining of a client False Imprisionment - Intentional Tort - a person is confined/restrained against their will-competent client put in restraints to prevent leaving facility Professional Negligence - failure of a person with professional training to act in a reasonable and prudent manner Responsiblities for informed consent - Provider-obtain consent; Client-give consent; Nurse-witnesses consent Types of Advance Directives - Living Will-expressin clients wishes regarding medical treatment; Durable Power of Attorney for Healthcare-designates a healthcare proxy; Providers Order-DNR-do not resuscitate; AND-allow natural death; CPR-cardiopulmonary resuscitation Chart Information - assessments; medication administration; treatments geven and the clients responses; client education Chart documentation - subjective data-what the client says in quotation marks; objective data-what you see; accurate/concise-info documented must be precise; complete/current-info is comprehensive and timely; organized-communicate in logical order Delegation and Supervision - RNs to RNs, LPNs and Nursing assistants Delegation Factors - Predictability of outcome; Potential for harm; Complexity of care; need for problem solving and innovation; level of interaction with the client Five Rights of Delegation - Right Task-identify task; Right Circumstance-access health status/complexity of care; Right person-verify compentencey of delegatee; Right direction/communication-data to collect; Right supervision/evaluation-provide direct/indirect supervision [Show Less]
participants of health care systems - 1. consumers (clients) 2. licensed providers (RN, LPN, MD, PT, OT, etc.) 3. unlicensed providers (assistive pers... [Show More] onnel) settings of the health care delivery system - hospitals, homes, assisted-living, schools, hospices, occupational health clinics, urgent care, etc. regulatory agencies of health care delivery systems - department of health and human services, FDA, state licensing boards, the Joint Commission (set quality standards for accreditation of health care facilities), etc. health care financing mechanisms - medicare (65 or older and those who have permanent disabilities), medicaid (low income), private plans levels of health care - preventative: focus on educating to reduce and control risk factors primary: emphasizes health promotion secondary: includes the diagnosis and treatment of acute illness and injury tertiary: acute care; involves provision of specialized and highly technical care restorative: intermediate follow-up care for restoring health and promoting self-care continuing: addresses long-term or chronic health care needs over a period of time safety in health care delivery - minimization of risk factors that could cause injury or harm while promoting high-quality care and maintaining a secure environment for clients, self, and others patient-centered care - caring and compassionate, culturally sensitive care that addresses clients' physiological, psychological, sociological, spiritual and cultural needs, preferences, and values. the client is included in the decision making process evidence based practice - use of current knowledge from research and other credible sources on which to base clinical judgement and client care informatics - the use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically-based nursing practice quality improvement - care-related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients' needs teamwork and collaboration - the delivery of client care in partnership with interprofessional members of the health care team to achieve continuity of care and positive client outcomes A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (select all) a. Home health care b. Rehabilitation facilities c. Diagnostic centers d. Skilled nursing facilities e. oncology centers - a. Home health care b. Rehabilitation facilities d. Skilled nursing facilities A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (select all) a. Preferred provider organization (PPO) b. Medicare c. Long-term care insurance d. Exclusive provider organization (EPO) e. Medicaid - b. Medicare e. Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? a. Collaborating with providers to perform obesity screenings during routine office visits b. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity c. Providing specialized intraoperative training in surgical treatments for obesity d. Educating acute care nurses about postoperative complications related to obesity - a. Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? a. Monitoring evidence-based practice for clients who have a specific diagnosis b. Ensuring that health care providers comply with regulations c. Setting quality standards for accreditation of health care facilities d. Determining whether medications are safe for administration to clients - b. Ensuring that health care providers comply with regulations A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (select all) [Show Less]
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Selec... [Show More] t all) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers - A. home health care B. rehabilitation facilities D. skilled nursing facilities A nurse is explaining the various types of healthcare coverage clients might have To a group of nursing students. Which of the following healthcare financing mechanisms are federally funded? (Select all) A. Preferred provider organization (PPO) B. Medicare C. Long term care insurance D. Exclusive provider organization (EPO) E. Medicaid - B. Medicare E. Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training regarding surgical treatments for obesity D. Educating active care nurses on post operative complications related to obesity - A. Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that healthcare providers comply with regulations C. Setting quality standards for accreditation of healthcare facilities D. Determining if medications are safe for administration to clients - B. ensuring that healthcare providers comply with regulations Rationale: The nurse should identify that state licensing boards are responsible for ensuring that healthcare providers and agencies comply with state regulations A nurse is caring for a group of clients on a medical-surgical unit. for which of the following client care needs should the nurse initiate a referral for a social worker? (Select all) A. A client who has terminal cancer request hospice care in her home B. A client asked about community resources available for older adults C. A client states that she wants her child baptized before surgery D. A client requests an electric wheelchair for use after discharge E. Client states that he does not understand how to use a nebulizer - A. A client who has terminal cancer I request hospice care in her home B. A client asked about community resources available for older adults D. A friend request an electric wheelchair for use after discharge A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist - D. Occupational Therapist A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medications effects? (Select all) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist - A. provider C. pharmacist D. registered nurse A client who has had a cerebral vascular accident has persistent problems with dysphasia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist - D. speech-language pathologist A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - B. Autonomy A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence - D. Beneficence A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - C. Justice A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - D. Nonmaleficence A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form. - C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill Rationale: Making the decision about initiating internal team feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue and it is not easy to resolve. The decision will have a profound effect on the situation and on the client A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the healthcare team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (Select all) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - A. Bathing B. Ambulating C. Toileting E. Measuring vital signs 1. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy - A. Assault Rationale: by threatening the client, the AP is committing assalt. Her threats could make the client become fearful and apprehensive. A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality - B. False imprisonment Rationale: The nurse gave the medication as a chemical restraint to keep a client from leaving the facility against medical advice. This is false imprisonment because the client neither requested nor consented to receiving the sedative A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week, The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C."I plan to write that I don't want them to keep me on a breathing machine." D."I will get my regular doctor to approve my plan before I hand it in at the hospital." - C."I plan to write that I don't want them to keep me on a breathing machine." Rationale: The client has a right to decide and specify which medical procedures he wants when a life-threatening situation arises A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply) A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery - A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form Rationale: A. It is the nurses responsibility to verify that the surgeon obtained the clients consent and that he understands the information the surgeon gave him. B. It is the nurses responsibility to witness the client signing of the consent form and to verify that he is consenting voluntarily and appears to be competent to do so. The nurse also should verify that he understands information the surgeon gave him A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A Alert the American Nurses Association. B. Fill out an incident report. C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep. - C. Report the observations to the nurse manager on the unit Rationale: any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as Tertiary care? Select all that apply A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care - A. Intensive care unit B. Oncology treatment center C. Burn center A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? A. Input and output for the shift. B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record - C) Bone scan scheduled for today [Show Less]
A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the... [Show More] side. B. Place two fingers in the client's mouth to open. C. Brush the client's teeth once per day. D. Inject a mouth rinse into the center of the client's mouth. - A. Turn the client's head to the side. A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. Inspect the feet daily. B. Use moisturizing lotion on the feet. C. Washing the feet with warm water and let them air dry. D. Use over-the-counter products to treat abrasions. E. Wear cotton socks. - A. Inspect the feet daily. B. Use moisturizing lotion on the feet. E. Wear cotton socks. A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client. - A. Schedule rest periods during morning care. A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms - A. Face A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry, storage container after cleaning them. - B. Brush the dentures with a toothbrush and denture cleaner. A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies. B. Determining public health priorities. C. Ensuring proper medical treatment. D. Identifying endemic disease. E. Monitoring for common-source outbreaks. - A. Planning and evaluating control and prevention strategies. B. Determining public health priorities. C. Ensuring proper medical treatment. E. Monitoring for common-source outbreaks. A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster - D. Herpes zoster A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness - D. Illness A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malasia C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate - A. Fever B. Malasia E. Increase in pulse and respiratory rate A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of that at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions. - B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. E. Wear a gown when performing care that might result in contamination from secretions. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. - C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. A nurse manager is reviewing with nurses on the unit the care of a client who has had seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C. "I will administer his medications." D. "I will prepare to insert an airway." - B. "I will go to the nurses' station for assistance." A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurses's priority. A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit. - C. Move clients who are nearby. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the clients and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in his possession. - A. Complete a fall-risk assessment. A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy. B. A middle adult who requires telemetry for a possible myocardial infarction. C. A young adult who is postoperative following an open reduction internal fixation of the ankle. D. An older adult who is postoperative following a below-the-knee amputation. - D. An older adult who is postoperative following a below-the-knee amputation. A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home. - B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following. [Show Less]
1. A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following treatment approaches should th... [Show More] e nurse plan to take? a)Restrict participation in group therapy sessions b)Establish consequences for self-mutilation c)Maintain close observation d) Provide an unstructered environment - c)Maintain close observation 2. Clients who have borderline personality disorder are at risk for self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury 3. A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. What action should the nurse take? - Administer the medication at bedtime. 4. A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in this room is being recorded." What response should the nurse make? - "That must be very frightening." 5. The nurse should respond to the client's delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship. 6. A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What finding should the nurse expect? - Confusion. 7. The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor, diplopia, and memory loss are expected findings of this disorder.8. A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which manifestations is a common adverse effect of this medication? - Dizziness. 9. The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined. 10. A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. What finding should the nurse question the provider's prescription? - Hypotension. 11. The nurse should question the provider's prescription for a benzodiazepine for a client who has hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for cardiac arrest. 12. A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding is the priority for the nurse to report to the provider? - Elevated blood pressure. 13. The nurse should identify that the greatest risk to the client is an elevated blood pressure, which increases the risk for a hypertensive crisis that can result from taking an MAOI, such as phenelzine. The nurse should apply the safety and risk reduction priority-setting framework when assessing this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting frame-work, or nursing knowledge to identify which risk poses the greatest risk. 14. A nurse is providing teaching to a client who has a new prescription for disulfiram for the management of alcohol dependence. What dietary choices should the nurse instruct the client to avoid? - Pure vanilla extract. 15. The nurse should instruct the client to avoid alcohol and alcohol-containing substances such as pure vanilla extract. The ingestion of alcohol while taking this medication causes a disulfiramalcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension.16. A nurse is providing teaching to the parents of a school-age child who has attention deficit hyperactivity disorder (ADHD).What should the nurse include in her teaching? - Ignore your child's attention-seeking behaviors that are not dangerous 17. A nurse is planning a staff education session about the administration of antidepressant medications to older adult clients. What should the nurse include in the teaching? - Older adult clients require a lower initial dose of antidepressant medication than adult clients 18. A nurse is caring for a client who has major depressive disorder and is severely withdrawn. What techniques should the nurse use to facilitate communication with the client? - Speak to the client using simple and concrete terminology 19. A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for what substance? - Opiates. 20. Opiates include opium, morphine, codeine, methadone, and heroin. Methadone is given as a substitute to prevent cravings and severe manifestions of opiate withdrawal. 21. A nurse is performing an admission assessment for a client who has restricting type anorexia nervosa. What finding should the nurse expect? - Decreased caloric intake. 22. A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. What is the nurses priority? - Protect the client from impulsive behavior. 23. A nurse in the emergency department is assessing a client who has heroin intoxication. What should the nurse expect? - Respiratory depression 24. A nurse is caring for a client who is receiving treatment for alcohol detoxification. What medication should the nurse expect to administer during this phase of the client's care? - Diazepam 25. Anti-anxiety agents, such chlordiazepoxide and diazepam, are long-acting CNS depressants that are used to minimize the manifestations of alcohol withdrawal26. A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The client is admitted under court order following the theft and destruction of a car. What behaviors should the nurse expect the client to display? - Anger with the nursing staff for hospitalizing him against his will 27. A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. What intervention should the nurse include in the plan? - Provide the client frequently with high-calorie finger foods. 28. A nurse is assessing a client who has conduct disorder. What finding should the nurse expect? - Aggressive behaviors towards others 29. A nurse is teaching a client who has agoraphobia about systematic desensitization. What comment should the nurse include in the teachings? - You will slowly be exposed to increasing level of public spaces 30. A nurse is interviewing a client who has anorexia nervosa. What findings should the nurse expect? - Strenuous excercise regimn 31. A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygience care. What action should the nurse take? - Talk to the client from two armlengths away. 32. A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. What client goals should the nurse identify as a priority? - Maintaining adequate hydration. 33. A nurse is speaking to a community group about the diagnosis and treatment of clients who have Alzheimer's disease. The nurse should conclude that a member of the group requires further teaching when she identifies what manifestation of the disease? - Sudden confusion 34. A nurse is assessing a client who has Stage 4 Alzheimer's disease. What finding should she expect? - The client is able to identify the names of family members.35. A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription of lithium. The nurse should identify that it is safe to administer what medication while the client takes lithium? - Valproic acid. 36. A nurse in a mental health unit is planning care for a client who is receiving treatment for selfinflicted injuries. The nurse should identify what interventions as the priority when planning care for this client? - Promoting and maintaining client safety 37. A nurse is providing teaching to the family of a client who has Alzheimer's disease about donepezil. What statement should the nurse include in her teaching? - Donepezil can improve cognitive functioning during the earlier stages of the disease 38. A nurse is planning care for a client who has a physical dependence to alprazolam and must discontinue the medication. WHAt action should the nurse include in the plan? - Taper the medication gradually over several weeks 39. A nurse in the emergency department is caring for a toddler who has a fractured arm. What findings should the nurse identify as a possible indication of physical abuse? - The parent provides history that is inconsistent with the child's injury 40. A nurse in an acute mental health facility is reviewing the medication records for a group of clients. The nurse should expect a prescription for memantine for a client who has what diagnosis? - Severe Alzheimer's disease 41. Memantine, an NMDA receptor agonist, is shown to slow the progression of manifestations and to improve cognitive function [Show Less]
A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid ... [Show More] volume excess? a. Decreased bowel sounds b. Distended neck veins c. Bilateral muscle weakness d. Thread pulse - b. Distended neck veins A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective? a. Absent Chvostek's sign b. Improved cognition c. Decreased vomiting d. Cardiac arrhythmias absent - b. Improved cognition A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following instructions should the nurse include? a. "Discontinue the patch if you experience a headache." b. "Apply a new patch if you have chest pain." c. "Cover the patch with dry gauze when taking a shower." d. "Remove the patch prior to going to bed." - d. "Remove the patch prior to going to bed." A nurse is reviewing he laboratory results of a client who has a prescription for sodium polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to the provider? a. Creatinine 0.72 mg/dL b. Sodium 138 mEq/L c. Magnesium 2 mEq/Ld. Potassium 5.2 mEq/L - d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassium level greater than 5.0 mEq/L) increases the client risk for fatal cardiac dysrhythmias. Kayexalate is used to decrease the serum potassium level so the PN should monitor the client's serum potassium level A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of the following outcomes indicates that the client is adhering to the medication regimen? a. The client has a negative sputum culture b. The client tests negative for HIV c. The client has a positive purified protein derivative test d. The client's liver function test results are within the expected reference range - a. The client has a negative sputum culture A client is caring for a client who develops an anaphylactic reaction to IV administration. After assessing the client's respiratory status and stopping the medication infusion. Which of the following actions should the nurse take next? a. Replace the infusion with 0.9% sodium chloride b. Give diphenhydramine IM c. Elevate the client's legs and feet d. Administer epinephrine IM - d. Administer epinephrine IM A nurse is caring for a client who is taking sertraline and reports a desire to begin taking supplements. Which of the following supplements should the nurse advise the client to avoid? a. St. John's Wort b. Ginger root c. Black cohosh d. Coenzyme Q10 - a. St. John's Wort A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For which of the following adverse effects should the nurse monitor when administering lisinopril? a. Bradycardia b. Hypokalemia c. Tinnitusd. Hypotension - d. Hypotension A nurse is assessing a client who is receiving heparin IV continuous IV. The client has an PPT of 90 seconds. They should monitor the client for which of the following changes in their vital signs? a. Decreased temperature b. Increased pulse rate c. Decreased respiratory rate d. Increased blood pressure - d. Increased blood pressure A nurse is preparing to administer medication to a client and discovers a medication error. The nurse should recognize that which of the following staff members is responsible for completing an incident report? a. The quality improvement committee b. The nurse who identifies the error c. The nurse who caused the error d. The charge nurse - b. The nurse who identifies the error A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following? a. Pruritus b. Cough c. Tachypnea d. Gastric bleeding - a. Pruritus - Sign of allergic reaction to morphine A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right placing them in the order of performance. Use all the steps.) - a. Obtain the client's apical heart rate b. Remove the medication from the dispensing system c. Open the medication package d. Compare the client's wristband to the medication administration record e. Document administration of the medicationA nurse is reviewing the medical record of an adult client who has a fever and a prescription for acetaminophen. Which of the following findings should the nurse identify as a contraindication for receiving this medication? a. Alcohol use disorder b. Chronic kidney disease c. Hepatitis B vaccine within the last week d. Diabetes mellitus - a. Alcohol use disorder b. Chronic kidney disease A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which of the following actions should the nurse take first? a. Encourage the client to dangle the legs while sitting in a chair b. Teach the client about foods low in sodium c. Determine medication adherence by the client d. Notify the provider of the client's weight gain - c. Determine medication adherence by the client A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection? a. Urticaria b. Bradycardia c. Pallor d. Dyspepsia - a. Urticaria A nurse is teaching a client who has angina a new prescription for sublingual nitroglycerin tablets. Which of the following instructions should the nurse include in the teaching? a. "Discard any tablets you do not use every 6 months." b. "Take one tablet each morning 30 minutes prior to eating." c. "Keep the tablets at room temperature in their original glass bottle."d. "Place the tablet between your cheek and gum to dissolve." - c. "Keep the tablets at room temperature in their original glass bottle." A nurse is providing teaching to a client who has a new prescription for theophylline a sustainedreleased capsule. Which of the following statements by the client indicates an understanding of the teaching? a. "I can take my medication in the morning with my coffee." b. "I may sprinkle the medication in applesauce." c. "I should limit my fluid intake while on this medication." d. "I will need to have blood levels drawn." - a. "I can take my medication in the morning with my coffee." A nurse is mixing regular insulin and NPH in [Show Less]
A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of t... [Show More] he following findings is an adverse effect of this medication? - Hypokalemia Rationale: Lactulose works by stimulating the production of excess stores to rid the body of excess ammonia. These excessive stores can result in a hypo kalemia and dehydration. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? - Instruct the client to allow the machine to breathe for them. Rationale: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions in emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness we're trying to "fight the ventilator." A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? - Add cabbage to the diet. Rationale: To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are all high in fiber. A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) - Visual spatial deficits, Left hemianopsia, One-sided neglect. Rationale: Visual spatial deficits and loss of depth perception occur secondary to a right hemispheric stroke. Left hemianopsia, or blindness in the left half of the visual field, occur secondary to right hemispheric stroke. One-sided neglect, or in unawareness of the affected side, occur secondary to a right hemispheric stroke. A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? - Nonrebreather mask Rationale: The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via non-rebreather mask. A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first? - Place the client in high-Fowler's position. Rationale: the greatest risk to this client is injury from airway obstruction. Therefore, their priority intervention the nurse should take us to move the client into high Fowlers position. High Fowlers position facilitate long expansion and improves been elation and gas exchange A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? - Avoid placing plants or flowers in the client's room. Rationale: live plants can harbor P. Aeruginosa, And this bacterium can infect burn moons and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the clients room. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? - Urine specific gravity 1.045 Rationale: a urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? - Administer an opioid analgesic to the client. Rationale: the nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? - Dysphagia Rationale: dysphasia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding. A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? - Roll each testicle between the thumb and fingers. Rationale: the nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to fill for any lumps deep in the center of the testicle. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? - "I should take this medication with a meal." Rationale: the client should take metformin with or immediately following Mills to improve absorption and to minimize gastrointestinal distress. A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - "I will wear clean graduated compression stockings every day." Rationale: the client should apply a clean pair of graduated compression stockings each day and clean stalls stockings with a mild detergent and warm water by hand. A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? - Tachycardia Rationale: when using the urgent versus non-urgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the clients bed flat airport this finding immediately to the provider. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - Current medications Rationale: the nurse should review the clients medication record to identify medications, including ace inhibitors , beta blockers,theophylline, nifedipine, And glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the clients reaction to the allergens, and the nurse should notify the provider and instruct the client to discontinue prednisone for two weeks before the allergy skin test. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? - A client who is receiving preoperative teaching for a right knee arthroplasty. Rationale: the nurse should make a referral to physical therapy so the client can begin understanding post operative exercises and physical restrictions. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? - BUN 32 mg/dL Rationale: DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and urine specific gravity levels resulting from the excess glucose present in the urine. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? - "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." Rationale: This is to minimize irritation of the skin from exposure to year end A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching? - Void before and after intercourse. Rationale this flushes bacteria out of the urinary tract and prevent the occurrence of infection. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? - Wear a mask. Rationale: bacterial meningitis requires droplet precautions. Those entering the room should wear a mask when coming within 3 feet of the client until 24 hours after the client has begun receiving anabiotic therapy. A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? - Place a pillow between the client's legs. Rationale: this helps to prevent hip dislocation. A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? - Naproxen Rationale: both impair platelet aggregation in place the client at risk for bleeding. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? - Calcium [Show Less]
1. A nurse in an acute care facility is planning care for a client who has chosen to follow Islamic dietary laws during Ramadan. Which of the following act... [Show More] ions should the nurse plan to take? - Provide a snack for the client after sunset 2. A nurse is creating a plan of care for a client who has mucositis following a head and neck radiation therapy to treat cancer. Which of the following interventions should the nurse include in the plan? - Increase fluid intake to 2 L per day 3. A nurse is providing discharge teaching to a postpartum client about breast milk use and storage. Which of the following statements should the nurse make? - "You cannot place thawed breast milk back in the freezer" 4. A nurse is caring for a client who adheres to a kosher diet. Which of the following food choices would be appropriate for this client? - Vegetable salad with cheese 5. A community health nurse is planning to teach a class about weight management for cardiovascular health. Which of the following statements should the nurse plan to include? - "Plan to lose weight gradually at 1/2 to 1 pound per week." 6. A client is experiencing anorexia related to cancer treatment. Which of the following interventions should the nurse implement to increase the client's nutritional intake? - Add extra calories and protein to every meal 7. A nurse is teaching about nutritional requirements for a client who is starting a vegetarian diet. Which of the following information should the nurse include in the teaching? - Include two servings per day of nuts when on a vegetarian diet 8. A nurse is teaching a female client about a healthy diet to control hypertension. Which of the following client statements indicates an understanding of the teaching? - "I will eat four servings of unsalted nuts per week." 9. A nurse is caring for a client who is dehydrated and is receiving intermittent enteral feeding. Which of the following actions should the nurse plan to take? - Provide the formula as a continuous infusion 10. A nurse is providing teaching to a client who has dumping syndrome and is experiencing weight loss. Which of the following instructions should the nurse include in the teaching? - Consume liquids between meals 11. A nurse is providing dietary instructions for a client who has a prescription for warfarin. Which of the following foods should the nurse recommend the client eat in moderation while taking this medication? - Leafy green vegetables 12. A nurse is teaching a client who has hypertension about decreasing sodium intake. Which of the following information should the nurse include in the teaching? - Season foods with herbs and spices 13. A nurse is teaching a prenatal education class about breastfeeding. Which of the following instructions should the nurse include in the teaching? - Plan 5-min feedings on each breast on the first day after birth. 14. A nurse is assessing a client who has type 2 diabetes mellitus. The nurse should recognize which of the following as a manifestation of hypoglycemia? - Confusion 15. A nurse is teaching a client who is newly diagnosed with type 1 diabetes mellitus how to count carbohydrates. Which of the following statements made by the client indicates an understanding of the teaching? - "I know the serving size can affect the number of carbohydrates I eat." 16. A nurse is assessing a client who is suspected of having lactose intolerance. Which of the following is an expected finding? - Flatulence 17. A nurse is performing a cultural nursing assessment for a client whose religious practices include fasting 1 day each week. Which of the following questions should the nurse ask the client? (Select all that apply.) - "Are you exempt from fasting during illness?" "Does fasting mean refraining from drinking liquids?" Does your fasting occur during certain hours of the day?" "Does fasting mean eating only a certain type of food?" 18. A nurse is planning dietary teaching for a client who has dumping syndrome following a gastrectomy. Which of the following interventions should the nurse include in the client's plan of care? - Select grains with less than 2 g fiber per serving. 19. A nurse is assessing a client's risk for pressure injuries using the Braden scale. The client eats more than half of most meals but occasionally refuses a meal. Which of the following information should the nurse document on the nutrition category of the Braden scale? - 3 (Adequate) 20. A nurse is providing teaching about lowering solid fat intake to an adolescent client who usually consumes about 2,000 calories per day. Which of the following instructions should the nurse include? - "Restrict your daily meat intake to 5 ounces." 21. A home health nurse is reviewing the medical record of a client who had an open reduction internal fixation of the tibia. Which of the following findings should the nurse identify as a risk factor for impaired would healing? - The client consumes 1,000 kcal daily. 22. A nurse is providing teaching to a client who has dumping syndrome. Which of the following information should the nurse include? - Apply pectin to foods. 23. A nurse in a long-term care facility is monitoring a client during mealtime who has Parkinson's disease. Which of the following findings should the nurse identify as the priority? - The client drools while eating. 24. A nurse is reviewing the laboratory values of a group of clients. Which of the following clients should the nurse identify as experiencing dehydration? - A client who has a sodium level of 150 mEq/L [Show Less]
1. A nurse is conducting a counseling session with a client who has a substance use disorder. The client repeatedly ask personal questions about the nurse.... [Show More] Which of the following actions should the nurse take? - Explain that this time is designated to focus on the client. 2. A nurse is preparing to apply restaurants on a client who is threatening to harm others and has not responded to lessen case of interventions. Which of the following actions should the nurse plan to take? - Document the clients behavior every 15 minutes while restraints are in place. 3. Community mental health nurse is planning strategies to address substance use my adolescence. Which of the following intervention should the nurse plan as a method of primary prevention?Community mental health nurse is planning strategies to address substance use my adolescence. Which of the following intervention should the nurse plan as a method of primary prevention? - Provide a presentation at area high school's and resisting peer pressure for substance use. 4. A nurse in an emergency department is caring for an 18 month old toddler who has a fractured left femur. What is the long statement by the toddler's parent should cause the nurse to suspect child abuse? - "My child was riding a bicycle and fell off." 5. A nurse is administering an oral sedative to a client who is receiving careful and involuntary admission. The client states, " I'm not taking any more medication." Which of the following actions should the nurse take? - Document the client refusal of the medication in the medical record. 6. A nurse is caring for a school age client who begins wetting the bed after finding out her parents are getting a divorce. The nurse should identify the client is exhibiting which is a fine defense mechanisms? - Regression 7. A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yells at her son stating, " Quit lying about your father!" The nurse should recognize that the client is demonstrating which of the following defense mechanisms? - Denial 8. A nurse is caring for a client called mental health counseling center. The client received a failing grade in the course and spends entire counseling session blaming the teacher. The nurse should recognize this behavior as example of which of the following defense mechanisms? - Projection 9. A nurse at a college campus health clinic is caring for a client who reports manifestations of bulimia nervosa. The client tells the nurse, " I know my eating binges and vomiting are not normal, but I cannot control it." Which of the following responses should the nurse make? - " You are feeling helpless about changing this behavior?" 10. A nurse is preparing to administer fluphenazine decanoate 12.5 mg subcutaneous. available is fluphenazine decanoate 25 mg/mL. How many mL should the nurse administer per dose? [Show Less]
A nurse is caring for a client who is receiving end-of-life care and has a prescription for fentanyl patches. Which of the following information regarding ... [Show More] the adverse effects of fentanyl should the nurse plan to give to the client and family? - Take a stool softener on a daily basis. Rationale: constipation is an adverse effect of opioid use. --Naloxone is only for use in the acute care setting. --Urinary retention is an adverse effect of opioids, including fentanyl. A nurse is caring for a client who has diabetes mellitus and is taking glyburide. The client reports feeling confused and anxious. Which of the following actions should the nurse take first? - Perform a capillary blood glucose test. A nurse is providing teaching to a client who is to start therapy with digoxin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider? A- Dry cough B- Pedal edema C- Bruising D- Yellow-tinged vision - D- Yellow-tinged vision Rationale: this is a sign of digoxin toxicity. Other manifestations of digoxin toxicity include nausea, vomiting, loss of appetite, and fatigue. A nurse is reviewing the laboratory results of a client who is taking carbamazepine for a seizure disorder. Which of the following findings should the nurse report to the provider? - WBC 3,500 Rationale: WBC reference range is 5,000 to 10,000 A nurse is reviewing lab results for a client who is to receive a dose of ceftazidime via intermittent IV bolus. Which of the following laboratory findings is the priority for the nurse to report to the provider before administering the medication? - Creatinine 2.6 mg/dL Normal creatinine levels are 0.8 to 1.2 mg/dL A nurse is caring for a client who has hypocalcemia and is receiving calcium citrate. The nurse should identify that which of the following findings indicates a therapeutic response to the medication? - Client report of decreased paresthesia. Rationale: paresthesia (tingling/numbness) is a manifestation of hypocalcemia. The nurse should also monitor for a decrease in other manifestations of hypocalcemia including muscle twitching and cardiac dysrhythmias. A nurse is providing teaching to a client who has a prescription for trimethoprim/sulfamethoxazole. Which of the following instructions should the nurse include in the teaching? - Drink 8 to 10 glasses of water daily. A nurse should instruct the client to increase water intake to 1,920 to 2,400ml a day to decrease the chance of kidney damage from crystallization. A nurse is preparing to administer hydrochlorothiazide to a client. Which of the following actions should the nurse take prior to administering the medication? - Take the client's BP. Rationale: HCTZ is a thiazide diuretic administered to promote urine output and reduce blood pressure and edema. A nurse is providing teaching for a client who has multiple sclerosis and a new prescription for methylprednisolone. Which of the following instructions should the nurse include? - --Blood glucose levels will need to be monitored --Avoid contact with persons who have known infections --Grapefruit juice can increase the blood levels of the medication A circulating nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse include in the plan of care? - Place monitoring cords and tubes in a stockinet. A nurse in a provider's office is assessing a client who has been taking aspirin daily for the past year. For which of the following findings should the nurse notify the provider immediately? - Hyperventilation. Rationale: This may occur due to acute salicylate poisoning, which causes respiratory alkalosis in the early stages. A nurse is monitoring for adverse effects of hydrochlorothiazide after administering the medication to an older adult client who has heart failure. Which of the following findings should the nurse identify as an adverse effect of the medication? - Orthostatic hypotension A nurse is caring for a client who is taking atorvastatin for hyperlipidemia. Which of the following client laboratory values should the nurse monitor? - Creatine kinase A nurse is providing teaching to a client who is to start taking sumatriptan. Which of the following adverse effects should the nurse instruct the client to monitor for and report to the provider? - Chest pressure Rationale: sumatriptan is an antimigraine agent which can cause coronary vasospasms, resulting in angina. The client should report chest pressure or heavy arms to the provider. A nurse is completing an incident report for a medication error. Which of the following should the nurse include in the report? - Administered propanolol 80 mg PO at 1800 to the client who did not have a prescription for the medication. A nurse is teaching a client who is taking allopurinol for the treatment of gout. Which of the following information should the nurse include in the teaching? - Drink 2L of water daily. The nurse should instruct the client to drink at least 2L of water each day to prevent renal stone formation and kidney injury, because allopurinol is eliminated through the kidneys A nurse is teaching about self-administration of transdermal medication with a male client who has a new prescription for nitroglycerin. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? - I will remove the patch after 14 hours. A nurse is caring for a client who has developed hypomagnesemia due to long-term therapy with lansoprazole. The nurse should monitor the client for which of the following manifestations? - Disorientation The nurse should monitor for disorientation and confusion as manifestations of hypomagnesemia; and for positive Chvostek's and Trousseau's signs. A nurse is preparing to administer 0.9% NaCl 1,500ml to infuse over 8hr to a client who is postoperative. The nurse should set the IV pump to deliver how many mL/hr? - 188ml/hr A nurse is providing discharge teaching to a client who has a new prescription for furosemide twice daily. The nurse should include which of the following instructions in the teaching? Select all. - --Increase intake of potassium-rich foods --monitor for muscle weakness --dangle your legs from the side of the bed before standing A nurse in a clinic is caring for a client who is taking aspirin for the treatment of arthritis. The nurse should identify which of the following findings as an indication that the client is beginning to exhibit salicylism? - Tinnitus Rationale: Tinnitus is a manifestation of aspirin toxicity, also called salicylism. Other manifestations include sweating, headache, and dizziness. A nurse is caring for a client who has pneumonia. The client tells the nurse she is pregnant and that she has not told her provider yet. The nurse should identify that pregnancy is a contraindication for receiving which of the following medications? - Doxycycline [Show Less]
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions shoul... [Show More] d the nurse include in the plan? - Provide small, frequent meals for the child. The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy. A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? - "I will place my infant's diapers under the harness straps." To prevent soiling of the harness, the parent should apply the infant's diaper under the straps. A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan? - Initiate seizure precautions for the child. A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety. A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? - Absence of peristalsis The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning. A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? - Apply topical analgesic cream to the site 1 hr prior to the procedure. The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted. A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? - Epinephrine This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs. A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching? - "I should keep my child indoors when I mow the yard." The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks. A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? - White rice The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease. A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? - Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity. A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take? - Perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease. A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? - Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider. A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? - Loud, harsh murmur The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle. A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? - Implement seizure precautions for the infant. An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child. A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? - Serum creatinine 3.0 mg/dL Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney. A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? - Substernal retractions When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure. A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make? - "Let's talk about some of the ways you have handled previous stressors in your life." This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation. A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? - A. The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness. A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy. Which of the following lab values should the nurse report to the provider? - Hgb 8.5 g/dL A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider. A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" Which of the following responses should the nurse make? - "You can sign the consent form because you are married." The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age. A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? - Cuts an outlined shape using scissors. [Show Less]
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include... [Show More] in the teaching? a. remove the outer cannula cautiously for routine cleaning b. use tracheostomy covers when outdoors c. use sterile technique when performing tracheostomy care at home d. cleanse irritated skin with full-strength hydrogen peroxide - b. use tracheostomy covers when outdoors -tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? a. the client is receiving formula at room temperature b. the feedings infuse at a slow, continuous drip over 8 hr each night c. the client's caregiver washes out the feeding bag with warm water once every 24 hr d. the client's caregiver flushes the tubing with water before and after administering medications - c. the client's caregiver washes out the feeding bag with warm water once every 24 hr -feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? a. "You would have so much more time to spend with your family." b. "You should consider getting a part-time job or doing volunteer work." c. "Let's talk about how the change in your job status will affect you." d. "Why wouldn't you want to retire and relax?" - c. "Let's talk about how the change in your job status will affect you." -this response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? a. "Is your pain constant or intermittent?" b. "What would you rate your pain on a scale of 0 to 10." c. "Does the pain radiate?" d. "Is your pain sharp or dull?" - d. "Is your pain sharp or dull?" -asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. discuss the risk factors of colon cancer b. focus teaching on what the client will need to do in the future to manage his illness c. provide the client with written information about the phases of loss and grief d. reassure the client that this is an expected response to grief - d. reassure the client that this is an expected response to grief -during the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? a. pad the client's wrist before applying the restraints b. evaluate the client's circulation every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails - a. pad the client's wrist before applying the restraints -the use of restraints without padding can abrade the client's skin, resulting in client injury A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client uses nonacetone nail polish remover c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment - b. the client uses nonacetone nail polish remover -the client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client identifies the location of a fire extinguisher. c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment - b. the client identifies the location of a fire extinguisher. - The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? a. insert the suction catheter while the client is swallowing b. apply intermittent suction when withdrawing the catheter c. place the catheter in a location that is clean and dry for later use d. hold the suction catheter with her clean, nondominant hand - b. apply intermittent suction when withdrawing the catheter -the nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a. administer the medication with the needle at a 45 degree angle b. administer the medication into the client's nondominant arm c. pull the client's skin laterally or downward prior to administration d. massage the injection site after administration - a. administer the medication with the needle at a 45 degree angle -the nurse should insert the needle at a 45-90 degree angle for a subQ injection -the nurse should administer enoxaparin into the abdomen at least 2 inches from the umbilicus -the nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? a. advocacy ensures clients' safety, health, and rights b. advocacy ensures that nurses are able to explain their own actions c. advocacy ensures that nurses follow through on their promises to clients d. advocacy ensures fairness in client care delivery and use of resources - a. advocacy ensures clients' safety, health and rights -advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care A nurse is administering an otic medication to an older adult. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. press gently on the tragus of the client's ear b. pack a small piece of cotton deep into the client's ear canal c. move the client's auricle down and back toward her head d. tilt the clients head backward for 5 min - a. press gently on the tragus of the client's ear -pressing gently on the tragus of the ear will help the medication get into the inner ear A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a. use a bed exit alarm system b. raise four side rails while the client is in bed c. apply one soft wrist restraint d. dim the lights in the client's room - a. use a bed exit alarm system -the nurse should identify that the client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance A nurse is initiating a protective environment for a client who has an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. make sure the client's room has at least six air exchanges per hour b. make sure the client wears a mask when outside her room if there is construction in the area c. place the client in a private room with negative-pressure airflow d. wear an N95 respirator when giving the client direct care - b. make sure the client wears a mask when outside her room if there is construction in the area -an allogenic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment -a protective environment requires at least 12 air exchanges per hour -the nurse should place the client in a private room that provides positive-pressure airflow -the nurse should wear a N95 respirator mask when caring for clients who require airborne precautions, not a protective environment. A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? a. "I can place an extension cord across my living room to plug in my TV." b. "I will hire someone to trim that tree that hangs low over the stairs of my front porch" c. "I will place my alarm clock on my bedroom dresser across the room." d. "I will replace the old throw rug in my kitchen with a new one." - b. "I will hire someone to trim that tree that hangs low over the stairs of my front porch." -clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? [Show Less]
A nurse is reviewing a client's medication administration record and finds that the client has not received a prescribed dose of warfarin for 2 days. which... [Show More] of the following actions should the nurse take first? - Check the client's INR. A nurse manager is presenting an in-service about preventing readmission of clients dues to complications following joint arthroplasty. Which of the following leadership tasks is the nurse performing? - Advocay a nurse is teaching an AP about caring for a client who has a DNR order. Which of the following statements by the AP indicates an understanding of the teaching? - "I will call for the client's nurse to come to the room if I cannot detect the client's pulse." The AP should contact the nurse for further assessment whenever a client's condition does not meet expected findings. The client who has a DNR order in place does not require resuscitation. A nurse is caring for four clients. Which of the following tasks can the nurse assign to an AP? - Perform chest compressions on a client who is in cardiac arrest. The nurse should assign an AP to perform chest compressions on a client who is in cardiac arrest. Performing basic CPR is within an AP's range of function. A Nurse is teaching a newly licensed nurse about using electronic medical records. which of the following statements by the newly licensed nurse indicated an understanding of the teaching? - "My access to client electronic medical records may be tracked by my nurse manager." The nurse should keep her password private and not share it with anyone else to decrease the risk for a breach of client confidentiality.The nurse should expect her employer to track access of client records to ensure client confidentiality.While a client has the right to read his medical record, and the nurse can allow him to do so by following facility protocol, a client's partner does not have that right unless granted by the client.The nurse should log out of the electronic medical record when not actively using it. Failure to log out increases the risk for breach of client confidentiality. a nurse is receiving change-of-shift report. which of the following clients should the nurse assess first? - A client who had abdominal surgery 6 hours ago and had a heart rate of 120/min for the last 2 hours. A RN delegates the task of obtaining the bp of a client who is 2hr post-op following a cholecystectomy to a LPN. The LPN reports a BP that is significantly higher than the clients previous reading. which of the following actions should the RN take first? - Recheck client's BP A public health nurse is developing a list of recommendations for her supervisior on how to use EBP to improve community outcomes. Which of the following should the nurse recommend as a qualitative research method? - Phenomenology Meta-analysis is a quantitative research method that provides a statistical analysis of multiple studies conducted on the same topic.Experimental study is a quantitative research method that uses control and treatment groups to test at least one independent variable.Phenomenology is a qualitative research method that provides additional understanding of participants' experiences with emotional variances, such as grief and hope.Secondary analysis is a quantitative research method that uses previously collected data to answer newly formed hypotheses. A nurse at a urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take to ensure care is provided according to policy? - Report this issue to the nurse manager. The nurse should report this issue to the nurse manager because it is the manager's responsibility to ensure that standards are met and that care is provided according to policy. A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? - "These will outline my wishes for medication treatment." The purpose of advance directives is to outline the client's wishes if they become unresponsive A nurse is caring for a client who recently learned he has a mutation of the BRCA2 gene. The client states that he does not plan to tell his adult children about the dx. Which of the following responses displays clients advocacy by the nurse? - "Let's review what you understand about this test result." The nurse should use therapeutic communication techniques to encourage the client to share his point of view and to convey respect for the client's decisions. By seeking to understand the client's perceptions in a nonjudgmental manner, the nurse is displaying client advocacy. A nurse is caring for a client who has breast cancer and is deciding on a plan of treatment. which of the following statements should the nurse make? - "Let's talk about the benefits of each treatment." Talking about the benefits of each treatment option supports the right of the client to make decisions regarding treatment and encourages comparison of the treatments. A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease? - Chlamydia trachomatis According to the Centers for Disease Control and Prevention, Chlamydia trachomatis is a nationally notifiable infectious disease in all 51 jurisdictions. The nurse should notify the state health department, which monitors and controls communicable diseases. A staff nurse detects alcohol on the breath of another nurse working on the unit. The staff nurse observes that the nurse's speech is slurred and their gait is unsteady. Which of the following actions should the nurse take? - Notify the charge nurse of the nurse's behavior. The charge nurse is responsible for the performance of the nurses on the shift; therefore, the staff nurse should follow the chain of command and notify the charge nurse about the nurse's behavior. A nurse overhears two staff members in the facility elevator discussing a clients care. which of the following actions should the nurse take? - Report the incident to the nurse manager. A Nurse manager is reviewing the stages of conflict resolutions with the nursing staff. The nurse manager should instruct the staff to expect the stages of conflict to occur in what order? STEPs: - 1. Latent Conflict. 2. Perceived Conflict 3. Felt Conflict 4. Manifest Conflict. 5. Conflict Aftermath A nurse is planning discharge care for a client who has rheumatoid arthritis and has difficulty buttoning clothing. Which of the following referrals should the nurse recommend for the client? - Occupational Therapy A nurse has just received report on four clients on a med-surg unit. which of the following clients should the nurse plan to assess first? - A client who is post-op following a total knee arthroplasty and has a cap. refill of 4 secs. A nurse is caring for several clients. which of the following actions should the nurse take to maintain client confidentiality - Tell a client's partner that the clients lab test cannot be disclosed without permission. A Charge Nurse is delegating tasks on a nursing unit that is short staffed. A client has a prescription for a wound irrigation twice per day. Which of the following actions should the CN take? - Assign the procedure to a LPN A nurse on a med-surg unit is terminally ill. which of the follwoing actions demonstrates that the nurse is practicing in an ethical manner when caring for the client? - Discuss end-of-life goals with the client. A nurse is teaching about the patient protection and affordable care act and their rights regarding insurance coverage. which of the following statements by the client indicates an understanding of the teaching? - "My insurance coverage no longer has lifetime coverage limits." A nurse is delegating tasks for a group of clients to an AP. Which of the following statements by the nurse provides the right direction of communication with the AP? - "Tell me what time the client in room 205 voids for the first time after catheter is removed." A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2hr. The client tells the nurse that she has called a taxicab and is leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next? - Inform the client about the risks she may encounter by leaving the facility. [Show Less]
A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is t... [Show More] he priority for the nurse to provide? A. Admitting diagnosis B. Breath sounds C. Body Temperature D. Diagnostic test results - B. Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A. Rinse the feeding bag with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30º. C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol. - B. Tell the client to keep the head of the bed elevated at least 30º. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in a room with negative pressure airflow. B. Wear gloves when assisting the client with oral care. C. Limit each visitor to 2-hr increments. D. Wear a surgical mask when providing client care. E. Use antimicrobial sanitizer for hand hygiene. - A, B, E A. Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. B. Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. C. Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room. D. Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions. E. Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled. A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? A. Touch the face with a cotton ball. B. Apply a vibrating tuning fork to the client's forehead. C. Have the client stand with their arms at their sides and their feet together. D. Perform direct percussion over the area of the kidneys. - C. Have the client stand with their arms at their sides and their feet together. A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance. A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? A. 92 mm Hg B. 102 mm Hg C. 112 mm Hg D. 122 mm Hg - D. 122 mm Hg To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff. A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg - B. 0.3 mg The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg. A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? A. "I can take echinacea to improve my immune system." B. "I can take feverfew to reduce my level of anxiety." C. "I can take ginger to improve my memory." D. "I can take ginkgo biloba to relieve nausea." - A. "I can take echinacea to improve my immune system." Echinacea is taken to promote immunity and reduce the risk of infection. A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? A. Place a pillow under the client's knees. B. Position a trochanter roll under each of the client's hips. C. Advise the client to wear rubber-soled slippers. D. Apply an ankle-foot orthotic device to the client's feet. - D. Apply an ankle-foot orthotic device to the client's feet. The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress. A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A. Insert an implanted port. B. Close a laceration with sutures. C. Place an endotracheal tube. D. Initiate an enteral feeding through a gastrostomy tube. - D. Initiate an enteral feeding through a gastrostomy tube. [Show Less]
A nurse is submitting a dietary request for a client who devoutly follows Mormon dietary practices. The nurse should ask the client if they would like whic... [Show More] h of the following foods or beverages excluded from meals? A. Bacon B. Coffee C. Shrimp D. Milk - B. Coffee A nurse is assessing a client who has a rash on their hands and forearms after working in a garden. The nurse should identify that which of the following findings indicates contact dermatitis? A. Pustules in a scatter pattern across the erythematous area B. Elevations of the skin with darkened areas and irregular borders C. Well-defined margins of the erythematous area D. Straight, black, threadlike lesions - C. Well-defined margins of the erythematous area A home health nurse is teaching a client about fire extinguishers. Which of the following instructions should the nurse include in the teaching? A. Store a fire extinguisher next to the kitchen stove. B. Call the fire department before using a fire extinguisher. C. Use a class A extinguisher to put out an electrical fire. D. Aim the hose of the fire extinguisher toward the top of the flames. - B. Call the fire department before using a fire extinguisher. A nurse is performing a fall risk assessment for a client. Which of the following findings should the nurse identify as a fall risk? A. The client uses a raised toilet seat. B. The client takes a flaxseed supplement. C. The client looks at the ground while walking. D. The client has a history of urinary frequency. - D. The client has a history of urinary frequency. A client who has a history of urinary frequency is at risk for a fall due to frequently getting out of bed at night to go to the bathroom. The nurse should place a commode next to the client's bed to reduce the risk for injury A nurse is assessing a 10-month-old infant who has a urinary tract infection (UTI). which of the following findings should the nurse expect? A. Decreased appetite B. Generalized rash C. Decreased respiratory rate D. Constipation - A. Decreased appetite Manifestations of a UTI in an infant include poor feeding, irritability, fever, and vomiting A nurse is preparing to administer acetaminophen drops 60 mg PO to an infant who has a fever. The amount available is 160mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a training zero.) - 1.9mL A nurse is teaching a client to self-administer 8 units of NPH insulin and 2 units of regular insulin in the same syringe. Which of the following client statements indicates an understanding of the teaching? A. "I'll draw up regular insulin into the syringe before the NPH insulin." B. "I'll inject air into the regular insulin vial before the NPH vial." C. "I'll inject 10 units of air into the regular insulin vial." D. "I'll inject 10 units of air into the NPH insulin vial." - A. "I'll draw up regular insulin into the syringe before the NPH insulin." A nurse on a mental health unit is planning an in-service for a newly hired staff about the use of restraints. Which of the following information should the nurse include? A. Document a client's condition every 15 min while in restraints. B. Request a prescription for PRN restraints for a client who has a history of violence. C. Restrain a client as a consequence of not following rules on the unit. D. Limit the time an adult client is in restraints to 5 hr. - A. Document a client's condition every 15 min while in restraints. A nurse is a part of an informatics committee to improve safety with medications administration. Which of the following recommendations should the nurse make to decrease the risk of errors at the bedside? A. Disable Internet access from computers used for medication administration. B. Use an electronic medication administration record for documentation. C. Create a computer-specific password that staff share for each computer on the unit. D. Ask providers to handwrite prescriptions that are then scanned into the computer. - B. Use an electronic medication administration record for documentation. A nurse is discussing informed consent with a group of newly licensed nurses. Which of the following actions is the responsibility of the nurses when obtaining informed consent? A. Answer a client's questions about the risks of a procedure. B. Provide information about alternative treatment options. C. Explain the steps of the medical procedure documented on the consent form. D. Verify that the client voluntarily gave consent for the procedure. - D. Verify that the client voluntarily gave consent for the procedure A nurse is teaching a client who has a new diagnosis of obstructive sleep apnea. Which of the following statements should the nurse include? A. "Obstructive sleep apnea occurs when you stop breathing for at least 10 seconds." B. "Obstructive sleep apnea is caused by a dysfunction in the brain." C. "Obstructive sleep apnea increases your risk for developing diabetes mellitus." D. "Obstructive sleep apnea causes excessive episodes of deep sleep." - A. "Obstructive sleep apnea occurs when you stop breathing for at least 10 seconds." A nurse is teaching the parent of a 5-month-old infant who is breastfed about the introductions of complementary foods. Which of the following statements should the nurse make? A. "Wait until your baby is 8 months old to begin solid foods." B. "Start by spoon-feeding your baby ¼ cup of a new food." C. "Introduce up to three new foods to your baby every week." D. "Give your baby iron-fortified infant rice cereals before starting other foods." - D. "Give your baby iron-fortified infant rice cereals before starting other foods." A nurse is teaching a group of newly licensed nurses about using abbreviations when transcribing prescriptions. Which of the following transcriptions should the nurse use as an example of the correct usage of abbreviations? A. Eszopiclone 1 mg PO hs PRN for sleep B. Nebivolol 5 mg PO OD C. Atorvastatin 20 mg PO qd D. Docusate sodium 100 mg PO bid - D. Docusate sodium 100 mg PO bid A nurse is preparing an in-service on different types of pain. Which of the following information should the nurse plan to include as a characteristic of acute pain? A. It can lead to social isolation. B. It is part of the body's attempt to protect itself. C. It lasts for an extended duration. D. It has no identifiable physical cause. - B. It is part of the body's attempt to protect itself. A nurse is teaching about applying the National Patient Safety Goals to reduce health care-associated infections in clients. Which of the following information should the nurse include in the teaching? A. Insert an indwelling catheter in clients who are incontinent. B. Use a safety razor to remove hair from surgical sites. C. Bathe clients using a chlorhexidine solution. D. Reposition clients who are immobile every 4 hr. - C. Bathe clients using a chlorhexidine solution. A nurse is teaching a client about carbon monoxide and home safety. The nurse should instruct the client that which of the following is a manifestation of carbon monoxide exposure? A. Rotten-egg odor B. Metallic taste C. Paresthesia D. Blurred vision - D. Blurred vision A nurse is providing change-of-shift report on a client using Situation Background Assessment Recommendation (SBAR) communication tool. The nurse should identify which of the following information is included in the background step? A. Admission diagnosis B. Current problem C. Recent vital signs D. Suggested nursing interventions - A. Admission diagnosis A nurse is using the SOAP format to document in the electronic medical record of a client who is 2 days postoperative following an open cholecystectomy. Which of the following entries should the nurse practice in the "A" portion of the SOAP progress note? A. "Respiratory rate 22. Temperature 99.8º F. O2 sat 92%. Lung sounds diminished in bases bilaterally. Has not ambulated or used incentive spirometer since last evening." B. "Client states, 'I've been coughing up some thick mucus this morning.'" C. "Set up ambulation schedule and offer incentive spirometer hourly during the day and when awake at night." D. "Ineffective airway clearance due to inadequate use of spirometer. - D. "Ineffective airway clearance due to inadequate use of spirometer. A nurse is performing a health screening assessment on a client. Which of the following findings should the nurse identify as a risk factor for developing colorectal cancer? A. History of polyps B. History of GERD C. History of a high-fiber diet D. History of an inguinal hernia - A. History of polyps A nurse is discussing a wellness approach to preventing excessive nutrition intake with a group of clients. Which of the following statements should the nurse make? A. "Keep a record of cues that trigger a desire to eat." B. "Use distractions to decrease the pleasure associated with eating." C. "Eat on a regular schedule, even if you are not hungry." D. "Consume most of your calories in the evening." - A. "Keep a record of cues that trigger a desire to eat." A nurse is preparing to administer enoxaparin to a client via subcutaneous injection. Which of the following actions should the nurse take? A. Expel the air from the syringe before administering the medication to the client. B. Administer the medication in the client's abdomen. C. Inject the needle at a 30° angle into the client's skin. D. Rub the injection site after administering the medication to the client. - B. Administer the medication in the client's abdomen. A nurse is applying a bed safety monitoring device for a client. Which of the following actions should the nurse take? A. Position the sensor pad below the client's calves. B. Place the sensor pad under the bottom sheet. C. Set the time delay for 20 seconds. D. Connect the sensor pad to the call system. - D. Connect the sensor pad to the call system. A public health nurse is preparing to care for a community that has a large population of clients who practice the Islamic faith. Which of the following practices should the nurse anticipate when care for clients in this community? [Show Less]
A nurse is assessing a preschooler who has a UTI. Which of the following should the nurse inspect? A. Diarrhea B. Abdominal Pain C. Increased Thirst ... [Show More] D. Skin Rash - B. Abdominal Pain Other manifestations include constipation, dysuria, foul-smelling urine, fever A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent GI cancers. Which of the following images indicated a food or beverage the nurse should encourage? A. Wine B. Fruit C. Fried Chicken D. Bread - B. Fruit Consume at least 2.5 cups of fruit and vegetables per day to help reduce the risk of cancers of the GI system A nurse is preparing to extinguish a small fire in a client's room. Which of the following actions should the nurse take? A. Aim the extinguisher at the top of the flames B. Pump the handles of the extinguisher up and down three times C. Sweep the fire extinguisher in a circular motion until fire is extinguished D. Slide the pin on the top of the fire extinguisher straight out - D. Slide the pin on the top of the fire extinguisher straight out A nurse is caring for a child who has celiac disease. Which of the following items should be removed from the meal tray? A. Corn-flake cereal B. Orange juice C. Scrambled eggs D. Oatmeal with raisins - D. Oatmeal with raisins Celiac disease is the intolerance to dietary gluten, which is a protein in wheat, rye, oats, and barley. This intolerance causes diarrhea, weight loss, abdominal pain, and fatigue A nurse at a provider's office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the clients preferences into sleep promotion plan? A. "If alcoholic beverages are desires, consume them in the early evening" B. "Sleep in the location of your home where you feel you rest best." C. "Turn on a favorite television show just before going to bed." D. "Allow your sleep and wake times to vary depending on how you feel each day." - B. "Sleep in the location of your home where you feel you rest best." Whether it be a bed, couch, or chair A nurse is assessing the spiritual wellbeing and development of a preschooler. The nurse asks "why is it wrong to kick your baby sister?" Which of the following responses should the nurse expect? A. "Its not wrong because she made me mad" B. "Its wrong because my dad said I cant kick her" C. "It wrong to kick her because the gods wont like it" D. "Its wrong because she would get hurt and be sad" - B. "Its wrong because my dad said I cant kick her" The nurse should expect the preschooler to be motivated to choose right from wrong because of rules taught to him by his parents. The nurse should understand that, even though the preschooler might know the rules, he is not yet able to understand the rationale for the rules A nurse in a long-term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take? A. Inform the client that he will not be receiving medications he took prior to his hospitalization B. Compare a list of the clients current medications with the ones he will take in long-term care C. Eliminate any OTC products from the clients current medication list D. Omit the medication indications when listing the clients medication dose information - B. Compare a list of the clients current medications with the ones he will take in long-term care The Joint Commission National Patient Safety Goals regarding medication reconciliation includes maintaining and communicating accurate client medication information. The nurse should complete a medication reconciliation to identify and resolve any discrepancies by comparing the client's list of current medications with the medications he will take in the long-term care facility and addressing any duplications, omissions, or interactions A nurse is caring for a client who is 2 days postoperative following an above-the- knee amputation. The client states he is experience in a dull, burning pain in the leg that was amputated. Which of the following should the nurse take to treat the client's neuropathic pain A. Inform the client that phantom limb pain is not real B. Administer a beta-blocking medication to the client C. Place the client on a soft mattress D. Loosen the bandage on the client's residual limb - B. Administer a beta-blocking medication to the client This classification of medication has been shown to relieve the phantom limb pain manifestations of constant dull and burning type pain A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the rolling statements by the parent indicates an understanding of the teaching? A. "I can offer her grapes as long as I peel them first?" B. "I can give her watermelon pieces after I remove the seeds." C. "I should give her popcorn that is air-popped and without salt or butter." D. "I should cut hot dogs into thin, round slices before giving them to her." - B. "I can give her watermelon pieces after I remove the seeds." The nurse should inform the parent that toddlers can easily choke on seeds from fruits, such as watermelon seeds or cherry pits, because of their round shape and size. Removing the seeds and cutting the watermelon into pieces provides the toddler with a nutritious snack that does not increase the toddler's risk of foreign body obstruction A nurse is searching electronic databases for clinical research about behavior indications of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue A. Cumulative Index to Nursing and Allied Health Literature (CINAHL) B. The Nursing Minimum Data Set C. The Omaha System D. The Nursing Intervention Classification (NIC) - A. Cumulative Index to Nursing and Allied Health Literature (CINAHL) A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? A. Delay the clients meal-time if he is fatigued B. Instruct the client to tilt his head to the side when swallowing C. Assist the client with fluid intake by inserting it into the client's mouth with a syringe D. Encourage the client to focus on a television program during mealtime - A. Delay the clients meal-time if he is fatigued A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for ambulation. Which of the following actions should the nurse take when using this test? A. Observe the client ambulating a distance of 3m(10 feet) during the TUG test B. Instruct the client to perform the TUG test without the use of the cane C. Assist the client to stand up from the chair when starting the TUG test D. Advise the client to use the arms of the chair to stand when starting the TUG test - A. Observe the client ambulating a distance of 3m(10 feet) during the TUG test The nurse should instruct the client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. The nurse should observe the client's ability to perform the test and use a stopwatch to time the client. The nurse should identify that the client is at increased risk of falls if it takes longer than 14 seconds to complete the test A nurse in an emergency room is caring for an infant who required emergency surgery. The infant is accompanies by his 16 year old mother and his sternal grandfather. Which of the following should the nurse take when assisting with informed consent A. Witness consent obtained from the infants mother B. Inform the family that informed consent is not needed due to the emergency surgery C. Notify the maternal grandfather that he is required to give informed consent D. Request that a court-appointed representative provide consent - A. Witness consent obtained from the infants mother The nurse should assist in obtaining informed consent from the infant's mother by witnessing her signature. Statutory guidelines indicate that a minor, even if unemancipated, can provide consent for her infant A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan A. Change bags of IV solution every 72 hours B. Perform hand hygiene before touching the IV tubing C. Use hydrogen peroxide to cleanse the IV insertion site D. Assess the IV insertion site every 12 hours for redness - B. Perform hand hygiene before touching the IV tubing A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to The parent? [Show Less]
1. A nurse is orienting a newly licensed nurse to the procedure involved in obtaining informed consent. The nurse knows informed consent is based on the et... [Show More] hical principle of - autonomy. 2. By the middle of a shift, two of the three nurses working have gone home ill, leaving the nursing unit short staffed. Which of the following is the most appropriate action for the charge nurse? - Call the nursing supervisor and request additional staff. 3. Which of the following observations made by a nurse should be reported to the nurse manager as a violation against HIPPA? - Talking about clients with other nurses in the cafeteria 4. An RN is part of a team that consists of a licensed practicval nurse (LPN) and an assistive personnel (AP). One of the clients the team is assigned to care for has a small bowel obstruction and is NPO with a nasogastric (NG) tube set to continuous drainage. Which of the following tasks must be retained by the RN? - Assess for bowel sounds every 2 hr. 5. A nurse manager calls a meeting of the unit's staff members to discuss cost containment issues. The nurse manager has asked for member input regarding strategies that might help reduce costs. The nurse understands that this is an example of which of the following types of leadership? - Democratic 6. A client receiving care from a home health nurse asks what is included in a living will. The nurse explains that a living will is a document that - allows the client to express personal wishes regarding health care decisions 7. A nurse is completing a variance (or incident) report after administering an incorrect dose of medication to a client, even though the client experienced no ill effects from the error. The nurse should understand that the purpose of completing the variance report is to - identify situations that contribute to the occurrence of mediation errors. 8. An assistive personnel (AP) who appears to be under the influence of alcohol reports to duty on the night shift. Which of the following is an appropriate response by the charge nurse? - Ask the nursing supervisor to observe the AP and validate the charge nurse's suspicions. 9. A nurse is concerned that some of the behaviors of the night charge nurse seem to be unprofessional. The charge nurse repeatedly asks the nurse for assistance with client care and brushes up against the nurse during the completion of the tasks. One night, the charge nurse asks the nurse to go out on a date and indicates that a sexual relationship between them would mean a better schedule for the nurse. The first action that the nurse should take in this situation is to - tell the charge nurse in clear terms that this conduct is causing feelings of discomfort and that the behaviors are to stop immediately. 10. An adult client who has an injury that requires immediate surgical intervention is being transferred from a small, rural hospital to a Level I emergency department. The client has been medicated during transport with intravenous meperidine (Demerol). The receiving nurse understands that consent for the surgery - should be obtained [Show Less]
1. Which of the following actions must be performed by RN? - Initial admission assessment. 2. Which of the following actions should the nurse take to co... [Show More] llect information? - Conduct a retrospective audit for the past 6 months. 3. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (incident reports) - "Incident reports are for unexpected client occurrences." 4. Which of the following should the nurse recommend as a qualitative research method? - Phenomenology. 5. Which of the following conditions is considered a nationally notifiable infectious disease? - Chlamydia. 6. Which of the following actions should the charge nurse take? (delegating wound care) - Delegate wound irrigation to LPN. 7. Which of the following actions demonstrates that the nurse is practicing in an ethical manner when caring for the client? - Discuss end-of-life care goals with the client. 8. Which of the following actions should the nurse take? (alcohol on breath) - Notify the charge nurse of the nurse's behavior. 9. Which of the following actions should the RN take first? (LPN gets high BP reading) - Recheck the patient's blood pressure. 10. Which of the following actions should the nurse take to validate that the client understands the procedure? (informed consent) - Ask the client to verbalize the purpose, risks, and benefits of the procedure. 11. Which of the following assessment findings should the nurse recognize as the priority to report to the charge nurse? - A client who is 2 days postoperative and has a urine output of 20 ml/hr. 12. Which of the following responses displays client advocacy by the nurse? - "Let's review what you understand about this test result." 13. Which of the following interventions should the charge nurse ensure is part of the plan of care? (NG tube feeding) - Use a 60 ml syringe to flush out a clogged tube. 14. Which of the following statements by the nurse provides the right direction of communication with the AP? - "Tell me what time the client in room 205 voids for the first time after the catheter is removed." 15. Which of the following statements by the AP indicates an understanding of the teaching? (DNR) - "I will call for the client's nurse to come to the room if I cannot detect the client's pulse." 16. Which of the following actions should indicate to the charge nurse that the nurse understands how to use the device? Select all that apply. (Aquathermia pad) - Ask the client to report if the aquathermia pad gets too warm. Ensures that the client's call light is in reach. 17. Which of the following referrals should the nurse recommend for the client? (Rheumatoid arthritis) - Occupational therapy. 18. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? (restraints) - "I should request the provider to examine the client within 1 hours of applying mechanical restraints." 19. Which of the following communication tools should the nurse use for management of this complication? (adverse effects) - SBAR framework. [Show Less]
Steps in Providing Educational Programs - 1) ID and Respond: to ID the need for knowledge or skill proficiency 2) Analyze: Deficiencies, develop lear... [Show More] ning objectives to meet need 3) Research: Resources available to address learning objectives based on EBP 4) Plan: Program to address objectives using available resources 5) Implement: Program at time conducive to staff-> online learning modules 6) Evaluate: Use materials and observations to measure behavior change secondary to learning The Five stages of Nursing Ability - Established by Patricia Benner (1984) Novice Nurse Advanced Beginner Nurse Competent Nurse Proficient Nurse Expert Nurse Novice Nurses - Can be students or newly licensed nurses who have minimal experience. They approach situations from theoretical perspective relying on context-free facts and established guidelines. Rules govern practice Advanced beginner - Most new nurses function at this level. Practice independently in the performance of many tasks, make some clinical judgements. They being to rely on prior experience to make practice descisions Competent Nurse - Usually have been in practice for 2-3 years. Increasing level of skill and proficiency and clinical judgement. They exhibit the ability to organize and plan care using abstract and analytical thinking. They can anticipate long term outcomes of personal actions. Proficient Nurse - These are nurses who have a significant amount of experience upon which to base their practice. Enhanced observational abilities allow nurses to be able to conceptualize situations more holistically. Well-developed critical thinking and decision making skills allow nurses to recognize and respond to unexpected changes. Expert Nurse - great experience that allows them to view situations holistically and process information efficiently. Make decisions using an advanced level of intuition and analytical ability. They do not need to rely on rules to comprehend and take action in a situation. Leadership Styles - Authoritative Democratic laizzez-faire Leadership - Ability to inspire others to achieve a desired outcome Management - Process of planning, organizing, directing, and coordinating the work with an organization Characteristics of Managers - Hold formal position of authority and power Possess clinical experience Network with members of the team Coach subordinates Makes decisions about organizing function, including resources, budget, hiring, and firing. Five Major management Functions - Organizing Staffing Directing Controlling (eval of staff performance and eval of unit goals to ensure identified goals are being met) Authoritative - Makes decisions for the group Motivates by coercion Communications occurs down the chain of command Work output by staff is usually high: *Good for crisis situations** Effective for employees with no education Democratic - Includes the group when decisions are made Motivates by supporting staff achievements Communication occurs UP and DOWN chain of command Work output is good quality: when cooperation and collaboration is necessary Laissez-faire - makes very few decisions, does little planning motivation is largely the responsibility of individual staff members communication occurs UP and DOWN the chain of command and between group members Work output is low unless and informal leader evolves from the group Effective with professional employess [Show Less]
An RN has to teach the client initially but can delegate ________to an LPN. - reinforcing the teaching An LPN can perform ______care. - tracheostomy car... [Show More] e Can an RN delegate to an LPN to perform suctioning? - yes Can an RN delegate to an LPN to put in a urinary catheter? - yes Can an RN delegate to an AP to feed a client not on swallow precautions? - yes Is an RN allowed to delegate to an AP to collect a urine sample? - yes A nurse delegates to an AP to assist in obtaining vital signs from a postop patient who required naloxone (narcan) for depressed respirations. Is this an appropriate task for the AP? - no An older adult client who is on fall precautions is found lying on the floor of his hospital room. Which of the following actions is most appropriate for the nurse to take first? A. Call the client's provider B. Ask a staff member for assistance getting the client back in bed C. Inspect the client for injuries D. Ask the client why he got out of bed w/out assistance - C. Inspect the client for injuries An RN on a med-surg unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the LPN? A. Obtain vitals for a client who is 2 hr postop following a cardiac cath B. Administering a unit of PRBCs C. Instructing a client in the performance of wound care D. Developing a plan of care for a newly admitted client - A A nurse is caring for an older adult client who has left the unit for a radiology procedure. The client's son asks the nurse what med is being given to the client. Which of the following is an appropriate response by the nurse? A. "I am sorry, but that is information you will need to ask your mother or her doctor." B. "Your mother is taking famotidine (Pepcid) for the ulcer & lorazepam (Ativan) for anxiety." C. "You will need to ask the charge nurse for that info." D. "Don't worry. We will give your mother all pertinent info before discharge." - A. A nurse works in a mental health facility that uses a case management nursing model to provide care. The nurse should recognize that which of the following describes a case management approach to care? A. A nurse provides total care for several clients B. Collaboration between disciplines creates a multidisciplinary care plan for each client. C. The focus of care is on detecting disorders at an early stage. D. The team leader assigns care for a group of clients - B A nurse overhears a client talking with an attorney, reporting physical abuse, use of restraints & denial of meals. What action should the nurse take? A. Report the conversation to the nurse manager to allow for follow-up investigation. B. Question the client about the allegations to identify staff who were allegedly involved. C. Ignore the conversation unless the client brings it to the attention of the nurse. D. Recognize this as a privileged communication that cannot be discussed w/anyone. - A A nurse manager is planning a department meeting to discuss client advocacy. Which of the following situations should be included in the discussion? Select all that apply. A. Discussing treatment options w/a client who was pancreatic cancer B. Notifying the surgeon when a client signing a surgical consent form has questions about the procedure C. Helping a client make a list of questions she would like to ask the provider D. Clarifying the dosage of a med prescribed for an older adult client who has impaired liver function E. Carrying out end-of-life wishes outlined in the living will of an older adult - B, C, D, E A nurse is assessing a client's negligible progress in following a weight loss program. Which of the following is a likely reason the client was unable to achieve a short-term goal established during the planning phase of the nursing process? A. The goals were realistic & formulated w/client input. B. The underlying problem behind past weight gain was misidentified. C. The implementation of the plan used flexibility in following the nursing actions D. The nurse obtained objective & subjective data during the assessment. - B A nurse has prepared an IM injection for a client who is preoperative, when another client suddenly calls for assistance. The nurse asks an LPN to give the injection since an AP is waiting to take the client to surgery. Which of the following is an appropriate action by the LPN? A. Prepare a new syringe for the client who is preop B. Give the prepared med to the client who is preop C. Help the client requesting assistance so the nurse can give the prepared injection D. Report this request to the charge nurse - C [Show Less]
A nurse enters the room of a client and finds the client lying on the floor. Which of the following actions should the nurse take first? A. Call the provi... [Show More] der B. Ask a staff member for assistance getting the client back to bed C. Inspect the client for injuries D. Instruct the client to ask for help if they need to get out of bed - C. Inspect the client for injuries A RN on a medical-surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the PN? A. Obtain vital signs for a client who is 2 hour postprocedural following a cardiac catheterization B. Administer a unit of PRBCs to a client who has cancer C. Instruct a client who is scheduled for discharge in the performance of wound care D. Notify the nurse manager - A. Obtain vital signs for a client who is 2 hour postprocedural following a cardiac catheterization A PN ending their shift reports tot eh RN that a newly hired AP has not calculated the intake and output for several clients. Which of the following actions should the nurse take? A. Complete an incidence report B. Delegate this task to the PN C. Ask the AP if they need assistance D. Notify the nurse manager - C. Ask the AP if they need assistance A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following information should the manager include in the plan? (Select all that apply) A. Skill proficiency B. Assignment to a preceptor C. Budgetary principles D. Computerized charting E. Socialization into unit culture F. Facility policies and procedures - A. Skill proficiency B. Assignment to a preceptor D. Computerized charting E. Socialization into unit culture F. Facility policies and procedures A nurse manager is providing information about the audit process to members of the nursing team. Which of the following information should the nurse manager include? (Select all that apply). A. A structure audit evaluates the setting and resources available to provide care B. An outcome audit evaluates the results of the nursing care provided C. A root cause analysis is indicated when a sentinel even occurs D. Retrospective audits are conducted while the client is receiving care E. After data collection is completed, it is compared to a benchmark - A. A structure audit evaluates the setting and resources available to provide care B. An outcome audit evaluates the results of the nursing care provided C. A root cause analysis is indicated when a sentinel even occurs E. After data collection is completed, it is compared to a benchmark A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following information will provide data regarding the efficacy of the procedure. A. Frequency with which procedure is performed B. Client satisfaction with performance of procedure C. Incidence of complications related to procedure D. Accurate documentation of how procedure was performed - C. Incidence of complications related to procedure A nurse if hired to replace a staff member who has resigned. After working on the unit for several weeks, the nurse notices that the unit manager does not intervene when there is conflict between team members, even when it escalates. Which of the following conflict resolution strategies is the manager demonstrating? [Show Less]
The ______________ _____________ is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline; outlines what th... [Show More] e team must complete in a timely manner to achieve *desired client outcomes & an appropriate length of stay for that particular dx*; *cost effective care* - critical pathway ___________ leaders use rewards to motivate followers and maintain status quo - transactional _______________ leaders empower followers to assume responsibility for communal vision, and personal development is a secondary outcome - transformational 5 Major Management functions - planning, organizing, staffing, directing, controlling The nurses uses ___________ _____________ to determine client outcomes desired and/or achieved as indicated by evidence-based practices - clinical judgment Process of transferring authority, accountability, and responsibility of client care to another member of the health care team - assigning Process of transferring authority and responsibility to another team member *to complete a task*, while retaining accountability - Delegating Process of directing, monitoring, and evaluating performance of tasks by another member of the health care team. RNs are responsible for the supervision of client care tasks delegated to APs and PNs - supervising Can a nurse delegate checking NG tube patency to a PN? - yes Can a PN insert a foley? - yes Can a PN perform trach care and suction? - yes Can a PN perform client teaching? - NO (they can reinforce it) 5 delegation rights - Right task Right circumstance Right person Right communication Right supervision Which is the correct "right task": "Delegate an AP to assist a client who has PNA to use a bedpan" *OR* "Delegate an AP to administer a nebulizer tx to a client who has PNA" - "Delegate an AP to assist a client who has PNA to use a bedpan" Which is the correct "right circumstance"? "Delegate an AP to measure VS of a client who is post op and stable" *OR* "Delegate an AP to measure VS of a client who is postop and received naloxone" - "Delegate an AP to measure VS of a client who is post op and stable" Which is the correct "right direction"? "Delegate an AP to assist Mr. Martin in room 312 w/ a shower before 0900" *OR* "Delegate an AP to assist Mr. Martin i room 312 w/ morning hygeine" - "Delegate an AP to assist Mr. Martin in room 312 w/ a shower before 0900" -*preceptors*: assigned to newly licensed nurses for limited time -*mentors*: can also serve as preceptor, but relationship lasts longer & focuses more on assumption of professional role & relationships, and socialization into practice -*coaches*: est. collaborative relationship to help a nurse est. specific individual goals. Relationship is often *task related* and *time limited* - --Orientation Plan Should Include-- Skill proficiency Assignment to preceptor Computerized charting Socialization to unit culture Facility policies and procedures Steps in providing educational programs - *Identify and respond:* I'D need for knowledge *Analyze:* Deficiencies, develop learning objectives *Research:* Resources available to address learning objectives based on evidence‑based practice. *Plan:* address objectives using available resources. *Implement:* Program(s) at time conducive to staff attendance; consider online learning modules. *Evaluate:* Use materials and observations to measure behavior changes secondary to learning objectives. When conducting staff development activities, you should always determine what first? - learning needs Quality Improvement Process - *Outcome*: reflect desired client outcomes r/t standard under review *Structure*: setting where care is provided & the available resources *Process*: how care is provided & est. by policies *Benchmarks*: goals set to determine at what level the outcome indicators should be met (*Step 1: Establish best practice guidelines/benchmark*......then data collection... if benchmark is NOT met, do a root cause analysis) __________ indicator measures whether a procedure is effective in meeting the desired benchmark - outcome ________________: made available to employees by way of policies and procedures: Standards Quality Data collection Benchmark - standards _____________ issues: are identified by staff, management, or risk management dept. [Show Less]
A nurse in the ED is performing triage for a group of clients following a MVC. Which of the following clients should the nurse request the provider assess ... [Show More] first? -A client who has a closed leg fracture and reports peripheral paresthesia -A client who reports a sprained ankle and has a laceration over the medial ankle -A client who has arm contusions and manifests asymmetrical thoracic movement -A client who has abrasions to the face and is requesting medication for severe pain - A client who has arm contusions and manifests asymmetrical thoracic movement A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2 hrs. The client tells the nurse that she has called a taxicab and is leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next? -Have the client sign the AMAM form -Inform the client about the risks she may encounter by leaving the facility -Document the client's statements in the medical record -Notify the risk manager - Inform the client about the risks she may encounter by leaving the facility A nurse case manager is planning a teaching session on the use of critical pathways with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching? -Critical pathways promote individualized care -Critical pathways decrease administrative work time -Critical pathways prevent unnecessary expense -Critical pathways incorporate provider preferences - Critical pathways prevent unnecessary expense (answered wrong) A nurse is caring for a client who has an informed consent form for an upcoming procedure in his health record. Which of the following actions should the nurse take to validate that the client understands the procedure? -Review documentation by the provider of discussing the procedure with the client -Verify that the client's signature is on the informed consent form -Ask the client to verbalize the purpose, risks, and benefits of the procedure -Document the client's completed pre-procedure checklist in the medical record - Ask the client to verbalize the purpose, risks, and benefits of the procedure A nurse at an urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take to ensure care is provided according to policy? -Check client satisfaction surveys for feedback on this issue -Post an article on pain assessment on the bulletin board -Document this finding on an incident report -Report this issue to the nurse manager - Report this issue to the nurse manager A client is being discharged with a post-op infection, requiring daily home IV antibiotics through a PICC line. Which of the following actions should the case manager perform prior to discharge? -Assess the client's home environment for possible reservoirs of infection -Verify the patency of the PICC line -Provide dressing change and wound assessment teaching -Ensure home infusion therapy has been arranged - Ensure that home infusion therapy has been arranged (answered wrong) A nurse manager is completing a performance improvement audit and determines documentation of client discharge teaching is below the expected benchmark. Which of the following actions should the nurse implement first? -Offer incentives for the staff once the unit's benchmark is above average -Train specific nurses to use a standard discharge teaching plan -Determine the factors that interfere with the documentation of client education -Include client discharge teaching as part of the annual performance evaluation - Determine the factors that interfere with the documentation of client education A charge nurse is orienting a newly licensed nurse to the facility's policies regarding EMRs. Which of the following statements by the newly licensed nurse indicates an understanding of the instructions? -I will make sure the monitor is turned off when I have to leave the computer terminal -I can share my password with nursing students assigned to my unit -I will allow a client to make changes directly to their medical record -After I finish with the printout of my assignment. I'll put it in the shredder - After I finish with the printout of my assignment, I'll put it in the shredder [Show Less]
A nurse is reviewing a client's medication administration record and finds that the client has not received a prescribed dose of warfarin for 2 days. which... [Show More] of the following actions should the nurse take first? - Check the client's INR. A nurse manager is presenting an in-service about preventing readmission of clients dues to complications following joint arthroplasty. Which of the following leadership tasks is the nurse performing? - Advocay a nurse is teaching an AP about caring for a client who has a DNR order. Which of the following statements by the AP indicates an understanding of the teaching? - "I will call for the client's nurse to come to the room if I cannot detect the client's pulse." The AP should contact the nurse for further assessment whenever a client's condition does not meet expected findings. The client who has a DNR order in place does not require resuscitation. A nurse is caring for four clients. Which of the following tasks can the nurse assign to an AP? - Perform chest compressions on a client who is in cardiac arrest. The nurse should assign an AP to perform chest compressions on a client who is in cardiac arrest. Performing basic CPR is within an AP's range of function. A Nurse is teaching a newly licensed nurse about using electronic medical records. which of the following statements by the newly licensed nurse indicated an understanding of the teaching? - "My access to client electronic medical records may be tracked by my nurse manager." The nurse should keep her password private and not share it with anyone else to decrease the risk for a breach of client confidentiality.The nurse should expect her employer to track access of client records to ensure client confidentiality.While a client has the right to read his medical record, and the nurse can allow him to do so by following facility protocol, a client's partner does not have that right unless granted by the client.The nurse should log out of the electronic medical record when not actively using it. Failure to log out increases the risk for breach of client confidentiality. a nurse is receiving change-of-shift report. which of the following clients should the nurse assess first? - A client who had abdominal surgery 6 hours ago and had a heart rate of 120/min for the last 2 hours. A RN delegates the task of obtaining the bp of a client who is 2hr post-op following a cholecystectomy to a LPN. The LPN reports a BP that is significantly higher than the clients previous reading. which of the following actions should the RN take first? - Recheck client's BP A public health nurse is developing a list of recommendations for her supervisior on how to use EBP to improve community outcomes. Which of the following should the nurse recommend as a qualitative research method? - Phenomenology Meta-analysis is a quantitative research method that provides a statistical analysis of multiple studies conducted on the same topic.Experimental study is a quantitative research method that uses control and treatment groups to test at least one independent variable.Phenomenology is a qualitative research method that provides additional understanding of participants' experiences with emotional variances, such as grief and hope.Secondary analysis is a quantitative research method that uses previously collected data to answer newly formed hypotheses. A nurse at a urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take to ensure care is provided according to policy? - Report this issue to the nurse manager. The nurse should report this issue to the nurse manager because it is the manager's responsibility to ensure that standards are met and that care is provided according to policy. A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? - "These will outline my wishes for medication treatment." The purpose of advance directives is to outline the client's wishes if they become unresponsive A nurse is caring for a client who recently learned he has a mutation of the BRCA2 gene. The client states that he does not plan to tell his adult children about the dx. Which of the following responses displays clients advocacy by the nurse? - "Let's review what you understand about this test result." The nurse should use therapeutic communication techniques to encourage the client to share his point of view and to convey respect for the client's decisions. By seeking to understand the client's perceptions in a nonjudgmental manner, the nurse is displaying client advocacy. A nurse is caring for a client who has breast cancer and is deciding on a plan of treatment. which of the following statements should the nurse make? - "Let's talk about the benefits of each treatment." Talking about the benefits of each treatment option supports the right of the client to make decisions regarding treatment and encourages comparison of the treatments. A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease? - Chlamydia trachomatis According to the Centers for Disease Control and Prevention, Chlamydia trachomatis is a nationally notifiable infectious disease in all 51 jurisdictions. The nurse should notify the state health department, which monitors and controls communicable diseases. A staff nurse detects alcohol on the breath of another nurse working on the unit. The staff nurse observes that the nurse's speech is slurred and their gait is unsteady. Which of the following actions should the nurse take? - Notify the charge nurse of the nurse's behavior. The charge nurse is responsible for the performance of the nurses on the shift; therefore, the staff nurse should follow the chain of command and notify the charge nurse about the nurse's behavior. A nurse overhears two staff members in the facility elevator discussing a clients care. which of the following actions should the nurse take? - Report the incident to the nurse manager. [Show Less]
A nurse enters the room of a client who is on contact precautions & finds the client lying on the floor. Which of the following actions should the nurse ta... [Show More] ke first? A. Call the Provider B. Ask a staff member for assistance getting the client back in bed C. Inspect the client for injuries D. Instruct the client to ask for help if he needs to get out of bed - C An RN on a medical-surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the LPN? A. Obtain vital signs for a client who is 2 hr post procedure following a cardiac catheterization B. Administer a unit of packed red blood cells (RBCs) to a client who has cancer C. Instruct a client who is scheduled for discharge in the performance of wound care D. Develop a plan of care for a newly admitted client who has pneumonia - A An LPN ending her shift reports to the RN that a newly hired assistive personnel has not calculated the intake and output for several clients. Which of the following actions should the RN take? A. Complete an incident report. B. Delegate this task to the LPN. C. Ask the AP if assistance is needed to complete the I&O records. D. Notify the nurse manager - C A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following information should the manager include in the plan? SATA [Show Less]
A chare nurse in an emergency department is informed that a tornado touched down in a nearby town and mass casualties are en route. which of the following... [Show More] actions should the nurse take first? A. Follow Facility policy to activate the disaster plan B. Prepare the triage rooms. C. Obtain additional supplies D. Call in off-duty staff - A is correct The nurse has little information other than that several clients are expected in a short period of time. According to evidenced-based practice, the nurse should first follow the facility's policy for activating the disaster plan (this might mean calling the nursing supervisor or the administrator). The disaster plan will then delineate the role and responsibilities of all responders, ensuring that clients are treated in a safe and orderly manner by an adequate number of caregivers. b. The nurse should prepare the triage rooms to facilitate rapid client prioritization; however, evidencebased practice indicates that the nurse should take a different action first. c. The nurse should obtain additional supplies to ensure the emergency department is stocked and ready for treatment of clients; however, evidence-based practice indicates that the nurse should take a different action first. d. The nurse might need to call in off-duty staff to care for a high number of incoming clients; however, evidence-based practice indicates that the nurse should take a different action first. A nurse is planning to participate in a public educaiton program about prevention of West Nile virus. Which of the following instructions should the nurse include in her presentation?A. "Eliminate sources of standing water." B. "Make sure your immunizations are up to date." C. "Keep all of your pets indoors." D. "Spray insect nests with a repellant that contains DEET." - A is correct Standing water provides an environment for mosquitoes to lay eggs. Therefore, clients should empty water from flower pots, pet food and water dishes, birdbaths, swimming pool covers, buckets, barrels, and cans at least once per week. Discarded tires and other items that collect water should be disposed of. b. There is no known immunization against the West Nile virus; therefore, clients should be educated about other prevention measures. c. West Nile virus is not transmitted through pets, but can be transmitted from person to person through blood products, breast milk, or organ transplantation. d. West Nile virus can be transmitted when an infected mosquito bites a human to take in blood. Diethyltoluamide (DEET) is the most effective and best-studied insect repellent available. Studies using humans and mosquitoes report that only products containing DEET offer long-lasting protection after a single application; however, DEET only repels, it does not kill. There would be no benefit to spraying DEET anywhere except on the human body or clothing [Show Less]
Care of specific populations: Migrants Migrant workers health problems include: - 1. Dental disease 2. TB 3. Chronic conditions 4. Stress, anxiety, & ... [Show More] other mental health conditions 5. Leukemia 6. Iron deficiency anemia 7. Stomach, uterine, & cervical cancers 8. Lack of prenatal care 9. Higher infant mortality rates Primary Prevention for Rural or Migrant Health care: - -educate on measures to reduce exposure to pesticides -teach on accident prevention -prenatal care -mobilize preventative services (dental, immunizations) Secondary Prevention measures for Rural/Migrant Health care: - SCREENING! screen for: -pesticide exposure -skin cancer -chronic preventable diseases -communicable diseases Tertiary Prevention measures for Rural/Migrant Health care: - -treat for symptoms of pesticide exposure -mobilize primary care and emergency servicesClient's rights include... - -right to info disclosure -privacy -informed consent -info confidentiality -participation in treatment decisions Autonomy - respecting a client's right to choose (i.e. refusing chemo) Nonmaleficence - doing no harm Beneficence - maximize benefits and minimize possible harms Justice situation: - determining eligibility for health care services based on income and fiscal resources HIPAA rules about information security: [Show Less]
A home health nurse is visiting with an older adult client. Which of the following observations indicate the need for home modification? A) The home has ... [Show More] power strips that have breakers. B) The client uses an electric toaster oven for cooking. C) There are two rocking chairs in the living room. D) The bathtub has a seat and a hand-held shower head. - There are two rocking chairs in the living room. Reasoning: rocking chairs and swivel chairs will require a modification. The nurse should block the motion of the chairs to keep them stable so that the client can easily get in and out. A case manager is planning an educational program for a client who has diabetes mellitus. Which of the following activities should the nurse include when using the psychomotor domain of learning? A) Review a color diagram of the food pyramid with the client. B) Show the client a video about how to monitor blood glucose levels. C) Observe the client's technique for drawing up insulin. D) Encourage the client to discuss their feelings of self-worth. - Observe the client's technique for drawing up insulin A case manager is developing a discharge plan for a client who has spinal cord injury and is in a rehab facility. Which of the following actions should the nurse take first? A) Hold a care conference with the client to discuss treatment options. B) Contact service providers to determine the availability of services offered. C) Determine the client's ability to perform self-care. D) Evaluate the client's satisfaction with the case manager's services. - Determine the client's ability to perform self-care. Reasoning: The first action the nurse should take when using the nursing process is toassess the client's needs. Determining a client's needs is the first step of the case management process which allows the case manager to plan client-centered care. A nurse is assessing a new client. Which of the following information should the nurse include in the cultural portion of the assessment? A) Food preferences B) Employment status C) History of illnesses D) Sexual orientation - food preferences. Reasoning: food preferences are a part of cultural assessment. A school nurse is teaching health promotion to a group of staff members who sit at a desk and use a computer for 8hr at a time. Which of the following information is the priority for the nurse to include A) "Take a walk after work." B) "Point and flex your toes periodically." C) "Have your visual acuity assessed regularly." D) "Adjust your chair so that your elbows are at desk height." - Point and flex your toes periodically. Reasoning: the greatest risk to staff members who are immobile for long periods of time is a venous thromboemobolism. Therefore, the nurse should encourage the staff members to frequently change the position of their feet and legs. A nurse is collecting demographic data as part of a community assessment. Which of the following information should the nurse include? A) Racial distribution B) Family genograms C) Number of open water sources D) Presence of condemned buildings [Show Less]
A home health nurse is visiting with an older adult client. Which of the following observations indicate the need for home modification? A) The home has ... [Show More] power strips that have breakers. B) The client uses an electric toaster oven for cooking. C) There are two rocking chairs in the living room. D) The bathtub has a seat and a hand-held shower head. - There are two rocking chairs in the living room. Reasoning: rocking chairs and swivel chairs will require a modification. The nurse should block the motion of the chairs to keep them stable so that the client can easily get in and out. A case manager is planning an educational program for a client who has diabetes mellitus. Which of the following activities should the nurse include when using the psychomotor domain of learning? A) Review a color diagram of the food pyramid with the client. B) Show the client a video about how to monitor blood glucose levels. C) Observe the client's technique for drawing up insulin. D) Encourage the client to discuss their feelings of self-worth. - Observe the client's technique for drawing up insulin A case manager is developing a discharge plan for a client who has spinal cord injury and is in a rehab facility. Which of the following actions should the nurse take first? A) Hold a care conference with the client to discuss treatment options. B) Contact service providers to determine the availability of services offered. C) Determine the client's ability to perform self-care. D) Evaluate the client's satisfaction with the case manager's services. - Determine the client's ability to perform self-care. Reasoning: The first action the nurse should take when using the nursing process is toassess the client's needs. Determining a client's needs is the first step of the case management process which allows the case manager to plan client-centered care. A nurse is assessing a new client. Which of the following information should the nurse include in the cultural portion of the assessment? A) Food preferences B) Employment status C) History of illnesses D) Sexual orientation - food preferences. Reasoning: food preferences are a part of cultural assessment. A school nurse is teaching health promotion to a group of staff members who sit at a desk and use a computer for 8hr at a time. Which of the following information is the priority for the nurse to include [Show Less]
A nurse is assessing a new client. Which of the following information should the nurse include in the cultural portion of the assessment? A. Food prefere... [Show More] nces B. Employment status C. History of illness D. Sexual orientation - A. Food preferences Rationale: Fodd preference are a part of a cultural assessment A nurse is preparing an educational program about influenza for a group of community health nurses. Which of the following activities should the nurse include as an example of tertiary prevention. A. Offer classes to elementary school teachers about hand washing B. Provide information to occupational nurses about the reasons for employees to not come to work C. Administer antiviral medications within 48 hr to clients who have manifestations of influenza. D. Provide immunizations at long-term care facilities. - C. Administer antiviral medications within 48 hr to clients who have manifestations of influenza. Rationale: Tertiary prevention involves ways to reduce the complications of illness. Which includes administering antiviral medications to clients who already have influenza.A nurse is collecting demographic data as a part of a community assessment. Which of the following information should the nurse include? A. Racial distribution B. Family genograms C. Number of open water sources D. Presence of condemned buildings - A. Racial distribution Rationale: Racial distribution is part of demographic data. A community health nurse suspects an outbreak of scabies in the local area. Which of the following actions should the nurse take first? A. Educate the community about disease transmission B. Determine the incidence rate C. Institute prophylactic treatment D. Discuss treatment plans with the client's families - B. Determine the incidence rate Rationale: The first action that the nurse should take when using the nursing process is to determine the number of new cases of scabies in the community A public health nurse is planning care for four clients. Which of the following interventions should the nurse recognize as tertiary prevention? A. Providing chemoprophylaxis for malaria to a client who is traveling to mosquito-infested countries. B. Performing a serologicial screening for HIV for a client who is pregnant C. Participating in partner notification for a client who has an STI [Show Less]
A charge nurse in an ED is informed that a tornado touched down in a nearby town and mass casualties are en route. Which of the following actions should t... [Show More] he nurse take first? 1. Follow facility policy to activate the disaster plan. 2. Prepare the triage rooms. 3. Obtain additional supplies. 4. Call in off-duty staff. - 1. Follow facility policy to activate the disaster plan. A nurse is planning to participate in a public education program about prevention of West Nile Virus. Which of the following instructions should the nurse include in her presentation? 1. "Eliminate sources of standing water." 2. "Make sure your immunizations are up to date." 3. "Keep all of your pets indoors." 4. "Spray insect nests with a repellent that contains DEET." - 1. "Eliminate sources of standing water." A nurse is performing a community assessment in a rural setting. Which of the following types of health care should the nurse recognize is most likely to be absent in this setting? 1. Tertiary care 2. Primary prevention 3. Chronic care 4. Secondary prevention - 1. Tertiary care A triage nurse is an ED when several hundred clients who were injured in a train collision arrive at the facility for treatment. The nurse should determine that which of the following requires immediate treatment?1. A client who has neck pain and was transported to the facility on a backboard 2. A client who has epigastric and left-arm pain and is diaphoretic 3. A client who has nasal and orbital ecchymosis and a respiratory rate of 16/min 4. A client who has abdominal pain and is 2 months pregnant - 2. A client who has epigastric and leftarm pain and is diaphoretic A nurse is providing teaching to a client who has a prescription for ciprofloxacin following exposure to anthrax. Which of the following statements by the client indicates that further teaching is required? [Show Less]
A nurse who is facilitating a support group in a community center noticies that one member of the group expresses anger repeatedly. which of the following... [Show More] strategies should the nurse use to facilitate the group process with this member? A. remind the group that everyone should have a chance to participate D. divide the group into pairs and give each pair a topic for discussion C. give the member extra time to compose her thought before expressing them D. focus more on the group members who have a positive outlook - D. the nurse should ask them in private to uncover the source of her ongoing anger a community health nurse is providing education to a group of children who have asthma. which of the following statements indicates an understanding of the teaching? A. i shouldn't play sports because it will make me too tired B. i will stay indoors during cold weather C. i will use my rescue medication every day D. I shouldn't get the flu shot because it might make me sick - B. cold air can be a trigger for asthma. this response indicates the student reconizes this risk a community health nurse is planning an in-service about STI to a group of adolescents. which of the following clinical findings should the nurse include as a manifestation of primary syphilis? A. malaise B. maculopapular rash on palms C. chancre D. lymphadenopathy - Ca public health nurse is working in a community that ha a population of 24, 096. There are 2,096 existing cases of heart disease within the populaiton. The nurse can determine which of the following from this information? A. mortality rate B. attack rate C. prevalence proportion D. incidence proportion - C a nurse is preparing a community education program about heatlh care needs during pregnancy. The nurse should include that which of the following vaccines is safe to administer to a client who is pregnant? A. herpes zoster B. tetanus, diphtheria, pertussis C. varicella D. measles, mumps, rubella - B a school nurse is notified that an elementary school child is newly diagnosed with pertussis. Which of the following actions should the school nurse take? (select all that apply) A. instruct the parent to keep the child home until the coughing stage has passed B. encourage family members to obtain prophylactic treatment C. quarantine the children in the child's class D. recommend the child receive a pneumococcal vaccine in 28 days E. check the immunizations of the child's classmates [Show Less]
A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take whi... [Show More] ch of the following actions during a seizure? - Clear the area of hard objects (ease child to the floor-lay child down???) A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider? - Tachypnea A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching? - You can replace milk with nondairy sources of calcium. A nurse is teaching a parent of an infant who has a pavlik harness for the treatment of development dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? - "I will place my infants diapers under the harness straps" a nurse in the ED is caring for a pt. with a 102.4 temp and an expected dx of bacterial meningitis. which of the following actions should be taken first? - implement droplet precautions Acetylsalicylic acid (aspirin) poisining - oliguria, diaphoresis A nurse is receiving change of shift report to four children. which of the following children should the nurse see first? - A school-age child who has sickle cell anemia with slurred speech When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.A nurse is planning care of r a toddler who has developed oral ulcers in response to chemotherapy. Which of the following actions should the nurse include in the plan of care? - Cleanse the gums with saline soaked gauze A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden infant death syndrome (SIDS). Which of the following statements by the parents indicates an understanding of the teaching? - "I will dress my baby in lightweight clothing to sleep." A nurse is providing postoperative care for a child following an arterial cardiac catheterization. Which of the following actions should the nurse take? - [Show Less]
a nurse who is facilitating a support group in a community center noticies that one member of the group expresses anger repeatedly. which of the following... [Show More] strategies should the nurse use to facilitate the group process with this member? A. remind the group that everyone should have a chance to participate D. divide the group into pairs and give each pair a topic for discussion C. give the member extra time to compose her thought before expressing them D. focus more on the group members who have a positive outlook - D. the nurse should ask them in private to uncover the source of her ongoing anger a community health nurse is providing education to a group of children who have asthma. which of the following statements indicates an understanding of the teaching? A. i shouldn't play sports because it will make me too tired B. i will stay indoors during cold weather C. i will use my rescue medication every day D. I shouldn't get the flu shot because it might make me sick - B. cold air can be a trigger for asthma. this response indicates the student reconizes this risk a community health nurse is planning an in-service about STI to a group of adolescents. which of the following clinical findings should the nurse include as a manifestation of primary syphilis? A. malaise B. maculopapular rash on palms C. chancre D. lymphadenopathy - Ca public health nurse is working in a community that ha a population of 24, 096. There are 2,096 existing cases of heart disease within the populaiton. The nurse can determine which of the following from this information? A. mortality rate B. attack rate C. prevalence proportion D. incidence proportion - C a nurse is preparing a community education program about heatlh care needs during pregnancy. The nurse should include that which of the following vaccines is safe to administer to a client who is pregnant? A. herpes zoster B. tetanus, diphtheria, pertussis C. varicella D. measles, mumps, rubella - B a school nurse is notified that an elementary school child is newly diagnosed with pertussis. Which of the following actions should the school nurse take? (select all that apply) A. instruct the parent to keep the child home until the coughing stage has passed B. encourage family members to obtain prophylactic treatment C. quarantine the children in the child's class D. recommend the child receive a pneumococcal vaccine in 28 days E. check the immunizations of the child's classmates - A B E a nurse is caring for a 50-year-old client who has DM, recently lost his job, and has no health insurance. The nurse should advise the client to do which of the following? A. contact medicare to determine eligibility B. contact medicaid to determine eligibility C. go to the ER when services are needed [Show Less]
A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an u... [Show More] nderstanding of the teaching? (Select all that apply). A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression. C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents." - A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression. C. "To assess language ability, I should instruct the client to write a sentence." A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of the medications. - D. Monitor the client for adverse effects of the medications. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social servicesB. Identify the client's perception of her mental health status. C. Include the client's family in the interview. D. Teach the client about her current mental health disorder. - B. Identify the client's perception of her mental health status. A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect? A. The client arouses briefly in response to a sternal rub. B. The client has a glasgow coma scale score less than 7. C. The client exhibits decorticate rigidity. D. The client is alert but disoriented to time and place. - A. The client arouses briefly in response to a sternal rub. A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion? (Select all that apply) A. The DSM-5 includes client education handouts for mental health disorders. B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders. D. The DSM-5 assists nurses in planning care for client's who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders. - B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. D. The DSM-5 assists nurses in planning care for client's who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders. A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year agoC. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to himself - C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? [Show Less]
Community-Oriented VS. Community-Based - Community-Oriented: Focus is on "health care" of individuals, families, and groups in community Community-Based:... [Show More] Manage acute and chronic conditions/Focus is on "illness care" of individuals and families across the life span (usually one-on-one) What is Public Health? - - A scientific discipline that includes the study of epidemiology, statistics, and assessment - ensure that conditions exist in which people can be healthy What are the benefits of public health? - - Increased life expectancy - Decreased deaths from strokes, cancer, heart disease, etc 3 public health core functions - 1. Assessment- Systematic data collection on the population 2. Policy Development- develop policies that support the health of the population 3. Assurance- Making sure that essential community-oriented health services are available The primary focus that has differentiated public health nursing from other specialties - the emphasis on the population rather than on single individuals or families The DIFFERENCE BETWEEN PHN AND OTHER FORMS OF NURSING - - In public health nursing, the nurse often reaches out to those who might benefit from a service or intervention - In other forms of nursing, the client is more likely to seek out and request assistance Primary goal of Public Health - the prevention of disease and disability and it is achieved by ensuring that conditions exist in which people can remain healthythe feature that distinguishes public health nursing from other specialties - The focus on populations in the community and the emphasis on health protection, health promotion, and disease prevention Population definition - A collection of individuals who share one or more personal or environmental characteristics The term population may be used interchangeably with what term? - aggregate Subpopulation definition - Subsets of the population who share similar characteristics - For example, people older than 65 years who live in a residential home would be a subpopulation of a larger population of older persons in the community Community definition - People and the relationships that emerge among them as they develop and use in common some agencies and institutions and share a physical environment Types of practice: Individual, family, and group focused [Show Less]
A nurse is assessing a 12 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? A. Closed ... [Show More] anterior fontanel B. Eruption of six teeth C. Birth weight doubled D. Birth length increased by 50% - C. Birth weight doubled -birth weight should be tripled by 12 months A nurse is performing a developmental screening on a 10 month old infant. Which of the following fine motor skills should the nurse expect the infant to perform (select all that apply) A. Grasp a rattle by the handle B. Try building a two block tower C. Use a crude pincer grasp D. Place objects in a container E. Walks with one hand held - A. Grasp a rattle by the handle C. Use a crude pincer grasp A nurse is conducting a well-baby visit with a 4-month-old infant. Which of the following immunizations should the nurse plan to administer to the infant? A. Measles, mumps, rubella (MMR) B. Polio (IPV) C. Pneumococcal vaccine (PVC)D. Varicella E. Rotavirus vaccine (RV) - B. Polio (IPV) C. Pneumococcal vaccine (PVC) E. Rotavirus vaccine (RV) A nurse is providing education about introducing new foods to the guardians of a 4-month-old infant. The nurse should recommend that the caregiver introduce which of the following foods first? A. Strained yellow vegetables B. Iron-Fortified Cereals C. Pureed Fruits D. Whole Milk - B. Iron-Fortified Cereals A nurse is providing teaching about dental care and teething to the caregiver of a 9 month old infant. Which of the following statements by the caregiver indicates an understanding of the teaching? A. "I can give my baby a warm teething ring to relieve discomfort." B. "I should clean my baby's teeth with a cool, wet wash cloth." C. "I can give Advil for up to 5 days while my baby is teething" D. "I should place diluted juice in the bottle my baby drinks while falling asleep." - B. "I should clean my baby's teeth with a cool, wet wash cloth." Age appropriate activities for an infant [Show Less]
1. a nurse is assessing a 12 month old infant during a well child visit. which of the following findings should the nurse report to the provider a. close... [Show More] d anterior fontanel b. eruption of six teeth c. birth weight doubled d. birth length increased by 50% - C 2. a nurse is performing a developmental screening on a 10 month old infant. which of the following fine motor skills should the nurse expect the infant to perform? (select all that apply) a. grasp a rattle by the handle b. try building a 2 block tower c. use a crude pincer grasp d. place objects into a container e. walk with one hand held - A C B (@ 12months) D (@ 11 months) E (@ 12 months) 3. a nurse is conducting a well-baby visit with a 4 month old infant. which of the following immunizations should the nurse plan to adminiter to the infant (select all that apply) a. MMR b. polio (IPV) c. pneumococcal vaccine (PCV) d. varicella e. rotavirus (RV) - B C EA (1st MMR is given between 12-15 months) D (given at minimum 12 months) 4. a nurse is providing education about introducing new foods to the parents of a 4 month old infant. the nurse should recommend that the parents introduce which of the following foods first a. strained yellow vegetables b. iron fortified cereals c. pureed fruits d. whole milk - B A (6 months) C (6 months) D (12 months) 5. a nurse is providing teaching about dental care and teething to the parent of a 9 month old infant. which of the following statements by the parents indicate an understanding of the teaching? a. I can give my baby a warm teething ring to relieve discomfort b. I should clean my baby's teeth with a cool, wet wash cloth c. I can give Advil for up to 5 days while my baby is teething d. I should place a diluted juice in the bottle my baby drink while falling asleep - b 6. a nurse is assessing a 2.5 year old toddler at a well child visit. which of the following findings should the nurse report to the provider a. height increased by 7.5 (3") in the past year b. head circumference exceeds chest circumferencec. anterior and posterior fontanels are closed d. current weight equals four times the birth weight - B 7. a nurse is performing a developmental screening on an 18 month old. which of the following skills should the toddler be able to perform (select all that apply) a. build a tower with 6 blocks b. throw a ball overhand c. walk up and down the stairs d. draw circles e. use a spoon without rotation - B E A (@ 2 years) C (@ 2 years) D (@ 2.5 years) 8. a nurse is providing teaching about age-appropriate activities to the parent of a 2 year old. which of the following statements by the parent indicates an understanding of the teaching? a. I will send my child's favorite stuffed animal when she will be napping away from home b. my child should be able to stand one foot for a second c. the soccer team my child will be playing on starts practicing next week d. I should expect my child to be able to draw circles - A 9. a nurse is providing anticipatory guidance to the parents of a toddler. which of the following should the nurse include (select all that apply) a. develop food habits that will prevent dental caries b. meeting caloric needs results in an increased appetite c. expression of bedtime fears is commond. expect behaviors associated with negativism and tribalism e. annual screening for phenylketonuria are important - A C D 10. a nurse is providing teaching to the parent of a preschool age child about methods to promote sleep. which of the following statements by the parent indicates an understanding of the teaching a. I will sleep in the bed with my child if she wakes up during the night b. I will let my child stay up an additional 2 hours on weekend nights c. I will let my child watch TV for 30 minutes just before bedtime each night d. I will keep a dim lamp on in my child's room during the night - D 11. a nurse is conducting a well child visit with a 5 year old. which of the following immunizations should the nurse plan to administer to the child (select all that apply) [Show Less]
A charge nurse is discussing mental status examination with a newly licensed nurse. Which of the following statements made by the newly licensed nurse ind... [Show More] icates and understanding of the teaching? (Select all that apply). A. "To assess cognitive ability, I should ask the client to count backwards by seven." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents." - A. "To assess cognitive ability, I should ask the client to count backwards by seven." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms. C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of medications. - D. Monitor the client for adverse effects of medications. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services. B. Identify the client's perceptions of her mental health status. C. Include the client;s family in the interview.D. Teach the client about her current mental health disorder. - B. Identify the client's perceptions of her mental health status. A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect? - The client arouses briefly in response to a sternal rub. A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion? (Select all that apply). A. The DSM-5 includes client education handouts for mental health disorders. B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. C. The DSM-5 indicates recommended pharmacological treatment. D. The DSM-5 assists nurses in planning care for clients. E. The DSM-5 indicates expected assessment findings of mental health disorders. - B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. C. The DSM-5 indicates recommended pharmacological treatment. D. The DSM-5 assists nurses in planning care for clients. E. The DSM-5 indicates expected assessment findings of mental health disorders. A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the underlying reasons? A. Narcissistic behavior. B. Fear of rejjection from staff C. Attempt to reduce anxiety. D. Adverse effect of antidepressant medication - C. Attempt to reduce anxiety. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? - Stay with the client and remain quiet. A nurse is assessing a client who has GAD. Which of the following findings should the nurse expect? (Select all that apply). [Show Less]
You are preparing to administer immunizations to a 4-month-old infant. Which of the following is an appropriate action for you to take in providing atraum... [Show More] atic care? A. Administer 81 mg of aspirin B. Use the Z track method C. Ask the parents to leave the room during the injection D. Provide sucrose solution on the pacifier - D. Allowing an infant to suck on dextrose will reduce pain with immunizations You are planning to administer recommended immunizations to a 2-month-old infant. Which of the following should you give? A. Rotavirus (RV) B. Diptheria, teatnus, and acellular pertussis (DTaP) C. Haemophilus influenzae type B (Hib) D. Hepatitis A (HepA) E. Pneumococcal conjugate (PCV13) F. Inactivated Poliovirus (PV) - A. B. C. E. F. Hep A is not given until 12-13 months of age You are preparing to administer the varicella vaccine to an adolescent. Which of the following questions should you ask to determine whether there is a contraindication to administering the vaccine? A. Do you have an allergy to eggs? B. Have you ever had encephalopathy following immunizations? C. Are you currently taking corticosteriod medications? D. Have you ever had an anaphylactic reaction to yeast? - C. Varicella is contraindicated with drugs that interact with the immune system [Show Less]
A 9 year old child with sickle cell anemia lives with her father, stepmother, and half sibling. Which of the following describes this family's composition... [Show More] ? A. Nuclear family B. Blended family C. Extended family D. Binuclear family - B. Blended family A blended family includes at least one stepparent, stepsibling, and/or half-sibling. A nuclear family includes two parents and their children. An extended family includes on or more parents, one or more children, and other family members such as a grandmother. A binuclear family includes parents that have terminated spousal roles but continue with parenting roles. Which of the following is an example of parents maintaining structure and routine in the home environment? A. A mother purchasing a bicycle safety helmet for her son. B. A father monitoring a chart of the children assigned to set the table. C. The parents attending a parent-teacher meeting at their child's school D. The parents discussing their vacation plans with the babysitter. - B. A father monitoring a chart of the children assigned to set the table. A nurse is collecting data from the parents of two school-age children. Which of the following data should be collected regarding the family? __ Health status of grandparents __ Family members living in the home __ Parents' involvement in children's school programs __ Recent stressful family events __ Heights and weights of children - _x_ Health status of grandparents_x_ Family members living in the home _x_ Parents' involvement in children's school programs _x_ Recent stressful family events ___ Heights and weights of children Medical history of the grandparents, identifying family members, developmental tasks of the family such as involvement ion their child's education, disciplinary activities and family stressors are all data to be collected regarding the family. The height and weight of the children is data related to physical assessment findings of the children. A nurse manager on a pediatric floor is preparing an education program on working with families for a group of newly hired nurses. Which of the following should the nurse include when discussing the developmental theory? A. Describes that stress is inevitable B. Emphasizes that change with one member affects the entire family C. Provides guidance to assist families adapting to stress D. Defines consistencies in how families change - D. Defines consistencies in how families change A nurse is assisting a group of adolescents to develop skills that will improve communication within the family. The nurse hears one parent state, "My son knows he better do what I say." Which of the following parenting styles is the parent exhibiting? A. Authoritarian B. Permissive C. Authoritative D. Passive - A. Authoritarian. Using this style the parent controls the adolescent's behaviors and attitudes through unquestioned rules and expectations. A nurse is performing family assessment. Which of the following should the nurse include? __ Medical history __ Parent's education level__ Child's physical growth __ Support system __ Stressors - _x_ Medical history _x_ Parent's education level ___ Child's physical growth _x_ Support system _x_ Stressors [Show Less]
A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. What is the appropriate action for the nurse to take? ... [Show More] - Place client on NPO status Change in level of consciousness is common and could lead to aspiration if PO A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. What are 3 indicators of viral meningitis? - Negative gram stain Normal glucose content Normal protein content A nurse is caring for a 4 month old infant who has meningitis. What is associated with the diagnosis - High-pitched cry A nurse is caring for a school age client who possibly has Reye syndrome. What is a risk factor for developing this syndrome? - Recent episode of gastroenteritis A nurse is developing an in-service about viral and bacterial meningitis. What are 2 immunizations that could decrease the incidence of meningitis. - Pneumococcal vaccine (PCV) Haemophilus influenzae type B vaccine (Hib) A nurse is caring for a child who has absence seizures. What are 3 findings the nurse can expect to find? - Loss of consciousness Appearance of daydreaming Dropping held objectsA nurse is caring for a child who just experienced a generalized seizure. What is the priority action for the nurse to take? - Maintain the child in a side lying position To prevent aspiration *ABCs* A nurse is providing teaching to the parent of a child who is to have an EEG. What should the nurse include in the teaching? - Decaffeinated beverages should be offered on the morning of the procedure A nurse is teaching a group of parents about the risk factors for seizures. What 3 things should the nurse include in the teaching? - Febrile episodes Hypoglycemia Sodium imbalances A nurse is reviewing treatment options with the parents of a child who has worsening seizures. What 4 treatment options should the nurse include in the discussion? - Vagal nerve stimulator Additional antiepileptic medications Corpus callosotomy Focal resection A nurse is in the ED and assessing a child following a motor-vehicle accident. The child is unresponsive, has spontaneous respirations of 22/minute and has a laceration on the forehead that is bleeding. What is the first action the nurse should take? [Show Less]
Nurse is reviewing lab results of a school age child 1 week postop following an open fracture repair. Which findings should nurse ID as indication of pote... [Show More] ntial complication? a. Erythrocyte sedimentation rate 18 mm/hr b. WBC count 6,200/mm3 c. C-reactive protein 1.4 mg/LRBC count 4.7 million/mm3 - a. Erythrocyte sedimentation rate 18 mm/hr - above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis. Wrong Answers: b. WBC count 6,200/mm3:- within the expected reference range of 5,000 to 10,000/mm3. -An elevated WBC count is an indication of osteomyelitis. c. C-reactive protein 1.4 mg/L:- within the expected reference range of <10.0 mg/L. -An elevated C-reactive protein level is an indication of osteomyelitis.RBC count 4.7 million/mm3:- within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC count can indicate hemorrhage. Nurse planning care for school age child with tunneled CVA device. Which interventions should the nurse include in plan? a. Use sterile scissors to remove the dressing from the site. b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use c. Access the site using a noncoring angled needle d. Use a semipermeable transparent dressing to cover the site - d. Use a semipermeable transparent dressing to cover the site- The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. Wrong Answers: a. Use sterile scissors to remove the dressing from the site - The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter. b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use - The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. c. Access the site using a noncoring angled needle - The nurse should use a noncoring angled or straight needle when accessing an implanted port. Nurse is planning care to address nutritional needs for preschooler with cystic fibrosis. Which interventions should the nurse include in plans? a. Administer pancreatic enzymes 2 hr after meals. b. Discontinue the use of pancreatic enzymes if steatorrhea develops. c. Limit fluid intake to 750 mL per day. d. Increase fat content in the child's diet to 40% of total calories. - d. Increase fat content in the child's diet to 40% of total calories - A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake. Wrong Answers: a. Administer pancreatic enzymes 2 hr after meals - The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis. b. Discontinue the use of pancreatic enzymes if steatorrhea develops - A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves.c. Limit fluid intake to 750 mL per day - The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration. Nurse in ED auscultates lungs of adolescent experiencing dyspnea. Nurse should ID sound as what? a. Wheezes b. Crackles c. Pleural friction rub d. Rhonchi - a. Wheezes - high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. Wrong answers: b. Crackles - high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted. c. Pleural friction rub - a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together. d. Rhonchi - low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed. Nurse assesses school age child with infratentorial brain tumor. Which findings should the nurse ID as manifestation of IICP? a. Hypotension b. Reports insomnia c. Difficulty concentrating d. Tachycardi [Show Less]
A child comes in with Tachycardia and delayed capillary refill, this child is currently is in shock. What other s/s would indicate a LATE sign of shock in... [Show More] children? A. Fever B. Restlessness C. Decreased B/P D. Headache - C. Decreased B/P T or F: Ipecac is the recommended home remedy for routine poison treatment - False What are signs of symptoms of Lead positioning (select all that apply) A. Nausea and Vomiting B. Increased activity C. Seizure D. No pain E. Lethargy F. Constipation - A. Nausea and Vomiting C. Seizure E. Lethargy F. Constipation In School-age children, what is the most common type of poisoning? A. Chemical B. LeadC. Acetaminophen (Tylenol) D. Alcohol - C. Acetaminophen (Tylenol) Which is a clinical manifestation of acetaminophen poisoning? A. Hyperpyrexia B. Hepatic involvement C. Severe burning pain in stomach D. Drooling and inability to clear secretions - B. Hepatic involvement Which is the most frequent source of acute childhood lead poisoning? A. Folk remedies B. Unglazed pottery C. Lead-based paint D. Cigarette butts and ashes - C. Lead-based paint Cardiopulmonary resuscitation (CPR) is begun on a toddler. Which pulse is usually palpated because it is the most central and accessible? A. Radial B. Carotid C. Femoral D. Brachial - B. Carotid Which drug is considered the most useful in treating childhood cardiac arrest? A. Bretylium tosylate (Bretylium) B. Lidocaine hydrochloride (Lidocaine) C. Epinephrine hydrochloride (Adrenaline) D. Naloxone (Narcan) - C. Epinephrine hydrochloride (Adrenaline) Effective lone-rescuer CPR on a 5-year-old child should includeA. Two breaths to every 30 chest compressions B. Two breaths to every 15 chest compressions C. Reassessment of child after 50 cycles of compression and ventilation. D. Reassessment of child every 10 minutes that CPR continues - A. Two breaths to every 30 chest compressions The Heimlich maneuver is recommended for airway obstruction in children older than _____ year(s). A. 1 B. 4 C. 8 D. 12 - A. 1 A nurse is caring for a child in acute respiratory failure. Which blood gas analysis indicates the child is still in respiratory acidosis? A. pH 7.50, CO2 48 B. pH 7.30, CO2 30 C. pH 7.32, CO2 50 D. pH 7.48, CO2 33 - C. pH 7.32, CO2 50 The nurse enters a room and finds a 6-year-old child who is unconscious. After calling for help and before being able to use an automatic external defibrillator, which steps should the nurse take [Show Less]
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse... [Show More] identify as a manifestation of pertussis? - Dry, hacking cough Rationale: The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night. A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? - Flank pain Rationale: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? [Show Less]
A nurse manager on a pediatric floow is preparing an education program on working w families for a group of newly hired nurses. Which should the nurse inc... [Show More] lude when discussing the developmental theory? A. Describes that stress in inevitable B. Emphasizes that change with 1 member affects the entire fam C. Provides guidance to assist families adapting to stress D. Defines consistencies in how families change - D. Defines consistencies in how families change A nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. First here's one parent state, " my son knows he better do what I say." Which of the following parenting styles is the parent exhibiting? A. Authoritarian B. Permissive C. Authoritative D. Passive - A. Authoritarian A nurse is performing a family assessment. Which of the following should the nurse include? (select all that apply) A. Medical Hx B. Parents' education level C. Child's physical growth D. Support systemsE. Stressors - A. Medical Hx B. Parents' education level D. Support systems E. Stressors C- performed during individual assessment A nurse is preparing to assess a preschool age child. Which of the following is an appropriate action by the nurse to prepare the child? A. allow the child to role play using miniature equipment B. Use medical terminology to describe what will happen C. Separate the child from her parent during the exam D. Keep the medical equipment visible to the child - A. allow the child to role play using miniature (or actual) equipment Encourage parental presence A nurse is checking the vital signs of a 3 year old child during a well child visit. which of the following findings should the nurse report to the provider? A. Temp 37.2 (99.0) B. Heart Rate 106/min C. Respirations 30/min D. BP 88/54 - C. Respirations 30/min above expeted range A nurse is assessing a child's ears. which of the following is an expected finding? A. Light reflex is located at the 2 o'clock position B. Tympanic membrane is red in colorC. Bony landmarks are not visible D. Cerumen is present bilaterally - D. Cerumen is present bilaterally Light reflex should be at 5 or 7 o clock position, membrane = gray or pearly pink & bony landmarks s/b visible A nurse is assessing our 6 month old infant. which of the following reflexes should the infant exhibit? A. Moro B. Plantar grasp C. Stepping D. Tonic neck - B. Plantar grasp (ends aroun 8 mo) Moro disappears at 4 mo, tonic neck at 3-4 mo and stepping at 4 weeks) A nurse is performing a neurological assessment on an adolescent. which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? (select all that apply) A. Clenching teeth together tightly B. Recognizing sour taste on the back of the tongue C. Identifying smells through each nostril D. Detecting facial touches with eyes closed E. Looking down and in with the eyes - A. Clenching teeth together tightly D. Detecting facial touches with eyes closed B = glossopharyngeal cranial nerve C = olfactory E = trochlerA nurse is assessing a 12 month old infant during a well child visit. which of the following fighting should the nurse report to the provider? A. Closed anterior fontanel B. Eruption of 6 teeth C. Birth weight doubled D. Birth length increased by 50% [Show Less]
What are 3 different ways to test Cerebellar function in children and adolescents? - 1. finger to nose test: should have rapid coordination 2. heel to sh... [Show More] in test: should be able to run heel of one foot down the shin of the other leg 3. Romberg Test: able to stand with slight swaying when eyes are closed What is the Denver Developmental Screening Test used for? - it is a standardized test that screens language, cognition, and fine and gross motor development in children and adolescents. When does the posterior fontanel close? - 6-8 weeks of age When does the anterior fontanel close? - 12-18 months of age Describe how an infant gains weight... - should gain 150-210 grams per week for the first 6 months. At 6 months the birth weight should be doubled, and tripled by 12 months. Describe how an infant grows in height... - should grow approx 2.5 cm per month for the first 6 months. growth will occur in spurts after 6 months, but birth length should be increased by 50% by 12 months. Describe the growth of an infant's head circumference.. - should increase approx 1.5 cm per month for the first 6 months, then approx 0.5 cm between6 - 12 months. How many teeth should an infant have by 12 months? - 6 -8 teeth, with first teeth coming in at about 6- 10 months. To help teething pain, what is the maximum amount of days that a parent should use acetaminophen or ibuprofen? - 3 days**Ibuprofen ONLY in babies over 6 months of age** At what age will an infant be able to hold a bottle? - 6 months At what age will an infant be able to place objects in a container? - 11 months At what age should an infant be able to pull to standing position? - 9 months At what age should an infant be able to grasp a rattle by the handle? - 10 months When will an infant begin using a pincer grasp? - 8 months 9 months: crude pincer grasp 11 months: neat pincer grasp At what age can an infant sit down from a standing position without assistance? - 12 months At what age will an infant try to build block towers, although not usually successful? [Show Less]
1. A nurse is completing a pain assessment of an infant. Which of the following pain scales should the nurse use? A. FACES B. FLACC C. Oucher D. Non-c... [Show More] ommunicating children's pain checklist - B. FLACC 2. A nurse is planning care for a child following a surgical procedure. Which of the following interventions should be included in the plan of care? A. Administer NSAIDs for pain greater than 7. B. Administer intranasal analgesics PRN. C. Administer IM analgesics for pain. D. Administer IV analgesics on a schedule. - D. Administer IV analgesics on a schedule. 3. A nurse is assessing an infant. Which of the following are clinical manifestations of pain in an infant? (Select all that apply.) A. Pursed lips B. Loud cry C. Lowered eyebrows D. Rigid body E. Pushes away stimulus - B. Loud cry C. Lowered eyebrows D. Rigid body4. A nurse is preparing a toddler for an intravenous catheter insertion using atraumatic care. Which of the following are appropriate interventions? (Select all that apply.) A. Explain the procedure using the child's favorite toy. B. Ask the parents to leave during the procedure. C. Perform the procedure with the child in his bed. D. Allow the child to make one choice regarding the procedure. E. Apply lidocaine and prilocaine cream to three potential insertion sites. - A. Explain the procedure using the child's favorite toy. D. Allow the child to make one choice regarding the procedure. E. Apply lidocaine and prilocaine cream to three potential insertion sites. 5. A nurse is planning care for an infant who is experiencing pain. Which of the following should be included in the plan of care? (Select all that apply.) A. Offer a pacifier. B. Use guided imagery. C. Use swaddling. D. Initiate a behavioral contract. E. Encourage kangaroo care. - A. Offer a pacifier. C. Use swaddling. E. Encourage kangaroo care. A nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool-age child? A. describing manifestation of illness B. relating fears to magical thinking C. understanding the cause of illness D. awareness of body functioning [Show Less]
A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency... [Show More] department, and is being discharged home. Instructions for diet for this child should include: A. BRAT diet (bananas, rice, applesauce, and toast) for 24 hours, then a soft diet as tolerated B. Chicken or beef broth for 24 hours, then resume a soft diet C. Offer a regular diet as child's appetite warrants D. Keep on clear liquids and toast for 24 hours - C A 5-month-old infant is seen in the well-child clinic for a complaint of vomiting and failure to grow. His birth weight was 7 lb, and he now weighs 8 lb, 10 oz. The infant's mother reports that he is taking 4 to 7 oz of formula every 4 to 5 hours, but he "spits up a lot after eating and then is hungry again." The child is noted to be alert but appears malnourished. The mother reports that his stools are brown in color, and he has 1 to 2 bowel movements every day. Based on these findings, the nurse anticipates the infant has: A. Meckel diverticulum B. Hypertrophic pyloric stenosis C. Intussusception D. Hirschsprung disease - B Because children with celiac disease must limit their intake of products containing gluten in wheat, rye, oats, and barley, they are at risk for which of the following nutritional deficiencies? Select all that apply. Iron deficiency anemia A. Folic acid deficiency B. Zinc deficiency C. Vitamin A, D, E, and K deficiency D. Vitamin B12 deficiency E. A formerly preterm infant - ABDA formerly preterm infant who had surgery for necrotizing enterocolitis is now 6 months old and has short-bowel syndrome. He is unable to absorb most nutrients taken by mouth and is totally dependent on parenteral nutrition, which he receives via a central venous catheter. The clinic nurse following this infant is aware that this infant should be closely observed for the development of: A. Gastroesophageal reflux B. Chronic diarrhea C. Cholestasis D. Failure to thrive - C The nurse caring for a 4-month-old infant with biliary atresia and significant urticaria can anticipate administering: A. Diphenhydramine B. Ursodiol (ursodeoxycholic acid) C. Loratadine D. Zantac - B Hepatitis A virus is transmitted by which of the following? Select all that apply. A. Breast milk from mother with HAV B. Ingestion of contaminated food C. Fecal-oral route D. Casual contact with infected person E. Blood transfusion - BC A nurse is caring for a child who has had watery diarrhea for the past 3 days.Which of the following is an action for the nurse to take? Offer chicken broth Initiate oral rehydration therapy Start hypertonic IV solution Keep NPO - B [Show Less]
1. A nurse on a pediatric floor is preparing an education program on working with families for a group of newly hired nurses. Which of the following shoul... [Show More] d the nurse include when discussing the developing theory? A. Describes that stress is inevitable. B. Emphasizes that change with one member affects the entire family. C. Provides guidance to assist families adapting to stress. D. Defines consistencies in how families change. - D. Defines consistencies in how families change. 2. A nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. The nurse hears one parent state, " My son knows he better do what i say." Which of the following parenting styles is the parent exhibiting? A. Authoritarian. B. Permissive. C. Authoritative. D. Passive. - A. Authoritarian. 3. A nurse is performing family assessment. which of the following should the nurse include? ( Select all that apply) a. medical history b. parents education level c. child's physical growth. d. support systems. e. stressors - A B D E4. A nurse is preparing assess a pre-school-age child. which of the following is an appropriate action by the nurse to prepare the child? A. Allow the child to role-play B. Use medical terminology to describe what will happen C. Separate the child from her parent during the examination D. Keep medical equipment visible to the child. - A. Allow the child to role-play 5. a nurse is checking the vital signs of a 3 yr old child during a well child visit. which of the following findings should the nurse report to the provider? A. Temp of 99.0 B. HR of 106 C. RR of 30 D. BP 88/54 - C. RR of 30 6. A nurse is assessing a 6-month old infant. Which of the following reflexes should the infant exhibit? A. moro B. plantar grasp C. steeping D. tonic neck - B. plantar grasp 7. a nurse is assessing a child's ears. which of the following is an expected finding? A. light reflex is located at the 2 o' clock position B. tympanic membrane is red in color C. bony landmarks are not visible D. cerumen is present bilaterally - D. cerumen 8. a nurse is performing a neurological assessment on an adolescent. which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? ( select all that apply)A. clenching teeth together tightly B. recognizing sour tastes on the back of the tongue C. identifying smells through each nostril D. detecting facial touches with eyes closed E. Looking down and in with the eyes - A D 9. a nurse is assessing a 12-month old infant during a well-child visit. which of the following findings should the nurse report to the provider? A. a closed anterior fontanel B. eruption of six teeth C. birth weight doubled D. birth length increased 50% - C. birth weight double. 10. a nurse is conducting a well-baby visit with a 4 month old infant. which of the following immunizations should the nurse plan to administer to the infant? (select all that apply) A. MMR B. IPV C. PCV D. Varicella E. RV - B C E 11. a nurse is providing education about introducing new foods to the parents of a 4 month old infant. the nurse should recommend that the parents introduce which of the following foods first? [Show Less]
1. A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions by the nurse is appr... [Show More] opriate? A. Place the client on NPO status. B. Prepare the client for a liver biopsy. C. Position the client dorsal recumbent. D. Put the client in a protective environment. - A A. Due to the client's decreased level of consciousness, placing the client on NPO status is an appropriate action by the nurse. 2. A nurse is caring for a 4-month-old infant who has meningitis. Which of the following findings is associated with this diagnosis? A. Depressed anterior fontanel B. Constipation C. Presence of the rooting reflex D. High-pitched cry - D D. A high-pitched cry is a finding associated with meningitis in a 4-month-old infant. 3. A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following results indicate viral meningitis? (Select all that apply.) A. Negative gram stain B. Normal glucose content C. Cloudy color D. Decreased WBC countE. Normal protein content - A B E A. A negative gram stain indicates viral meningitis. B. Normal glucose content indicates viral meningitis. E. Normal protein content indicates viral meningitis. 4. A nurse is developing an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (Select all that apply.) A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vaccine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. Haemophilus influenzae type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV) - B B. The introduction of the PCV decreased the incidence of bacterial meningitis in children, as it provides immunity against bacteria that causes the illness. D. 5. A nurse is caring for a school-age client who possibly has Reye syndrome. Which of the following is a risk factor for developing Reye syndrome? A. Recent history of infectious cystitis caused by Candida B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis - C C. A recent episode of gastroenteritis, a viral illness, is a risk factor for Reye syndrome.Reye syndrome typically follows a viral illness, such as influenza, gastroenteritis, or varicella. 5. A nurse is providing teaching about the management of epistaxis to a child and his family. Which of the following positions should the nurse instruct the child to take when experiencing a nosebleed? A. Sit up and lean forward. B. Sit up and tilt the head up. C. Lie in a supine position. D. Lie in a prone position. [Show Less]
A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions by the nurse is appropr... [Show More] iate? A) Place the client on NPO status B) Prepare the client for a liver biopsy C) Position the client dorsal recumbent D) Put the client in a protective environment - A A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as viral meningitis? (Select all that apply). A) Negative gram stain B) Normal glucose content C) Cloudy color D) Decreased WBC count E) Normal protein content - A, B, E A nurse is caring for a 4-month-old infant who has meningitis. Which of the following findings is associated with this diagnosis? A) Depressed anterior fontanel B) Constipation C) Presence of the rooting reflex D) High-pitched cry - DA nurse is caring for a school-age client who possibly has Reye syndrome. Which of the following is a risk factor for developing Reye syndrome? A) Recent history of infectious cystitis caused by Candida B) Recent history of bacterial otitis media C) Recent episode of gastroenteritis D) Recent episode of Haemophilus influenzae meningitis - C A nurse is developing an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (Select that apply.) A) Inactivated polio vaccine (IPV) B) Pneumoccocal conjugate vaccine (PCV) C) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D) Haemophilus influenzae type B (Hib) vaccine E) Trivalent inactivated influenza vaccine (TIV) - B, D A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (Select all that apply.) A) Loss of consciousness B) Appearance of daydreaming C) Dropping held objects D) Falling to the floor E) Having a piercing cry [Show Less]
A nurse manager on a pediatric floor is preparing an education program on working with families for a group of newly hired nurses. Which of the following ... [Show More] should the nurse include when discussing the developmental theory? A. describes that stress is inevitable B. emphasizes that change with one member affects the entire family C. provides guidance to assist families adapting to stress D. Defines consistencies in how families change - D. Defines consistencies in how families change A nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. The nurse hears one parent state, "My son knows he better do what I say." Which of the following parenting styles is the parent exhibiting? A. Authoritarian B. Permissive C. Authoritative D. Passive - A. Authoritarian A nurse is performing family assessment. Which of the following should the nurse include? A. Medical history B. Parents' education level C. Child's physical growth D. Support systems E. Stressors - Medical history Parents' education level Support systems stressorsA nurse is preparing to assess a preschool-age child. Which of the following is an appropriate action? A. Allow the child to role-play using mini equipment B. Use medical terminology to describe what will happen. C. Separate the child from her parent during the examination D. Keep medical equipment visible to the child - Allow the child to role-play using miniature equipment A nurse is checking the vital signs of 3-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider Temperature 37.2 HR 106 Resp 30 BP 88/54 - Resp 30 A nurse is assessing a child's ears. Which of the following is an expected finding light reflex is located at 2 oclock position tympanic membrane is red in color bony landmarks are not visible cerumen is present bilaterally - Cerumen is present bilaterally A nurse is assessing a 6 mo old infant which of the following reflexes should the infant exhibit - plantar grasp A nurse is performing a neuro assessment on an adolescent. Which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? clenching teeth together tightly recognizing sour tastes on the back of the tongue identifying smells through each nostril Detecting facial touches with eyes closed Looking down and in with the eyes - Clenching teeth together tightly Detecting facial touches with eyes closedA nurse is assessing a 12 mo child infant during a well-child visit. Which of the following findings should the nurse report to the provider Closed anterior fontanel Eruption of six teeth Birth weight doubled Birth length increased by 50% - birth weight doubled A nurse is performing a developmental screening on a 10-month-old infant. which of the following fine motor skills should the nurse expect the infant to perform> Grasp a rattle by the handle Try building a 2 block tower Use a crude pincer grasp Place objects in a container Walks with one hand held - Grasp rattle by the handle Use a crude pincer grasp A nurse is conducting a well-baby visit with a 4 mo old infant. Which of the following immunizations should the nurse plan to administer to the infant? MMR PV PCV RV Varicella - PV PCV RV A nurse is providing education about introducing new foods to the parents of a 4-month-old infant. The nurse should recommend that the parents introduce which of the following foods first? Strained yellow vegetables [Show Less]
A nurse on a pediatric floor is preparing an education program on working with families for a group of newly hired nurses. Which of the following should t... [Show More] he nurse include when discussing the developing theory? A. Describes that stress is inevitable. B. Emphasizes that change with one member affects the entire family. C. Provides guidance to assist families adapting to stress. D. Defines consistencies in how families change. - D. Defines consistencies in how families change. A nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. The nurse hears one parent state, " My son knows he better do what i say." Which of the following parenting styles is the parent exhibiting? A. Authoritarian. B. Permissive. C. Authoritative. D. Passive. - A. Authoritarian. A nurse is performing family assessment. which of the following should the nurse include? ( Select all that apply) a. medical history b. parents education level c. child's physical growth. d. support systems. e. stressors - A B D EA nurse is preparing assess a pre-school-age child. which of the following is an appropriate action by the nurse to prepare the child? A. Allow the child to role-play B. Use medical terminology to describe what will happen C. Separate the child from her parent during the examination D. Keep medical equipment visible to the child. - A. Allow the child to role-play a nurse is checking the vital signs of a 3 yr old child during a well child visit. which of the following findings should the nurse report to the provider? A. Temp of 99.0 B. HR of 106 C. RR of 30 D. BP 88/54 - C. RR of 30 A nurse is assessing a 6-month old infant. Which of the following reflexes should the infant exhibit? A. moro B. plantar grasp C. steeping D. tonic neck - B. plantar grasp a nurse is assessing a child's ears. which of the following is an expected finding? A. light reflex is located at the 2 o' clock position B. tympanic membrane is red in color C. bony landmarks are not visible D. cerumen is present bilaterally - D. cerumena nurse is performing a neurological assessment on an adolescent. which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? ( select all that apply) A. clenching teeth together tightly B. recognizing sour tastes on the back of the tongue C. identifying smells through each nostril D. detecting facial touches with eyes closed E. Looking down and in with the eyes - A D a nurse is assessing a 12-month old infant during a well-child visit. which of the following findings should the nurse report to the provider? A. a closed anterior fontanel B. eruption of six teeth C. birth weight doubled D. birth length increased 50% - C. birth weight double. a nurse is conducting a well-baby visit with a 4 month old infant. which of the following immunizations should the nurse plan to administer to the infant? (select all that apply) A. MMR B. IPV C. PCV D. Varicella E. RV - B C E a nurse is providing education about introducing new foods to the parents of a 4 month old infant. the nurse should recommend that the parents introduce which of the following foods first? [Show Less]
a nurse is reviewing sick-day management with a parent of a child who has type 1 DM. which of the following should the nurse include in the teaching (SATA... [Show More] ) a. monitor blood glucose levels every 3 hours b. discontinue taking insulin until feeling better c. drink 8 oz of fruit juice every hour d. test urine for ketones e. call the provider if blood glucose is greater than 2540 mg/dL - A D E a nurse is teaching a child who has type 1 DM about self care. which of the following statements by the child indicates understanding of the teaching? a. I should skip breakfast when I am not hungry b. I should increase by insulin with exercise c. I should drink a glass of milk when I am feeling irritable d. I should draw up the NPH insulin into the syringe before the regular insulin - C a nurse is caring for a child who has type 1 DM. which of the following are manifestations of diabetic keotacidosis (SATA) a. blood glucose 58 b. weight gain c. dehydration d. mental confusion e. fruit breath - C D Ea nurse is teaching a school-age child who has DM about insulin administration. which of the following should the nurse include in the teaching? a. you should inject the needle at a 30 degree angle b. you should combine your glargine and regular insulin in the same syringe c. you should aspirate for blood before injecting the insulin d. you should give four or five injections in one area before switching sites - D a nurse is teaching an adolescent who has DM about manifestations of hypoglycemia. which of the following findings should the nurse include in the teaching (SATA) a. increased urination b. hunger c. signs of dehydration d. irritability e. sweating f. kussmaul respirations - B D E [Show Less]
A nurse manager on a pediatric floor is preparing an education program I'm working with families for a group of newly hired nurses. Which of the following... [Show More] should the nurse include when discussing the developmental theory? A. Describe that stress is inevitable B emphasizes that change with one member affects the entire family C provides guidance to assist families adapting to stress D defines consistencies in how families can change - D A nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. The nurse here is one parent state my son knows he better do what I say. Which of the following parents Styles is the parent exhibiting? A. Authoritarian B. Permissive C. Authoritative D. Passive - A A nurse is performing family assessment. Which of the following should the nurse include? Select all that apply A. Medical history B. Patient education C. Child's physical growth D. Support systems E. Stressors - Abde A nurse is preparing to us at a preschool age child which of the following is an appropriate action by the nurse to prepare the child?A. Allow the child to role play using miniature equipment Be. Used medical terminology to describe what will happen C. Separate the child from her parents during the examination D. Keep medical equipment visible to the child - A A nurse is checking the vital signs of a 3 year old child during a well child visit. Which of the following findings should the nurse report to the provider? A. temperature 37. 2 degrees Celsius B. Pulse 114 C. Respirations 30 D. Blood pressure 88/ 55 - c A nurse is assessing a child's ears. Which of the following is an expected finding? A. Light reflex is located at the 2 o'clock position B. Tympanic membrane is red in color C. Bony landmarks are not visible D. Cerumen is present bilaterally - D And nurse is assessing a 6 month old infant. Which of the following reflexes should exist? A. Moro B. Plantar grasp C. Stepping D. Tonic neck - B a nurse is performing a neurological assessment on an adolescent. Which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? Select all that apply A. Clenching teeth together tightly B. Recognizing sour taste on the back of the tongue c. Identifying smells through each nostril D. Detecting facial touches with eyes closedE. Looking down and in with the eyes - Ad A nurse is assessing a 12 month old infant at a well child visit. Which of the following findings should the nurse report to the provider? A. Closed anterior fontanelle B. eruption of 6 teeth C. Birth weight doubled D. Birth length increased by 50% - C A nurse is performing a developmental screening on a 10 month old infant. Which of the following fine motor skills should the infant be able to perform? Select all that apply A. Grasping a rattle by the handle B. Try building a 2 block tower C. using a crude pincer grasp D. Place objects into a container E. Move objects from hand to hand - [Show Less]
A nurse is preparing to assess a preschool age child. Which is an appropriate action by the nurse to prepare the child? - Allow the child to role-play usi... [Show More] ng miniature equitment Nurse is checking VS in a 3 year old child. Which should the nurse report to the provider? - RR 30/min Nurse is assessing a child's ears. Which is an expected finding? - Cerumen is present bilaterally Nurse is assessing a 6 month old infant. Which reflexes should the infant exhibit ? - Plantar grasp Nurse is performing a neuro assessment on an adolescent. Which is an appropriate reaction by the adolescent when the nurse checks the rigeminal cranial nerve? - - clenching teeth together tightly - detecting facial touches with eyes closed Nurse is assessing a 12 month old infant. Which findings should the nurse report to the provider? - Birth weight doubled Which fine motor skills should the nurse expect the 10 month old infant to perform? - - grasp a rattle by the handle - use a crude pincer grasp Which immunizations should the nurse plan to administer a 4 month old infant? - - polio (IVP) - pneumococcal vaccine (PCV) - Rotavirus vaccine (RV)Nurse is providing education about introducing new foods to the parents of a 4 month old infant. The nurse should recommend that the parents introduce which foods first? - Iron - fortified cereals Nurse is providing teaching about dental care & teething to the parent of a 9 month old infant. Which statement by the parent indicates an understanding of the teaching ? [Show Less]
hindu post mortem - dont touch the patient's body Vancomycin Resistant Enterococcus (VRE) Methicillin Resistant Enterococcus (MRE); Precaution? PPE? - Co... [Show More] ntact Precaution Gloves and Gown What is the signs of digoxin toxicity? - blurred vision Patient taking warfarin and INR is 5 what to do? - vitamin k Patient reports frequent vomitting what's the indication that the patient have hyperemesis gravidum - Ketonuria Proteinuria indication of what in pregnancy - Preeclampsia Blurred vision during pregnancy is an indication of - Preeclampsia Newborn normal heart rate - 110-160 Dorsalis pedis location - front of the foot Bathing infant - Sponge until the cord falls off A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? [Show Less]
Better peripheral perfusion? - Elevate veins, D-Angle Arteries Airborne precautions protective equip - private room, neg pressure with 6-12 air exchanges/... [Show More] hr mask & respirator N95 for TB;measles, chickenpox (varicella) Herpes zoster/shingles TB Droplet precautions - spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precautions - Protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by microorganisms (C diff), [Show Less]
Autonomy - client's right to make own personal decisions, even when those decisions might not be in the client's own best interest Beneficence - positive... [Show More] actions to help others Fidelity - agreement to keep promises Justice - fairness in care delivery and use of resources Nonmaleficence - avoidance of harm or injury Paternalism - assumption that one person can assume responsibility for making the decisions of another person Advocacy - support of clients' health, safety, and personal rights Responsibility - willingness to respect obligations and follow through on promises Accountability - ability to answer for one's own actions Confidentiality - protection of privacy without diminishing access to high-quality care When is a problem an ethical dilemma? - When: - A review of scientific data is not enough to solve it. - It involves a conflict between two moral imperatives. - The answer will have a profound effect on the situation and the client.Ethical decision making - Process that requires striking a balance between science and morality A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - B. Autonomy In this situation, the client is exercising his right to make his own personal decision about surgery, regardless of others' opinions of what is "best" for him. This is an example of autonomy. A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence - D. Beneficence Beneficence is taking positive actions to help others. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client. A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fideli [Show Less]
Nuchal rigidity (neck stiffness), photophobia (intolerance of bright light) and headache. - 180. A nurse is assisting with the admission of an adolescent ... [Show More] client who is suspected of having bacterial meningitis. Which of the following findings should the nurse expect? 179. A nurse is planning client care for a shift. Which of the following should the nurse plan to delegate to an assistive personnel? - d. Ambulating a client receiving patient-controlled analgesia. 178. A nurse is reinforcing teaching to an adult client who is prescribe Lipitor. The nurse should advise the client that which of the following is an adverse effect of this medication and should be reported to the provider? - b. Unexplained muscle pain 177. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? - a. Dependent edema A pregnant client presents with bright red painless vaginal bleeding at 30 weeks. What should the nurse plan to assess for? a. Placenta previa b. Placental abruption c. Cervical dilation d. Cervical tears - a. Placenta previa The new graduate nurse on a surgical oncology floor is reviewing osteosarcoma signs and symptoms. Which of the following findings does the nurse review that can be seen in a client with osteosarcoma? Select all that apply a. Localized acute pain b. increased range of motion c. gait disturbance d. increased appetitee. palpable mass - a. Localized acute pain -e. palpable mass-. c. gait disturbance A client with COPD is receiving care at the primary provider's clinic with worsening of symptoms of emphysema. The provider orders an outpatient chest xray to determine if there have been any changes in lung structure. Which best describes what would show on a chest x-ray in the later stages of emphysema? a. increase size of heart b. flattened diaphragm c. plaque formation scattered throughout the lung d. mediastinal shift to the right - b. flattened diaphragm A client presents for the care of a primary care facility. The client is coughing and has a fever of 102. Which statement from the nurse regarding protective equipment is most appropriate in preventing the potential spread of this client's infection? a. please wait while I put on a mask before taking your vital signs b. I'm sorry, but you cannot come in here with your symptoms c. you will need to wear a mask, gown, and gloves while you wait to see the doctor d. you will need to wear a mask while you wait to see the provider - you will need to wear a mask while you wait to see the provider [Show Less]
- What are specific considerations for adult clients, clients who are taking anticoagulants, and clients who have fragile veins? - avoiding tourniquets, ... [Show More] using BP cuff to visualize. - no slapping - hold their hand below the heart. - avoid using the back of the hand - avoid rigorous friction while cleaning site. Infiltration - An IV that is pale, has local swelling, decreased skin temperature around the site, damp dressing and slowed infusion is what complication? Extravasation (infiltration of vesicant) - An IV is painful, burning, red and swelling what complication is occurring? - Stop the infusion and remove catheter - elevate extremity - encourage ROM - apply a cold or warm compress depending on the solution infiltrated. - check with the provider to determine whether they still need IV therapy. - What is the treatment for infiltrated IV? Fluid overload - A pt receiving IV solutions begins appearing with distended neck veins, hypertension, tachycardia, SOB, crackles in lungs, and edema what complication is occurring? - Stop the infusion and notify the provider - follow facility protocol. (withdrawing the vesicant solution from the IV access and infusing an antidote through catheter before removal. - repeated treatment for infiltration. - what is the treatment for extravasation?- What is the treatment for fluid overload? - Slow IV rate or stop. - raise HOB - monitor VS & O2 - Adjust the rate after correcting fluid. - anticipate administering diuretics Phlebitis/thrombophlebitis - A pt with an IV appears edematous, erythema, throbbing, burning, or pain at the site, increased skin temperature, red line, and slowed infusion are s/s of what IV complication? - promptly d/c the infusion and remove the catheter. - elevate extremity - apply a cold compress to minimize flow of blood, then warm to increase circulation. - restart if needed. - obtain a specimen for culture at site. - what treatments are there for phlebitis/thrombophlebitis? - Rotate sites at least every 72 hours according to facility policy. - Monitory IV sites using phlebitis scale - avoid lower extremities - use hand hygiene - use surgical aseptic technique. - What are some ways to prevent thrombophlebitis? Central nervous system stimulation - what type of medication would put a patient at risk for seizures and precautions should be taken. Central nervous system depression - what type of medication would require a patient to do not drive, operate heavy machinery, or participate in other activities can be dangerous.Anticholinergic drugs - what type of medications will require clients to increase fluids for their dry mouth, wear sunglasses for photophobia, maintaining urinary habits, and avoid overheating. Cardiovascular medications - What type of medications would make clients monitor for indications of orthostatic hypotension (lightheadedness, dizziness). - monitoring AST and ALT - n/v - jaundice - dark urine - abdominal discomfort - anorexia Primarily with acetaminophen. - A nurse should do what when giving medications that can create hepatoxicity? Primarily result of antimicrobial agents and NSAIDs. - monitor creatinine and BUN - peak and trough - What should the nurse monitor for drugs that cause nephrotoxicity? [Show Less]
A nurse is monitoring a client who received their first dose of an antibiotic. For which of the following findings should the nurse call the rapid respons... [Show More] e team? - Hypotension A nurse discovers that a client received a dose of furosemide instead of the famotidine the provider prescribed. For which of the following findings should the nurse monitor the client? - Hypotension A nurse is preparing an insulin injection for a client who has type 1 diabetes mellitus. Which of the following insulins can the nurse combine in the syringe? - NPH and regular A nurse is reinforcing teaching with a client who has a new prescription for bus-irons. The nurse should instruct the client to avoid drinking which of the following beverages while taking this mediation? - Grapefruit juice A nurse in a long-term care facility is performing medication reconciliation for a client who is being transferred from an acute care facility. Which of the following actions should the nurse take? - Compare a list of the client's current medications with the medications they will receive in the long-term care facility. A nurse is reviewing the laboratory results of a client who is taking lithium and has a lithium level of 2.1 mEq/L. For which of the following findings should the nurse monitor the client? - Seizure activity A nurse is preparing a liquid medication from a multidose bottle to administer to a client. Which of the following actions should the nurse take? - Measure the liquid at the base of the meniscus in a medication cup A nurse is preparing to administer several medications through a client's NG tube for a client who is receiving enteral feedings. All of the medications are crushable tablets. Which of the following actions should the nurse take? - Flush the tube with water before and after medication administration. A nurse is preparing to administer ear drops to a client. Which of the following actions should the nurse take? - Place the client in a lateral position after administration of the medication.A nurse is administering 1.5 mg of hydromorphone IM from a 2-mg/mL vial to manage a client's postoperative pain. Which of the following action should the nurse take when handling the remainder of the medication in the vial? - Have a second nurse witness the disposal of the medication. A nurse is monitoring a client who is receiving 0.9% sodium chloride IV. For which of the following findings should the nurse slow or stop the infusion rate and notify the provider? - Crackles A nurse is reinforcing teaching with an adult client who has a new prescription for etanercept to treat rheumatoid arthritis. Which of the following instructions should the nurse include? - "Inject the medication once per week." A nurse is caring for a client who has a cancer-related pain and is receiving an around-the-clock analgesic. The client has an additional prescription for a PRN analgesic. Which of the following actions should the nurse take to determine when to administer the PRN analgesic? - Have the client rate their pain using a standard scale. A nurse is reviewing the medical record of a client who is to start therapy with epoetin alfa. Which of the following findings should the nurse report to the provider as a contraindication for receiving the medication? - Uncontrolled high blood pressure. A nurse is caring for a client who is receiving oxycodone and has a respiratory rate of 8/min. For which of the following medications should the nurse expect a stat prescription? - Naloxone A nurse is caring for a client who is receiving lisinopril. The nurse should withhold the next dose and notify the provider when the client reports which of the following adverse effects of the medication? - Swollen tongue A nurse is caring for a client who has type 1 diabetes mellitus and just refined consciousness following administration of .5 mg of glucagon subcutaneously. Which of the following findings should the nurse identify as an indication that the medication was effective? [Show Less]
A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nur... [Show More] se take? - Tell the nurses that this conversation is not appropriate A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing following surgery. The client's religion prohibits eating meat on particular days. Which of the following actions should the nurse take? - Ask the dietitian to recommend alternative food choices for the client A nurse is collecting data from a client who requires bed rest and reports abdominal discomfort. The nurse notes abdominal distention. Which of the following conditions should the nurse identify as an adverse effect of bed rest? - Constipation A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? - The client has redness and warmth in his calf A nurse is contributing to the plan of care for four clients. Four which of the following clients should the nurse initiate airborne precautions? - A client who has measles A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following actions should the nurse recommend to the include in the plan? - Support the client's feet with foot boots A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? - Instruct the client to tilt her head forward while eating A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? - A client who has just experienced the death of his child A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off her right leg. Which of the following is the proper crutch gait for the client? - Three-pointA nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask? - Have you had small liquid stools? A nurse is collecting data from a client who is 2 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider? - A purple-colored stoma A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? - Urine specific gravity 1.045 A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions should the nurse take to maintain the client's confidentiality while providing care? [Show Less]
A nurse is contributing to the plan of care for a client who is newly admitted to a rehabilitation facility. Which of the following actions should the nur... [Show More] se take first? - Ask the client to identify his goals for recovery A nurse is preparing to reinforce discharge teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take? - Select an interpreter who is the same gender as the client. Ensure interpreters provided by the facility have knowledge of medical terminology. Choose an interpreter from the same ethnic background as the client. A nurse on a facility's performance improvement team is assisting to develop practice guidelines for performing bladder scans. Which of the following actions should the nurse take prior to developing a policy and procedure for this task? - Review evidence-based practice data related to bladder scanner use. A charge nurse is talking with two assistive personnel (AP) who are angry about the way lunch breaks are scheduled on the unit. Which of the following statements by the charge nurse demonstrates the use of compromise? - "You can take turns going to lunch first every other week" A community health nurse is reinforcing teaching with a group of parents about home safety for children of various age groups. Which of the following information should the nurse plan to include? - The supine position is the safest for sleeping infants. A nurse is participating in the unit's performance improvement program. The nurse should recognize that which of the following is a quality indicator? - The facility-wide fall injury rate for the previous quarter is 3% A nurse is monitoring an assistive personnel (AP) who is calculating I&O for a postoperative client. The client has a Jackson-Pratt drain and an indwelling urinary catheter. The nurse should recognize that theclients output is calculated and recorded correctly when the AP performs which of the following actions? - Includes emesis and wound drainage in the total recorded output A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday scheduling. Which of the following actions should the charge nurse take? - Encourage each staff nurse to give up something as part of the negotiation. A charge nurse in a long-term care facility is monitoring the activities of an assistive personnel (AP). Which of the following actions by the AP indicates that the charge nurse should intervene? - Stands with feet close together while transferring a client from the bed to a chair A nurse is reinforcing discharge teaching with a client who is 2 days postpartum. The client expresses concern about a lack of family support and limited financial resources. Which of the following responses should the nurse make? - "How do you feel about discussing your concerns with a social worker?" A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. Which of the following actions should the nurse take first? - Check the client for injuries. A nurse is contributing to the development of a fall prevention policy for clients who have dementia. Which of the following sources of information should the nurse identify as the primary guideline for the creation of the policy? [Show Less]
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take... [Show More] ? - D. Use a photometer to monitor the lamp's energy The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective. A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? - Dark red vaginal bleeding The nurse should expect this client with a mild placental abruption to have minimal dark red vaginal bleeding. A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? - Correct Answer: B. Assess the newborn's blood glucose level Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia. Incorrect Answers: A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal perforation. Instead, the nurse should obtain an axillary temperature. C. Bathing a newborn will increase heat loss. The infant should not be bathed until the temperature has stabilized within the normal range.D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally, there is a potential fire risk from the bassinet linens and the vent. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? - Correct Answer: C. Calcium gluconate The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent cardiac and respiratory arrest. Incorrect Answers: A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate. B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate. D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not magnesium sulfate. A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? - Correct Answer: "Place fresh cabbage leaves on your breasts." After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts.Leaves should be replaced when they become wilted. Incorrect Answers: A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate engorgement and swelling. C. Application of warmth to the breasts should be avoided because heat can stimulate milk production. An ice pack should be used to relieve engorged breasts. D. Milk should not be expressed from the breasts. This intervention would increase milk production rather than decrease it. A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? - Correct Answer: D. "You should eat dry foods that are high in carbohydrates when you wake up." The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast or crackers upon waking or when nausea occurs. Incorrect Answers: A. The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea and vomiting. B. The nurse should instruct the client to avoid brushing her teeth immediately after eating to decrease vomiting. C. The nurse should instruct the client to eat salty and tart foods during periods of nausea. A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? - [Show Less]
A nurse is caring for a client who is pregnant and states that her last menstrual period was April 1, 2013. Which of the following is the client's estimat... [Show More] ed date of delivery? A. Jan. 8, 2014 B. Jan. 15, 2014 C. Feb. 8, 2014 D. Feb. 15, 2014 - A. CORRECT: April 1, 2013, minus 3 months plus 7 days and 1 year equals an estimated date of delivery of Jan. 8, 2014. B. INCORRECT: This is incorrect using Nägele's rule. C. INCORRECT: This is incorrect using Nägele's rule. D. INCORRECT: This is incorrect using Nägele's rule. NCLEX® Connection: Health Promotion and Maintenance, Ante/Intra/Postpartum and Newborn Care A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply.) A. Client has delivered one newborn at term. B. Client has experienced no preterm labor. C. Client has been through active labor. D. Client has had two prior pregnancies. E. Client has one living child. - A. CORRECT: T1 indicates the client has delivered one newborn at term. B. INCORRECT: P0 indicates the client has had no preterm deliveries. C. INCORRECT: A1 indicates the client has had one miscarriage. D. CORRECT: G3 indicates the children has had two prior pregnancies and the client is currently pregnantE. CORRECT: L1 indicates the client has one living child. NCLEX® Connection: Health Promotion and Maintenance, Ante/Intra/Postpartum and Newborn Care A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following would be included? (Select all that apply.) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening - A. INCORRECT: Montgomery's glands are a presumptive sign of pregnancy. B. CORRECT: Goodell's sign is a probable sign of pregnancy. C. CORRECT: Ballottement is a probable sign of pregnancy. D. CORRECT: Chadwick's sign is a probable sign of pregnancy. E. INCORRECT: Quickening is a presumptive sign of pregnancy. NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following is an appropriate response by the nurse? A. "This is due to an increase in blood volume." B. "This is due to pressure from the uterus on the diaphragm." C. "This is due to the weight of the uterus on the vena cava." D. "This is due to increased cardiac output." - A. INCORRECT: An increase in blood volume during pregnancy results in cardiac hypertrophy. B. INCORRECT: Pressure from the gravid uterus on the diaphragm may cause the client to experience shortness of breath. C. CORRECT: Maternal hypotension occurs when the client is lying in the supine position, and the weight of the gravid uterus places pressure on the vena cava, decreasing venous blood flow tothe heart. D. INCORRECT: An increase in cardiac output during pregnancy results in cardiac hypertrophy. NCLEX® Connection: Reduction of Risk Potential, Changes/Abnormalities in Vital Signs A nurse in a clinic receives a phone call from a client who believes she is pregnant and would like to be tested in the clinic to confirm her pregnancy. Which of the following information should the nurse provide to the client? A. "You should wait until 4 weeks after conception to be tested." B. "You should be off any medications for 24 hours prior to the test." C. "You should be NPO for at least 8 hours prior to the test." D. "You should collect urine from the first morning void [Show Less]
Around what time period is it possible to first hear the fetal heart tones? - End of first trimester. 10th or 11th week of gestation. Where should you po... [Show More] sition the device to listen to a fetal heart tone? - Start at midline above the symphysis pubis. Slowly move around abdomen if not heard right away. What two things can make it hard to hear fetal heart tones? - Excessive amniotic fluid (hydraminos) or excessive subcutaneous fat. What is the name of the assessment for assessing gestational age? What age group is it appropriate for? - New Ballard Score (20-44 weeks of gestation) What is the time limit for using the new ballard score after a baby is born? - Specifically within 12 hours for less than or equal to 26 gestational weeks. (Within 48 hours for majority of babies). What things do you assess with the new ballard score? - Six neuromuscular and six physical characteristics. What is the leopold maneuver used for [Show Less]
A nurse in a health clinic is reviewing contraceptive use with a group of clients. Which of the following client statements demonstrates understanding? A... [Show More] . "A water-soluble lubricant should be used with condoms." B. "A diaphragm should be removed 2 hours after intercourse." C. "Oral contraceptives can worsen a case of acne." D. "A contraceptive patch is replaced once a month." - A. "A water-soluble lubricant should be used with condoms." A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include? A. Reduced menstrual flow B. Breast tenderness C. Shortness of breath D. Increased appetite - C. Shortness of breath A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "An IUD should be replaced annually during a pelvic exam." B. "I cannot get an IUD until after I've had a child." C. "I should plan on regaining fertility 5 months after the IUD is removed." D. "I will check to be sure the strings of the IUD are still present after my periods. - D. "I will check to be sure the strings of the IUD are still present after my periods. A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (Select all that apply.) A. Tinnitus B. Irregular vaginal bleeding C. Weight gain D. NauseaE. Gingival hyperplasia - B. Irregular vaginal bleeding C. Weight gain D. Nausea A nurse in a clinic is teaching a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Weight fluctuations can occur." B. "You are protected against STIS." C. "You should increase your intake of calcium." D. "You should avoid taking antibiotics." E. "Irregular vaginal spotting can occur." - A. "Weight fluctuations can occur." C. "You should increase your intake of calcium." E. "Irregular vaginal spotting can occur." A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor? A. A client whose sister has alopecia B. A client whose partner has von Willebrand disease C. A client who has an allergy to sulfa D. A client who had rubella 3 months ago - B. A client whose partner has von Willebrand disease A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? A. "You will need to see a genetic counselor as part of the assessment." B. "It is usually the female who is having trouble, so the male doesn't have to be involved." C. "The male is the easiest to assess, and the provider will usually begin there." D. "Think about adopting first because there are many babies that need good homes." - C. "The male is the easiest to assess, and the provider will usually begin there."A nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following data should the nurse assess? (Select all that apply.) A. Occupation B. Menstrual history C. Childhood infectious diseases D. History of falls E. Recent blood transfusions - A. Occupation B. Menstrual history C. Childhood infectious diseases A nurse in a clinic is caring for a client who is postoperative following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? A. "It is good to know that I won't have a tubal pregnancy in the future." B. "The doctor said that this surgery can affect my ability to get pregnant again." C. "I understand that one of my fallopian tubes had to be removed." D. "Ovulation can still occur because my ovaries were not affected." - A. "It is good to know that I won't have a tubal pregnancy in the future." A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A. January 8 B. January 15 C. February 8 D. February 15 - A. January 8 A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 PO A1 L1. How should the nurse interpret this information? (Select all that apply.) A. Client has delivered one newborn at term. B. Client has experienced no preterm labor. C. Client has been through active labor.D. Client has had two prior pregnancies. E. Client has one living child. - A. Client has delivered one newborn at term. D. Client has had two prior pregnancies. E. Client has one living child. A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (Select all that apply.) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening - B. Goodell's sign C. Ballottement D. Chadwick's sign A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? A. "This is due to an increase in blood volume." B. "This is due to pressure from the uterus on the diaphragm." C. "This is due to the weight of the uterus on the vena cava." D. "This is due to increased cardiac output." - C. "This is due to the weight of the uterus on the vena cava." A nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm a pregnancy. Which of the following information should the nurse provide to the client? A. "You should wait until 4 weeks after conception to be tested." B. "You should be off any medications for 24 hours prior to the test." C. "You should be NPO for at least 8 hours prior to the test."D. "You should collect urine from the first morning void." - D. "You should collect urine from the first morning void." A nurse is teaching a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? (Select all that apply.) A. Avoid any lifting. B. Perform Kegel exercises twice a day. C. Perform the pelvic rock exercise every day. D. Use proper body mechanics. E. Avoid constrictive clothing [Show Less]
A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan... [Show More] to administer? - Betamethasone Rationale: The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression. a diet teaching for hyperemesis gravidarum "I will eat foods that taste good instead of balancing my meals." "I will avoid having a snack before I go to bed each night." "I will have a cup of hot tea with each meal." "I will eliminate products that contain dairy from my diet." - "I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed. should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal. do not need to eliminate dairy products from their diet. The client should be encouraged to consume dairy products, because they are less likely to cause nausea than other foods. performing Leopold maneuvers steps? - The first step- palpate the client's fundus to identify the FETAL part.Second, determine the location of the fetal BACK. Third, palpate for the fetal part presenting at the INLET. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head. A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? Oligohydramnios Hyperemesis gravidarum Leukorrhea Periodic tingling of the fingers - Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, postterm pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis. Hyperemesis gravidarum is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. Leukorrhea is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. Periodic tingling of the fingers is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring. assessing a pregnant is at the end of the first trimester. Place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones FHT? Just above the umbilicus Just above the symphysis pubisThe right lower quadrant The left lower quadrant - Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. Therefore, the nurse might not hear FHT in the right or left lower quadrant. The nurse should assess FHT using the Doppler stethoscope just above the umbilicus if the fetus is in a transverse or breech presentation and the client is at a minimum of 22 weeks of gestation. A nurse is caring for a client who is at 35 weeks of gestation and is experiencing placenta previa. Which should take? Perform a vaginal exam to determine cervical dilation every 2 hr. Instruct the client to ambulate in the hallway once every 4 hr. Administer betamethasone to the client via IM injection. Initiate continuous external fetal monitoring. - Initiate continuous external fetal monitoring. The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth. Betamethasone is given to enhance fetal lung maturity for clients who are experiencing preterm labor. It is given to clients between 24 and 34 weeks of gestation. A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. Ambulating frequently could potentially stimulate labor and increase vaginal bleeding. Therefore, the nurse should place the client on bed rest with bathroom privileges.A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should place the client on pelvic rest and should not perform vaginal or rectal examinations. A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following laboratory tests will be used to confirm her pregnancy? - A urine test for the presence of human chorionic gonadotropin Rationale: Human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone and estrogen. This hormone is the basis for pregnancy testing. A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? - Palpable fetal movement rationale: Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy. Chadwick's sign A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? [Show Less]
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? ... [Show More] a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings - b. place the naked newborn on the mothers bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding. A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment - a. place the newborn directly on the client's chest The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature. A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? a. apply barrier ointment to the newborn's perianal regionb. offer the newborn glucose water between feedings c. use photometer to monitor the lamp's energy d. keep the newborn's eye patches on during feedings - c. use photometer to monitor the lamp's energy the nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm - c. I will place my baby on his back when it is time for him to sleep The newborn should always sleep on his back to prevent sudden infant death syndrome. A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7 - b. 9 The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2 to each of five categories. The nurse should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl supp d. assist the client to empty her bladder - d. assist the client to empty her bladder When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia. A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer? - 0.25 A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? a. continue routine monitoring b. place newborn prone c. request a script for supplemental o2 d. perform chest percussion - [Show Less]
A nurse in a health clinic is reviewing contraceptive use with a group of clients. Which of the following client statements demonstrates understanding? A... [Show More] . "A water-soluble lubricant should be used with condoms." B. "A diaphragm should be removed 2 hours after intercourse." C. "Oral contraceptives can worsen a case of acne." D. "A contraceptive patch is replaced once a month." - A. "A water-soluble lubricant should be used with condoms." A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include? A. Reduced menstrual flow B. Breast tenderness C. Shortness of breath D. Increased appetite - C. Shortness of breath A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "An IUD should be replaced annually during a pelvic exam." B. "I cannot get an IUD until after I've had a child." C. "I should plan on regaining fertility 5 months after the IUD is removed." D. "I will check to be sure the strings of the IUD are still present after my periods. - D. "I will check to be sure the strings of the IUD are still present after my periods. A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (Select all that apply.) A. Tinnitus B. Irregular vaginal bleedingC. Weight gain D. Nausea E. Gingival hyperplasia - B. Irregular vaginal bleeding C. Weight gain D. Nausea A nurse in a clinic is teaching a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Weight fluctuations can occur." B. "You are protected against STIS." C. "You should increase your intake of calcium." D. "You should avoid taking antibiotics." E. "Irregular vaginal spotting can occur." - A. "Weight fluctuations can occur." C. "You should increase your intake of calcium." E. "Irregular vaginal spotting can occur." A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor? A. A client whose sister has alopecia B. A client whose partner has von Willebrand disease C. A client who has an allergy to sulfa D. A client who had rubella 3 months ago - B. A client whose partner has von Willebrand disease A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? A. "You will need to see a genetic counselor as part of the assessment." B. "It is usually the female who is having trouble, so the male doesn't have to be involved." C. "The male is the easiest to assess, and the provider will usually begin there." D. "Think about adopting first because there are many babies that need good homes." - C. "The male is the easiest to assess, and the provider will usually begin there."A nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following data should the nurse assess? (Select all that apply.) A. Occupation B. Menstrual history C. Childhood infectious diseases D. History of falls E. Recent blood transfusions - A. Occupation B. Menstrual history C. Childhood infectious diseases A nurse in a clinic is caring for a client who is postoperative following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? A. "It is good to know that I won't have a tubal pregnancy in the future." B. "The doctor said that this surgery can affect my ability to get pregnant again." C. "I understand that one of my fallopian tubes had to be removed." D. "Ovulation can still occur because my ovaries were not affected." - A. "It is good to know that I won't have a tubal pregnancy in the future." A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A. January 8 B. January 15 C. February 8 D. February 15 - A. January 8 A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 PO A1 L1. How should the nurse interpret this information? (Select all that apply.) A. Client has delivered one newborn at term. B. Client has experienced no preterm labor.C. Client has been through active labor. D. Client has had two prior pregnancies. E. Client has one living child. - A. Client has delivered one newborn at term. D. Client has had two prior pregnancies. E. Client has one living child. A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (Select all that apply.) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening - B. Goodell's sign C. Ballottement D. Chadwick's sign A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? A. "This is due to an increase in blood volume." B. "This is due to pressure from the uterus on the diaphragm." C. "This is due to the weight of the uterus on the vena cava." D. "This is due to increased cardiac output." - C. "This is due to the weight of the uterus on the vena cava." A nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm a pregnancy. Which of the following information should the nurse provide to the client? A. "You should wait until 4 weeks after conception to be tested." B. "You should be off any medications for 24 hours prior to the test." C. "You should be NPO for at least 8 hours prior to the test."D. "You should collect urine from the first morning void." - D. "You should collect urine from the first morning void." A nurse is teaching a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? (Select all that apply.) A. Avoid any lifting. B. Perform Kegel exercises twice a day. C. Perform the pelvic rock exercise every day. D. Use proper body mechanics. E. Avoid constrictive clothing. - C. Perform the pelvic rock exercise every day. D. Use proper body mechanics. A nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. Which of the following complications should the nurse include? [Show Less]
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? - ... [Show More] Massage the clients fundus. A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? - Late decelarations A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? - Blurred vision A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? - Vaginal Pressure A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plain to prepare the client for which of the following diagnostic tests? - Biophysical profile A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? - Depression A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? - Maintain the client on bed rest. A nurse is providing teaching to a client is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? - "I can administer oxytocin 4 hours after the insertion of the medication."A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? - A newborn who is 18 hr old and has an axillary temperature of 37.7 C (99.9 F) A nurse is caring for a client is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? - Respiratory rate 10/min A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? - "I should take 600 micrograms of folic acid each day" A nurse is assessing a late preterm newborn. Which of the following manifestation is an indication of hypoglycemia? - Respiratory distress A nurse is a prenatal clinic is assessing a group of clients. Which of the following client should the nurse see first? - A client who is 11 weeks of gestation and reports abdominal cramping A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse preform the following actions? [Show Less]
what is tonic neck reflex? - quickly and gently turn neonates head to one side what is the babinski reflex? - stroke bottom of foot upward along the later... [Show More] al aspect the along the ball of the foot with a finger. normal: toes will hyperextend while big toes dorsiflexes when do a nurse administers erythromycin ophthalmic (ilotycin) to neonates? - within 1 hour after delivery, for prophylactic treatment of opthalmia neonatorum PID? - places pt at risk for ectopic pregnancy jaundice in the first 24 hours of life? - get a stat bilirubin level what is cephalohematoma? - is normal soft spot on the new borns is bluish, with edema that does not cross the suture line there is no need for treatment because it will disappear within 2-6 weeks what is important in breast milk production? - fluid intake a nurse checks a postpartum pt peripad and finds a large amount of lochia rubra with several clots? - the first thing that must be done is to check the fundus acrocyanosis? - normal finding in neonate, cool, slightly blue tinged distal extremities related to immature circulatory system the nurse should swaddle the neonate in blankets what is a s/s of congenital hip dysplasia? - is limited abduction of the hip, that means the head of the femur may have slip out of the acetabulumwhat will help a pt with a cessarian and abdominal distention? - to ambulate in hallway normal glucose for newborns? - 40-95 normal RR for newborns? - 40-60 turn lbs to kg? - 4lbs 4 oz there is 16 oz in one lb divide 4oz/16=0.25 4.25 lbs the expectant father feels resentful of added attention to wife and pregnancy? - these feelings are common and normal a postpartum pt is out of bed for first time, she passes a blood clot and notices an increase in her lochia? - this finding is normal following a period of time in bed in the imediate postpartum period whats is an inappropriate action for an infant who is receiving phototherapy for elevated bilirubin? - the infant should never be swaddle, he should be left exposed to the light to make therapy successful when does lanugo begins? - lanugo is a fine hair covering and is greatest between 28-30 weeks gestation and then begins to disappear how would the fundus look after a laceration? [Show Less]
Maternal Newborn ATI Questions - Exam 1 Are diaphragms one-size-fits-all? - No, a female client should be fitted with a diaphragm properly by a provider... [Show More] . How long should a diaphragm be used before replacement? What other situations warrant replacement? - A client must be refitted by the provider every 2 years. If there is a 15 lb weight change, full-term pregnancy, or second-term abortion, the client should be refitted. Does the diaphragm work all by itself or do you need something else? - It should be inserted with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim. How long does the diaphragm need to be in place following coitus? - 6 hours. Should spermicide be reapplied with each act of coitus? - Absolutely. What should the client do prior to inserting the diaphragm (besides using the spermicide)? - The client should empty her bladder. Can you buy a diaphragm at the drug store? - No, a prescription and a visit to the provider is necessary. What is a major risk/possible complication of using a diaphragm? - Toxic Shock Syndrome (TSS). If you have a history of TSS, you should use a diaphragm. Risk of getting TSS goes up by using one. It's a bacterial infection. Proper hand hygiene should be observed when inserting and removing the device. What two hormones are found in combined oral contraceptives? - Estrogen + progestin How do these two hormones work to prevent conception? - Suppresses ovulation, thickening the cervical mucus to block semen, and altering the uterine deduce to prevent implantation.How does a client get access to this medication? - Requires a prescription and follow-up appointments with the provider. What side effects and danger signs should be observed? - Chest pain, shortness of earth, leg pain from a possible clot, headache, or eye problems from a stroke, or hypertension. What happens if a dose is missed? 2-3 doses? - Take the missed does as soon as possible. If 2-3 doses are missed, follow manufacturer's instructions. Use alternative forms of contraception or abstinence to precent pregnancy until regular dosing is resumed. What are the advantages to combined oral contraceptives? - Highly effective if taken correctly and consistently. Can alleviate dysmenorrhea by decreasing menstrual flow and menstrual cramp. Reduces acne. What are the disadvantages to combined oral contraceptives? - Do not protect against STIs. Can increase thromboses, breast tenderness, scant or missed menstruation, stroke, nausea, headaches, and hormone-dependent cancers. Exacerbates conditions affected by fluid retention such as migraine, epilepsy, asthma, kidney, or heat disease. What risks/possible complications exist with combined oral contraceptives? - Caution to client's with history of: blood clots, stroke, cardiac problems, breast or estrogen-related cancers, pregnancy, or smoking (if over 35 years). What medications decrease the effectiveness of combined oral contraceptives? - Those that effect liver enzymes, such as anticonvulsants and some antibiotics. What hormones make up the mini pill? - Progestins than provide the same action as combined oral contraceptives. Is ok to miss a dose of the mini pill? - No, a client CANNOT miss a pill. How often is the mini pill take? - Should be take EVERY day at the SAME time. Another form of birth control may need to be utilized during the first month of use to prevent pregnancy.Advantages of the mini pill? - Fewer side effects when compared with a combined oral contraceptive. Considered safe to take while breastfeeding. Disadvantages of the mini pill? [Show Less]
A nurse in a health clinic is reviewing contraceptive use with a group of adolescent clients. Which of the following statements by an adolescent reflects ... [Show More] an understanding of the teaching? a. "A water-soluble lubricant should be used with condoms." b. "A diaphragm should be removed 2 hours after intercourse." c. "Oral contraceptives can worsen a case of acne." d. "A contraceptive patch is replaced once a month." - A. A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following? a. Reduced menstrual flow b. Breast tenderness c. SOB d. Headaches - C. A nurse in a OB clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? a. "An IUD should be replaced annually during a pelvic exam." b. "I cannot get an IUD until after I've had a child." c. "I should expect intermittent abdominal pain while the IUD is in place." d. "A change in the string length of my IUD is unexpected." - D.A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (SATA) a. Tinnitus b. Irregular vaginal bleeding c. Weight gain d. Breast changes e. Gingival hyperplasia - B., C., D. A nurse in a clinic is teaching a client about her new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (SATA) a. "Weight loss can occur." b. "You are protected against STIs" c. "You should increase your intake of calcium." d. "You should avoid taking antibiotics." e. "Irregular vaginal spotting can occur." - C., E. A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor? a. A client whose sister has alopecia b. A client whose partner has von Willebrand disease c. A client who has an allergy to sulfa d. A client who had rubella 3 months ago - B.A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? a. "You will need to see a genetic counselor as part of the assessment." b. "It is usually the woman who is having trouble, so the man doesn't have to be involved." c. "The man is the easiest to assess, and the provider will usually begin there." d. "Think about adopting first because there are many babies that need good homes." - C. A nurse in an infertility clinic is providing care to a couple who has been unable to conceive for 18 months. Which of the following data should be included in the assessment? (SATA) a. Occupation b. Menstrual history c. Childhood infectious diseases d. History of falls e. Recent blood transfusions - A., B., C. A nurse in a clinic is caring for a client who is to be seen by the provider for a post-op appointment following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? a. "It is good to know that I won't have a tubal pregnancy in the future." b. "The doctor said that this surgery can affect my ability to get pregnant again." c. "I understand that one of my fallopian tubes had to be removed." d. "Ovulation can still occur because my ovaries were not affected." - A.A nurse is reviewing the health record of a client who is to undergo hysterosalpingography. Which of the following data alert the nurse that the client is at risk for a complication related to this procedure? Vital: temp 98.9 and BMI of 40.3 H&P: radiology technician Lab: glucose 103 and total cholesterol of 265 mg/dL a. Vital signs b. H&P c. Lab findings d. Medications - B. A nurse is caring for a client who is pregnant and states that her last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? a. January 8 b. January 15 c. February 8 d. February 15 - A. A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (SATA) a. Client has delivered one newborn at term b. Client has experienced no preterm labor c. Client has been through active labor d. Client has had two prior pregnancies e. Client has one living child- A., D., E. A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (SATA) a. Montgomery's glands b. Goodell's sign c. Ballottement d. Chadwick's sign e. Quickening - B., C., D. A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? a. "This is due to an increase in blood volume." b. "This is due to pressure from the uterus on the diaphragm." c. "This is due to the weight of the uterus on the vena cava." d. "This is due to increased cardiac output." - C. A nurse in a clinic receives a phone call from a client who believes she is pregnant and would like to be tested in the clinic to confirm her pregnancy. Which of the following information should the nurse provide to the client? a. "You should wait until 4 weeks after conception to be tested." b. "You should be off any medications for 24 hours prior to the test." c. "You should be NPO for at least 8 hours prior to the test." d. "You should collect urine from the first morning void."- D. A nurse is teaching a group of women who are pregnant about measures to relieve a backache during pregnancy. Which of the following measures should the nurse include in the teaching? (SATA) a. Avoid any lifting b. Perform Kegel exercises twice a day c. Perform the pelvic rock exercise everyday d. Use proper body mechanics e. Avoid constrictive clothing - C., D. A nurse is caring for a client who is pregnant and reviewing signs of complications the client should promptly report to the provider. Which of the following complications should the nurse include in the teaching? a. Vaginal bleeding b. Swelling of the ankles c. Heartburn after eating d. Lightheadedness when lying on back - A. A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include in the teaching [Show Less]
What is the fourth stage of labor and when does it start? - Postpartum period- starts after the delivery of the placenta What are the greatest risks duri... [Show More] ng the postpartum period? - Hemorrhage Shock Infection When is RH immune globulin (RhoGAM) administered to post partum women? - Administered 72 hours for women who are Rh-negative and gave birth to infants who are Rh-positive This prevents sensitization to Rh in future pregnancies What is included in the postpartum nursing assessment? - Monitoring vital signs Assessing uterine firmness & location in relation to umbilicus Uterine position in relation to midline (if deviated, assist mom in emptying bladder) Amount of vaginal bleeding (lochia) How often should vitals be monitored after delivery? - Every 15 min for the first hour Every 30 minutes for second hour Every 4-8 hr depending on remaining medication regimen This occurs with contractions of the uterine smooth muscle, whereby the uterus returns to its prepregnant state - Involution Defined as blood flow from the uterus during postpartum period - Lochia This type of lochia is bright red in color, bloody consistency, fleshy odor, may contain small clots - Lochia rubraThis type of lochia is pinkish brown in color & serosanguineous consistency - Lochia serosa This type of lochia is yellowish, white creamy color, fleshy odor - Lochia alba When is colostrum present in the new mother's breasts? - During pregnancy and 2-3 days immediately after birth Defined as an infection in a milk duct of the breast with concurrent flulike symptoms - Mastitis What are therapeutic and approved holding positions when breast feeding? - Cradle hold Side-lying hold Football hold What does breast feeding cause the release of? What does this prevent? - Breast feeding causes the release of oxytocin which stimulates uterine contractions (will prevent hemorrhage) What are normal lab values in the post partum period? - Increased Hct & Hgb up to 72 hours Leukocytosis (WBC count up to 20,000-25,000 for the first 10-14 days, without presence of infection) Increased coagulation factors Increased fibrinogen A medical condition during pregnancy defined as excessive nausea and vomiting that is prolonged past 12 weeks of gestation. Results in weight loss & electrolyte imbalance - Hyperemesis gravidarum What are nursing responsibilities when caring for a patient diagnosed with hyperemesis gravidarum? - Monitor client's I&O Assess client's skin turgor/mucous membranes Monitor vital signs Monitor client's weightHave client remain NPO for 24-48 hours This medical condition occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron - Anemia This medical condition is defined as an impaired tolerance to glucose with the first onset or recognition during pregnancy - Gestational diabetes mellitus What is the ideal blood glucose level during pregnancy? - 70-110mg/dL What are the clinical manifestations of hypoglycemia? - Nervousness Headache Weakness Irritability Hunger Blurred vision Tingling of mouth/extremities What are the clinical manifestations of hyperglycemia? [Show Less]
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse ex... [Show More] pect? A. Reports increased urinary output B. Diaphoresis C. Reports blurred vision D. Shallow respirations - A. Reports increased urinary output Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? A. Administer penicillin G 2.4 million units IM to the client B. Instruct the client to schedule an annual pelvic examination. C. Tell the client she will start medication for HIV immediately after delivery D. Report the client's condition to the local health department - D. Report the client's condition to the local health department The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported. A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?A. Depression B. Polyuria C. Hypotension D. Urticaria - A. Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness. A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? A. "I can administer oxytocin 4 hours after the insertion of the medication." B. "You will need a full bladder prior to the insertion of the medication." C. "Remain in a side-lying position for 15 minutes after the medication is inserted." D. "An antacid will be given 20 minutes prior to the insertion of the medication." - A. "I can administer oxytocin 4 hours after the insertion of the medication." The nurse can administer oxytocin no sooner than 4 hours after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor. A nurse is caring for a prenatal client who has parovirus B19 (fifth disease). Which of the following actions should the nurse take? A. Administer antiviral medication B. Schedule an ultrasound examination C. Administer Haemophilus influenzae type b vaccine D. Schedule an indirect Coombs' test - B. Schedule an ultrasound examinationThe nurse should serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? A. Apply a cool pack fo 10 minutes to the heel prior to the puncture. B. Request a prescription for IM analgesic C. Use a manual lance blade to pierce the skin D. Place the newborn skin to skin on the mother's chest. [Show Less]
Around what time period is it possible to first hear the fetal heart tones? - End of first trimester. 10th or 11th week of gestation. Where should you po... [Show More] sition the device to listen to a fetal heart tone? - Start at midline above the symphysis pubis. Slowly move around abdomen if not heard right away. What two things can make it hard to hear fetal heart tones? - Excessive amniotic fluid (hydraminos) or excessive subcutaneous fat. What is the name of the assessment for assessing gestational age? What age group is it appropriate for? - New Ballard Score (20-44 weeks of gestation) What is the time limit for using the new ballard score after a baby is born? - Specifically within 12 hours for less than or equal to 26 gestational weeks. (Within 48 hours for majority of babies). What things do you assess with the new ballard score? - Six neuromuscular and six physical characteristics. What is the leopold maneuver used for? - Determine number of fetuses, the presenting part, the fetal lie, the fetal altitude, the fetal position, the degree of the descent into the pelvis, and the best location for auscultating fetal heart tones. What should you do before starting the leopold maneuver? - Have patient use the bathroom to avoid discomfort. What is the minimum hospital stay that all health care plans are mandated to cover for a vaginal birth? C-section? - 48 Hours; 96 hoursWhen can you remove the cord clamp? - When the cord is dry, about 24 hours of age. Patient education for cord care? - Clean the stump with water, let dry. Watch for swelling, redness at the base, purulent drainage, and a foul odor. Do not cover stump with diaper. When does the rest of the umbilical cord usually fall off? [Show Less]
Are diaphragms one-size-fits-all? - No, a female client should be fitted with a diaphragm properly by a provider. How long should a diaphragm be used bef... [Show More] ore replacement? What other situations warrant replacement? - A client must be refitted by the provider every 2 years. If there is a 15 lb weight change, full-term pregnancy, or second-term abortion, the client should be refitted. Does the diaphragm work all by itself or do you need something else? - It should be inserted with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim. How long does the diaphragm need to be in place following coitus? - 6 hours. Should spermicide be reapplied with each act of coitus? - Absolutely. What should the client do prior to inserting the diaphragm (besides using the spermicide)? - The client should empty her bladder. Can you buy a diaphragm at the drug store? - No, a prescription and a visit to the provider is necessary. What is a major risk/possible complication of using a diaphragm? [Show Less]
What *is* Maternity Nursing? - Caring for women and infants during the childbearing cycle What are the components of women's health nursing? - Meeting p... [Show More] hysical, psychologic, and social needs of women throughout the lifespan How did maternity nursing start? - With Lay immigrant midwives and "granny midwives" in the South What is the term of using hard sedatives for maternity nursing? - twilight sleep How did people in the 1700s do midwife stuff - with like distraction Who started the Children's Bureau and what did she do - Lillian Wald, discovered when you keep things clean and seek help, they have better birth outcomes Who stared "pain free birthing" [Show Less]
Antihypertensives - These drugs affect both the blood pressure and the rhythm of the heart. Monitor patient blood pressure. *Orthostatic hypotension is a... [Show More] common side effect*. 1) Betablockers 2) Alpha 1 Blockers 3) Calcium Channel blockers 4) ACE Inhibitors 5) ARB Inhibitors 6) Diuretics Betablockers - Usually end in *-olol*. Propranolol (Inderal) Atenolol (Tenormin) Metoprolol (Lopressor) What additional effects of betablockers should the nurse monitor? - The nurse should monitor for broncho constriction and bronchospasms due to beta-2 adrenergic blocking mechanisms. In what population should betablockers be used cautiously in? - Betablockers should be used cautiously in patients who suffer from asthma. Beta blockers can mask tachycardia in patients suffering from *hypovolemia* and hypoglycemic symptoms seen in diabetic patients. What affects do betablockers cause? - Therapeutic effects include decreasing blood pressure and heart rate. Alpha 1 blocker - Clonidine (Catapres)What affects do alpha 1 blockers cause? - They cause systemic vasodilation by directly acting on smooth muscle of arteries. What adverse effects can alpha 1 blockers cause? - Hypotension, dizziness, sedation. In what form are alpha 1 blockers usually administered? - Alpha 1 blockers are generally administered as a patch and are changed once a week. Calcium Channel Blockers [Show Less]
A nurse is caring for a client who is experiencing acute alcohol withdrawal. For which of th client outcomes should the nurse administer chlordiazepoxide?... [Show More] - A: Prevent delirium trem A nurse is teaching a client about the use of risedronate for the treatment of osteoporosis should identify which of the following statements as an indication that the client understa teaching? - A: "I should sit up 30 minutes after taking the risedronate." A nurse is assessing a client 1 hour after administering morphine for pain. The nurse shou which of the following findings as the best indication that the morphine has been effectiv client rates pain as a 3 on a scale from 0 to 10 A nurse is administering donepezil to a client who has Alzheimer's disease. Which of the f findings should the nurse report to the provider immediately? - A: Dyspnea A nurse is caring for a client who is take acetazolamide for chronic open-angle glaucoma. the following adverse effects should the nurse instruct the client to monitor and report? - fingers A nurse is teaching a client who is to start taking hydrocodone with acetaminophen tablet Which of the following information should the nurse include in the teaching? - A: Decreas might occur A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for Which of the following instructions should the nurse include? - A: "Report yellowing of th Math question: ciproflaxin 15mg/kg PO q12 hr to a child who weighs 44lb. - A: 300 mg A nurse administers a dose of metformin to to a client instead of the prescribed dose of metoclopramide. Which of the following actions should the nurse take first? - A: Check th glucose [Show Less]
A nurse is caring for a client who has streptococcal pharyngitis and an allergy to penicillin. The nurse should recognize that which of the following drug... [Show More] s can be safely administered to this client? - Azithromycin/Erythromycin. Rationale: Azithromycin, a macrolide, is an acceptable alternative to penicillin for patients who have bacterial infections and are allergic to penicillin. The medication is effective against many gram-positive and gram-negative bacteria and is used for streptococcal pharyngitis. - Nafcillin and amoxicillin/clavulanic acid are penicillins and are contraindicated for those w/a penicillin allergy. Vancomuycin and clindamycin are safer alternatives. - A small percentage of clients who are allergic to penicillin have a cross sensitivity to cephalosporins. Cephalexin is a cephalosporin and is an inappropriate choice for the client. A nurse is administering cefotetan IV to a client to treat an intra-abdominal infection. The nurse notes that the IV insertion site is warm, edematous, and painful to the touch. Which of the following actions should the nurse take? - Stop the cefotetan infusion. Rationale: The nurse should stop the infusion, remove the IV catheter, assess for tissue damage, and treat the client accordingly. The nurse should then initiate IV access via another site, continuing cefotetan therapy according to prescribed parameters. - Because the client could have thrombophlebitis, slowing the infusion will not alleviate the potential tissue damage or risk of embolus, and the IV site should be changed. To prevent thrombophlebitis, the nurse should dilute cefotetan, a second-generation cephalosporin, and infuse it slowly over 20 to 30 min. - The edematous, painful, and warm IV insertion site does not indicate an allergic reaction. The nurse should administer an antihistamine, such as diphenhydramine, if the client has hives, a rash, or other indications of an allergy to cephalosporins. - Switching the client to another antibiotic is essential when the current drug is ineffective or the client has an intolerable reaction to it. A nurse is caring for a client who has a new prescription for aztreonam to treat a respiratory tract infection. Which of the following findings in the client's medical record should the nurse recognize as requiring cautious use for this rx and report to the provider? - Renal impairment.Rationale: Aztreonam, a monobactam, requires cautious use with clients who have renal dysfunction because it is excreted in the urine. Renal impairment could affect the excretion of aztreonam, allowing the level of the drug to accumulate. The nurse should report this finding to the provider, so the provider can prescribe a lower dose for the client or prescribe a different antimicrobial drug. - Contraindicated in those with a viral infection, used cautiously in older adults. - Metronidazole is an antimicrobial drug that req's cautious use in those with HF. A nurse is providing teaching for a client who takes an oral contraceptive and is about to begin rifampin therapy to treat TB. Which of the following instructions should the nurse include? - Use additional/nonhormonal form of contraception, as the drug can increase the metabolism of oral contraceptives. A nurse is caring for a client who has a gynecologic infection and a hx of alcohol use disorder. The nurse should identify that which of the following drugs can cause a rxn similar to disulfiram if the client drinks alcohol while taking it? SATA. - Cefotetan + Metronidazole [Show Less]
Nurse is caring for pt who is experiencing acute EtOH w/drawl. For which of following pt outcomes should nurse administer chlordiazepoxide? - Prevent deli... [Show More] rium tremens The client should take chlordiazepoxide to prevent delirium tremens during acute alcohol withdrawal. Nurse is teaching pt about use of risedronate for treatment of osteoporosis. Nurse should identify which of following statements as an indicaiont about pt understands teaching? - "I should sit up for 30 minutes after taking the risedronate." Sitting upright for at least 30 min after taking risedronate will reduce the adverse gastrointestinal effects of esophagitis and dyspepsia. Risedronate is contraindicated for a client who cannot sit or stand upright for this length of time. Nurse is assessing pt 1 hr after administering morphine for pain Nurse should identify which of following findings as best indication that morphine has been effective? - The client rates pain as 3 on a scale from 0 to 10. The client's description of the pain is the most accurate assessment of pain. Nurse is administering donepezil to a pt who has Alzheimer's disease. Which of following findings should nurse report to provider immediately? - Dyspnea When using the airway, breathing, circulation approach to client care, the nurse should report the adverse effect of dyspnea, caused by bronchoconstriction, to the provider first. Bronchoconstriction, dyspepsia, diarrhea, and dizziness are caused by the increase in acetylcholine levels, which is a primary effect of donepezil. Nurse is caring for pt who is taking acetazolamide for chronic open-angle glaucoma. For which of following adverse effects should nurse instruct pt to monitor and report? - Tingling of fingers The nurse should instruct the client to report the adverse effect of paresthesia, a tingling sensation in the extremities, when taking acetazolamide. Nurse is teaching pt who is to start taking hydrocodone w/ acetaminophen tablets for pain. Which of following information should nurse include in teaching? - Decreased respirations might occur.The nurse should instruct the client that hydrocodone with acetaminophen might cause respiratory depression, which is an adverse effect of the medication. The client should avoid taking over-thecounter medications or newly prescribed medications without consulting their provider to avoid increased respiratory depression. Nurse is providing teaching to pt who has gastric ulcer and new prescription for ranitidine. Which of following instructions should nurse include? - [Show Less]
An immunizing agent that confers active immunity protects by: - providing antibodies obtained from immune humans or animals. Antacids should be given one... [Show More] hour apart from most other drugs. Which is the rationale? - Antacids may interfere with absorption of drugs taken at the same time. Vancomycin should not be used to treat minor infections because it: - can cause "red man syndrome", a hypertensive crisis that is almost always fatal. The antagonist for a client who has overdosed on morphine is: - narcan. The most serious adverse reaction to oral contraceptives is: - thromboembolism. When a client develops tolerance to a drug, the nurse would expect: - higher dose needed to achieve same effect. Antihyperglycemic agents are prescribed for clients with: - Type 2 diabetes mellitus. The nurse assesses a client shortly after an intravenous infusion of the osmotic diuretic mannitol is started. Which finding represents an early adverse effect of mannitol? - Bounding pulse Compared to other beta adrenergic blockers, cardioselective beta adrenergic blockers: - are less likely to cause bronchoconstriction. A client who experiences motion sickness during airplane flights obtains a prescription for meclizine (Antivert). When is the best time to take the drug? - One hour before the flight Before prescribing a cephalosporin, the nurse practitioner asks if the client is allergic to penicillin. Why is this important to assess? - A client who is allergic to penicillin can have a cross sensitivity to cephalosporins. The use of which class of antibiotics should be avoided in children? - Tetracyclines In a walk-in clinic, clients are often given intramuscular injections. Which drug should be readily available in case a client has an anaphylactic reaction? - Epinephrine Thiazide and loop (high ceiling) diuretics are similar in that both: - decrease tubular reabsorption of sodium and water. Which of the statements by the nurse most accurately describes the effects of declined plasma albumin levels in older adults? - "There is an increased risk for adverse effects."To prevent oral fungal infections, the nurse should instruct the client who uses a beclomethasone inhaler to take which action? - Rinse the mouth after each use. A client takes ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) birth control pills. She calls the clinic and relates that she missed her medication yesterday. Which instructions will the nurse give? - "Take two pills today then continue on a daily basis." The nurse may administer acetylcysteine (Mucomyst) inhalation to: - facilitate mucus expectoration. Development of a chronic cough is an adverse effect associated with which class of anti-hypertensive drugs? - Angiotensin converting enzyme (ACE) inhibitors The nurse may administer baclofen (Lioresal) for the treatment of which condition? - Protracted muscle spasticity Oral diazepam (Valium), a benzodiazepine, has been prescribed for a client who has anxiety and muscle spasms. Which nursing intervention is appropriate for the care of this client? - Assess for incoordination and daytime drowsiness. The nurse practitioner prescribed anhydrous theophylline (Theo-Dur) for the client with chronic bronchitis. With which disorder would the nurse practitioner reconsider the use of this medication? - Hypertension When a client is receiving intravenous fluid with supplementary potassium chloride, it is especially important for the nurse to monitor for which potential adverse effect? - Cardiac dsyrhythmias Which adverse effect is common for a client being treated with the antidepressant fluoxetine (Prozac)? - Sexual dysfunction After giving a dose of dextromethorphan, an antitussive, which data reflects evaluation of the drug's effectiveness? - Client states that cough has been relieved. Prior to giving a client a dose of digoxin, the nurse counts the apical pulse. If the rate is 62 bpm and regular, which is the appropriate nursing action? - Give the drug and document the heart rate. Digoxin is started for a client with an atrial arrhythmia. Within three days, the client's heart rate has decreased from 94 to 74. What action of digitalis explains this change? - Slowed impulse conduction One mechanism by which antihypertensive drugs lower blood pressure is to: - dilate peripheral blood vessels.There are many agents that are useful in the treatment of gastric ulcers. Which agent reacts with hydrochloric acid to form a viscous protective barrier over the ulcer? - Sucralfate (Carafate) A client whose asthma has been poorly controlled is prescribed cromolyn sodium (Intal) for inhalation. Client teaching should include which statement by the nurse? - "Using this drug regularly will reduce the frequency of acute attacks." The combination of aluminum and magnesium in many antacids decreases the risk of: - diarrhea or constipation. A client who is taking one daily dose of a thiazide diuretic should be instructed to: - take the medication in morning to avoid nighttime voiding. Which phase of pharmacokinetics is affected most by abnormal liver function? - Metabolism A medication order is written for ciprofloxacin (Cipro). For which client should the nurse question use of this medication? - Child age 10 A home health client tells the nurse that she is taking triamterene (Dyrenium) for fluid retention. She tells the nurse she is using a salt substitute so she will not retain so much water. What is the most appropriate nursing response? - "Using a salt substitute with this medication could cause you to have too much potassium." Orders are written for anticholinergic drugs for each of the following clients. Which order should the nurse question? [Show Less]
A nurse is caring for a client who is receiving morphine, what assessment is priority - RR a nurse is assessing a client who has been using beclomethasone... [Show More] for 2 weeks to manage her asthma, what is the priority to report to the provider - bronchospasms a nurse is providing teaching to a client who has a new prescription for beclomethasone inhaler to use with an albuterol inhaler for asthma maintenance, what should the nurse instruct? - you should gargle with water after each use of this inhaler a nurse is planning a staff education session on AE of meds, what info should the nurse discuss about anticholinergic adverse effects? - blurred vision tachycardia constipation a nurse is providing teaching to a client who has a new prescription for guaifenesin, what info regarding the action of guaifenesin should the nurse include in the teaching? - guaifenesin increases cough production a nurse is preparing to administer verapamil to a client who is 2 days postmyocardial infarction. the nurse should monitor the client for which of the following outcomes as therapeutic response to the medication? - decreased anginal pain a nurse is providing teaching to a client who has a new prescription for levothyroxine, which statement indicates understanding of the teaching? - "i might not realize the full effect of the medication for several weeks" take on empty stomach with glass of water, first thing in the morning 30-60min prior to breakfasta nurse is assessing a client who has HF is taking digoxin. the nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider? - vomiting (n/v, anorexia, blurred vision) a nurse is providing teaching for a pt with a prescription for oral metronidazole, what is the priority teaching point? [Show Less]
What routes of medication go through the first pass effect? What routes do not? - FIRST PASS: Oral, enteral NON-FIRST PASS: Sublingual, buccal, IV, SC, I... [Show More] M, ID, Inhalation MIXED: Rectal When should medication reconciliation happen? - On admission, transferring and at discharge. What are the six rights of medication administration? - -Right patient -Right Medication -Right dose -Right time -Right route -Right documentation What are the PINCH medications? - Potassium/PCA Insulin Narcotics Chemo Heparin What should you do in the event of a medicinal error? - -Complete an occurrence report -Document in the EMR what happened. DO NOT state that there was a med error. -Always assess your patientWhat class of medication is Albuterol? What does it do? What side effects are common? Who should you not give them to? What do they interact with? – -Short Acting Beta 2 Adrenergic -Relieves bronchospasms by bronchodilating. (Acute asthma attack) -Tachycardia, anxiety, tremors -Tachydysrhythmias, diabetes, HTN, angina, CVD pts -Beta blockers What are long acting drugs for asthma? - Formoterol, salmeterol How would you teach a patient to use a metered dose inhaler? – -Hold 1-2 inches away. -Exhale. -Press trigger (prime before if new one) -Inhale slowly (3-5 seconds). -Hold breath for 10 seconds. -Rinse your mouth if it's a glucocorticoid- to prevent thrush. -Clean products with water and let dry What are some frequently used glucocorticoids? Adverse effects? Contraindications? Interactions – [Show Less]
Nurse is providing teaching to a group of new parents about meds. Nurse should include that aspirin is contraindicated for children who have viral infecti... [Show More] on d/t risk of developing which of following adverse effects? - Reye's syndrome Aspirin should not be given to children or adolescents who have a viral infection, such as chickenpox or influenza, due to the risk of developing Reye's syndrome. Nurse is providing teaching to pt who has CKF w/ AV fistula for hemodialysis and new prescription for epoetin alfa. Which of following therapeutic effect of epoetin alfa should nurse include in teaching? - Promotes RBC production Epoetin alfa stimulates erythropoiesis in the bone marrow to increase RBC production and reduce anemia. Anemia is common in clients who have chronic kidney failure, since erythropoietin is produced by the kidney. Nurse is caring for pt who has peptic ulcer disease and reports headache. Which of following meds should nurse plan to administer? - Acetaminophen Acetaminophen is an analgesic used for mild to moderate pain. It can be administered to a client who has peptic ulcer disease because it does not affect blood coagulation and does not increase the risk of gastrointestinal bleeding. Ibuprofen is an NSAID that is contraindicated for clients who have peptic ulcer disease because it can reduce platelet aggregation and increase the risk of gastrointestinal irritation and hemorrhage. Naproxen is an NSAID that is contraindicated for clients who have peptic ulcer disease because it can reduce platelet aggregation and increase the risk of gastrointestinal irritation and hemorrhage. Aspirin is an NSAID that is contraindicated for clients who have peptic ulcer disease because it can reduce platelet aggregation and increase the risk of gastrointestinal irritation and hemorrhage. Nurse is preparing to administer heparin 8,000 units subq q8h. Available is heparin 10,000 units/ml. How many mL should nurse administer per dose? (Round to nearest tenth) [Show Less]
A nurse is providing teaching for a client who has a new prescription for a drug with a high potential for toxicity. Which of the following information sh... [Show More] ould the nurse include? (select all that apply) [] periodic laboratory tests are essential to measure serum drug levels [] monitoring for indications of toxicity is important [] taking the drug with an inducing agent will increase the possibility of toxicity [] taking the smallest effective dose is crucial [] increasing fluid intake is recommended to avoid toxicity - Periodic laboratory tests are essential for measuring serum drug levels is correct. *Clients who are taking drugs that have a high potential for toxicity should undergo regular monitoring of serum drug levels to be certain the drug level stays within the therapeutic range. Monitoring for indications of toxicity is important is correct. *Drugs that have a high potential for toxicity can quickly build up to toxic levels in the blood, resulting in effects that can be irreversible or life-threatening. Therefore, the nurse should monitor for manifestations of toxicity particular to the drug the client is taking. Taking the smallest effective dose is crucial is correct. *It is optimal to use the lowest effective dose of a drug to achieve therapeutic effects because doing so helps minimize the risk for toxicity. A nurse is teaching a client about the adverse effects of digoxin. which of the following statements should the nurse include in the teaching? [] "adverse effects are the intended effects of the medication." [] "adverse effects indicate a severe allergy to the medication." [] "decrease your medication dose if adverse effects occur." [] "contact your provider if adverse effects occur." - "contact your provider if adverse effects occur."A nurse is caring for a client who has a history of renal insufficiency and is taking lithium. The nurse should monitor the client for which of the following? [] tolerance to the drug [] drug interaction [] drug toxicity [] dependence on the drug - Drug toxicity Drug toxicity develops when the amount of a drug that is taken is greater than its rate of excretion, and it results in the drug accumulating in the body. A client who has renal insufficiency might have delayed or impaired excretion of the drug. The drug dosage should be reduced if toxicity occurs. A nurse is teaching a client about naproxen enteric-coated tablets. Which of the following statements should the nurse include in the teaching? [] "drug absorption occurs in the stomach." [] "you should expect immediate absorption of the drug." [] "you should allow the tablet to dissolve in your mouth." [] "do not crush or chew the tablet." - "do not crush or chew the tablet." Drugs that irritate the stomach are often covered with an enteric coating that does not dissolve until the drug enters the alkaline environment of the small intestine. Clients should not crush or chew entericcoated drugs because this will damage the enteric coating. A nurse is caring for a client who is newly admitted to the facility for chest pain. At which of the following times should the nurse begin teaching about drugs and discharge planning? [Show Less]
A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid ... [Show More] volume excess? a. Decreased bowel sounds b. Distended neck veins c. Bilateral muscle weakness d. Thread pulse - b. Distended neck veins A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective? a. Absent Chvostek's sign b. Improved cognition c. Decreased vomiting d. Cardiac arrhythmias absent - b. Improved cognition A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following instructions should the nurse include? a. "Discontinue the patch if you experience a headache." b. "Apply a new patch if you have chest pain." c. "Cover the patch with dry gauze when taking a shower." d. "Remove the patch prior to going to bed." - d. "Remove the patch prior to going to bed." A nurse is reviewing he laboratory results of a client who has a prescription for sodium polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to the provider? a. Creatinine 0.72 mg/dL b. Sodium 138 mEq/L c. Magnesium 2 mEq/L d. Potassium 5.2 mEq/L - d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassium level greater than 5.0 mEq/L) increases the client risk for fatal cardiac dysrhythmias. Kayexalate is used to decrease the serum potassium level so the PN should monitor the client's serum potassium level A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of the following outcomes indicates that the client is adhering to the medication regimen? a. The client has a negative sputum culture b. The client tests negative for HIV c. The client has a positive purified protein derivative testd. The client's liver function test results are within the expected reference range - a. The client has a negative sputum culture A client is caring for a client who develops an anaphylactic reaction to IV administration. After assessing the client's respiratory status and stopping the medication infusion. Which of the following actions should the nurse take next? a. Replace the infusion with 0.9% sodium chloride b. Give diphenhydramine IM c. Elevate the client's legs and feet d. Administer epinephrine IM - d. Administer epinephrine IM A nurse is caring for a client who is taking sertraline and reports a desire to begin taking supplements. Which of the following supplements should the nurse advise the client to avoid? a. St. John's Wort b. Ginger root c. Black cohosh d. Coenzyme Q10 - a. St. John's Wort A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For which of the following adverse effects should the nurse monitor when administering lisinopril? a. Bradycardia b. Hypokalemia c. Tinnitus d. Hypotension - d. Hypotension A nurse is assessing a client who is receiving heparin IV continuous IV. The client has an PPT of 90 seconds. They should monitor the client for which of the following changes in their vital signs? a. Decreased temperature b. Increased pulse rate c. Decreased respiratory rate d. Increased blood pressure - d. Increased blood pressure A nurse is preparing to administer medication to a client and discovers a medication error. The nurse should recognize that which of the following staff members is responsible for completing an incident report? a. The quality improvement committee b. The nurse who identifies the error c. The nurse who caused the error d. The charge nurse- b. The nurse who identifies the error A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following? a. Pruritus b. Cough c. Tachypnea d. Gastric bleeding - a. Pruritus - Sign of allergic reaction to morphine A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right placing them in the order of performance. Use all the steps.) [Show Less]
An immunizing agent that confers active immunity protects by: - providing antibodies obtained from immune humans or animals. Antacids should be given one... [Show More] hour apart from most other drugs. Which is the rationale? - Antacids may interfere with absorption of drugs taken at the same time. Vancomycin should not be used to treat minor infections because it: - can cause "red man syndrome", a hypertensive crisis that is almost always fatal. The antagonist for a client who has overdosed on morphine is: - narcan. The most serious adverse reaction to oral contraceptives is: - thromboembolism. When a client develops tolerance to a drug, the nurse would expect: - higher dose needed to achieve same effect. Antihyperglycemic agents are prescribed for clients with: - Type 2 diabetes mellitus. The nurse assesses a client shortly after an intravenous infusion of the osmotic diuretic mannitol is started. Which finding represents an early adverse effect of mannitol? - Bounding pulse Compared to other beta adrenergic blockers, cardioselective beta adrenergic blockers: - are less likely to cause bronchoconstriction. A client who experiences motion sickness during airplane flights obtains a prescription for meclizine (Antivert). When is the best time to take the drug? - One hour before the flight Before prescribing a cephalosporin, the nurse practitioner asks if the client is allergic to penicillin. Why is this important to assess? - A client who is allergic to penicillin can have a cross sensitivity to cephalosporins. The use of which class of antibiotics should be avoided in children? - Tetracyclines In a walk-in clinic, clients are often given intramuscular injections. Which drug should be readily available in case a client has an anaphylactic reaction? - EpinephrineThiazide and loop (high ceiling) diuretics are similar in that both: - decrease tubular reabsorption of sodium and water. Which of the statements by the nurse most accurately describes the effects of declined plasma albumin levels in older adults? - "There is an increased risk for adverse effects." To prevent oral fungal infections, the nurse should instruct the client who uses a beclomethasone inhaler to take which action? - Rinse the mouth after each use. A client takes ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) birth control pills. She calls the clinic and relates that she missed her medication yesterday. Which instructions will the nurse give? - "Take two pills today then continue on a daily basis." The nurse may administer acetylcysteine (Mucomyst) inhalation to: - facilitate mucus expectoration. Development of a chronic cough is an adverse effect associated with which class of anti-hypertensive drugs? - Angiotensin converting enzyme (ACE) inhibitors The nurse may administer baclofen (Lioresal) for the treatment of which condition? - Protracted muscle spasticity Oral diazepam (Valium), a benzodiazepine, has been prescribed for a client who has anxiety and muscle spasms. Which nursing intervention is appropriate for the care of this client? - Assess for incoordination and daytime drowsiness. The nurse practitioner prescribed anhydrous theophylline (Theo-Dur) for the client with chronic bronchitis. With which disorder would the nurse practitioner reconsider the use of this medication? - Hypertension When a client is receiving intravenous fluid with supplementary potassium chloride, it is especially important for the nurse to monitor for which potential adverse effect? [Show Less]
Patient identifiers -Medical record number -home telephone number What lab values should a nurse monitor for a patient with chronic renal failure? - �... [Show More] � Urinalysis ☐ Hematuria, proteinuria, and alterations in specific gravity ☐ Serum creatinine - Gradual increase of 1 to 2 mg/dL per every 24 to 48 hr for acute renal failure (ARF) - Gradual increase over months to years for chronic renal failure (CRF) exceeding 4 mg/dL ■ Blood urea nitrogen (BUN) - 80 to 100 mg/dL within 1 week with ARF - Gradual increase with elevated serum creatinine over months to years for CRF - 180-200 mg/dL with (CRF) ■ Serum electrolytes - Decreased sodium (dilutional) and calcium, increased potassium, phosphorus, and magnesium ■ Complete blood count (CBC) - Decreased hemoglobin What food should you increase when taking Lasix? - -increased amounts of potassium-rich foods (e.g., bananas, prunes, raisins, and orange juice) Patient reports IV discomfort, what is your first action? - color and temperature Sumatriptan (treats migraine headaches) adverse effect - pain, tightness, pressure, or heaviness in the chest, throat, neck, and/or jaw slow or difficult speech Know about Transdermal patch -• Apply at the same time once each day, preferably in the morning. Keep patch on for 12 to 14 hr each day. • Remove the patch at night to reduce the risk of developing tolerance to nitroglycerin. Be medication-free a minimum of 10 to 12 hr each day (usually at night). • Do not cut patches to ensure appropriate dosage.• Place the patch on a hairless area of skin (chest, back, or abdomen) and rotate sites to prevent skin irritation. • Wash skin with soap and water and dry thoroughly before applying new patch. RBC Blood transfusion - http://www.atitesting.com/ati_next_gen/FocusedReview/data/datacontext/RM%20AMS %20RN%208.0%20Chp%2044.pdf (prime with normal saline and infuse with sodium chloride). What to understand about Parkinson's Meds? - -they don't cure disease, they slow the process. NEUPOGEN (filgrastim)-what is the appropriate route of this med? [Show Less]
Cephalosporin – -broad spectrum -ceph/cefs -Similar to PCN/ don't give if PCN allergy -can cause bleeding w/ other bleeding meds monitor bleeding tim... [Show More] e (tonsil story) - Disulfiram reaction (puke & puke & puke) just like Flagyl, the protozoal drug - Store in fridge & take with food ALL antibiotics have these side effects – - allergy, hypersensitivity - suprainfection - organ (kidney & ear) toxicity - lowers OC effectiveness Vancomyocin - serious infections like MRSA - colitis by c-diff - ototoxicity: get hearing test, tell dr. if hearing getting worse -given over 60 minutes Tetracyclines - - Sumycin, Doxycycline (Vibramycin) - broad, rocky mtn fever, lyme disease, acne, GI infections by H. Pylori - bad GI discomfort - Don't give to kids ≤8; teeth permanently yellow - Bad photosensitivity- wear sunscreen! - Can't take with milk, iron, or antacids - Take on empty stomach with a full glass of water When is Arythromycin given? What class of drugs is it? worse adverse effect? - When pt allergic to PCN and needs abx. Bacteriostatic inhibitor bad GI issues Aminoglycosides - ototoxicity, Renal toxicity, Can't take with PCN at all! - gentamicin, neomycin, streptomycin TMP-SMZ -Contains Sulfa - use for UTI - Blood problems; get CBC baseline -photosensitivity wear sunscreen and glasses!- empty stomach with a full glass of water Isoniazid (INH) - antiTB - take daily for 6-12 months and most likely with other meds too -worked if 3 neg. sputum cultures, no temp. - Liver toxicity (hepato) check liver fxn - Don't take with alcohol (liver fxn remember?) - Take on empty stomach Antiviral: Acyclovir, Ganciclovir - Teratogenic preg. X; put on rubber gloves if topical! remember my purple glove experience -thrombocytopenia, lowers WBC What class of drugs if Flagyl? What is the weird effect it has? - protozoal. works on C. diff & H. Pylori PUD. Antibuse effect if taken with alcohol Amphotericin B - anti-fungal. HIGHLY TOXIC - infusin rxns (fever and chills) - nephrotoxicity - hypokalemia - hepatoxicity - gynecomasita - C/I with aminoglycosides (just like PCN) -azole - Fungal ______ causes malignant hyperthermia. Use ____ to stop it - succinylcholine, Dantrium/Dantrolene. Morphine adverse effects – -Constipation -Resp depression -urinary retention -Sedation - Orthostatic HOTN - Cough suppression Morphine drug-drug interactions (think of what morphine does to the body) - - MAOI [Show Less]
Nurse contacts a pt's provider on telephone to obtain prescription for pain med. Which of following actions should nurse take? - Have the provider spell o... [Show More] ut the unfamiliar medication names. The nurse should ask the provider to spell out the name of the medication if the stated name is one the nurse is not familiar with. Nurse in clinic is caring for a pt who is taking aspirin for Tx of arthritis. Nurse should identify which of following findings as indication that pt is beginning to exhibit salicylism? - Tinnitus Tinnitus is a manifestation of aspirin toxicity, also called salicylism. Other manifestations include sweating, headache, and dizziness. Circulating nurse is planning care for pt who is schedule for surgery and has latex allergy. Which of following actions should nurse include in plan of care? - Place monitoring cords and tubes in a stockinet. The nurse should place monitoring devices in a stockinet to prevent direct contact with the client's skin. Nurse is assessing pt who is receiving epoetin alfa to Tx anemia. Which of following findings should nurse monitor? - Increased blood pressure The therapeutic effect of epoetin alfa is an increase in hematocrit levels, which can result in an increase in a client's blood pressure. If the client's hematocrit level rises too rapidly, hypertension and seizures can result. The nurse should monitor the client's blood pressure and ensure hypertension is controlled prior to administering the medication. Nurse is preparing to administer hydrochlorothiazide to pt. Which of following actions should nurse take prior to administering the med? - Obtain the client's blood pressure. HCTZ is a thiazide diuretic administered to promote urine output and reduce blood pressure and edema. The nurse should obtain the client's blood pressure prior to administration of the medication.Nurse is caring for pt who is receiving Tx for opioid use disorder. Which of following medications should nurse expect to administer? - Methadone The nurse should expect to administer methadone for treatment of opioid use disorder. Methadone can be administered for withdrawal and to assist with maintenance and suppressive therapy. The nurse should administer bupropion to assist the client with smoking cessation. The nurse should administer disulfiram as an aversion therapy to assist with maintaining abstinence from alcohol. The nurse should administer modafinil to assist with the fatigue and prolonged sleep from methamphetamine withdrawal. Nurse is reviewing medical record of pt who has HTN. Nurse should identify which of following findings as contraindication for receiving propranolol? - Asthma Asthma is a contraindication for receiving propranolol. Propranolol is an adrenergic antagonist which blocks the beta2 receptors in the lungs, causing bronchoconstriction and leading to serious airway resistance and possibly respiratory arrest. Nurse is caring for pt who has pneumonia. Pt tells nurse she is pregnant and that she hasn't told provider yet. Nurse should identify that pregnancy is contraindicated for receiving which of following meds? - Doxycycline Doxycycline is a tetracycline antibiotic. The nurse should identify that doxycycline can cause teratogenic effects such as staining of the infant's teeth when exposed to this medication. Therefore, this medication is contraindicated for the client. Nurse is teaching about self-administration of transdermal medication w/ male pt who has new prescription for nitroglycerin. Nurse should identify that which of following statements by pt indicates understanding of teaching? - " [Show Less]
Addison's disease skin ma Acromegaly occurs as a re twelve hours after thyroid hypertension laryngeal stridor and hoar positive Trouseau's sign Grave... [Show More] s' disease expect - d instruction for type 1 diab hyperglycemia - increased Type 2 Diabetes patho - M Cushing's Disease Compli Somogyi effect - Monitor Graves' Disease - hyperte abdominal pain tachycardia fever [Show Less]
nutrients that the body can't manufacture - essential nutrients which nutrients are energy yielding - carbs, fats, proteins dietary reference intake is c... [Show More] omprised of? - estimated average requirement, adequate intake, tolerable upper intake levels, recommended daily allowance average minimum amount of carbs the body needs to fuel the brain a day - 130g median carb intake for men - 200-330g/day median carb intake for women - 180-230g/day acceptable macro nutrient range for carbs - 45%-65% of calories monosaccharides - simple, glucose, fructose, galactose disaccharides - simple, sucrose, lactose, maltose polysaccharides - complex, starches, fiber, glycogen glycogen - stored energy in the liver and muscles how many calories in one gram of carbs? - 4 examples of fiber - pectin, gum, cellulose, mucilagefunction of monosacc - basic energy function of disacc - energy, aids in absorption of calcium and ph function of polysacc - energy storage, digestive aid (fiber) three types of protein? - complete, incomplete, complementary what factors influence the body's need for protein? - tissue growth, illness, quality of protein consumed (complete vs incomplete) daily requirement of protein for adults (%) - 10% of intake daily requirement of protein for women (g/day) - 46 daily requirement of protein for men (g/day) - 56 disorders caused by lack of protein (2) - kwashiorkor and marasmus how many calories/g does protein provide - 4 what percent of calories should come from fat - 20-35% what percentage of saturated fat is recommended? - 10% from the recommended 20-35% at least what percentage of fat in the diet is necessary to prevent wasting - 10% how many calories/g does fat provide [Show Less]
A pregnant woman is taking iron supplements during her pregnancy. Which other supplement should the nurse advise her to avoid taking with the iron? A. Vi... [Show More] tamin A B. calcium C. zinc D. potassium - Calcium Which vitamin helps with normal vision, tissue healing, and tissue strength? - Vitamin A Which food has the highest amount of calcium? A. 1 cup of low fat yogurt B. 1 oz. of cheddar cheese C. 1 egg D. 1/2 cup of spinach - 1 cup of low fat yogurt Which of the following foods is a good source of magnesium? A. hot dogs B. almonds C. cottage cheese D. watermelon - Almonds Calcium is a vital nutrient in preventing osteoporosis. At what age in women does bone loss normally begin? A. 45B. 50 C. 60 D. 35 - 35 A nurse caring for a patient with chronic renal disease should include which of the following in the patients diet? A. roasted peanuts B. sweet potatoes C. eggs D. bananas - Eggs A patient with cirrhosis and ascites should limit the intake of which nutrient? A. potassium B. Vitamin C C. iron D. sodium - Sodium A nurse is assisting a vegetarian to increase zinc in his diet. Which of the following foods should she suggest? [Show Less]
What does prealbumin levels indicate for a patient? - if the patient is receiving adequate nutrition how often do you flush a gastrostomy tube and with ho... [Show More] w much do you flush? - every four hours with 30mL a patient with iron deficiency would show which signs and symptoms? - tingling and muscle spasms what is a preferred snack for a child who is 9 months old? - graham crackers what would you educate your patient about when it comes to eating for someone with chronic kidney disease? - limit protein intake food recommendation for someone with ill-fitting dentures - tuna fish indications for effective probiotic therapy: - soft form stools how would you educate someone who is undergoing radiation therapy when it comes to eating? - dense foods multiple servings of fruit per day would benefit which type of patients? - hypertensive patients GERD is commonly associated with which patients - obese those with stomatitis stomatitis should wash their mouths how? - with frequent rinses using normal saline which patients would be recommended to receive TPN? - client with colon cancer and hemicolectomywhat would you want to include in each meal for someone who has dumping syndrome? - protein how would you teach a patient with dumping syndrome to eat their meals? - eat small frequent meals should a patient with a BMI of 28 should be referred to a weight loss group T/F - True Islamic patients with dietary restrictions for the month of Ramadan by - fasting during daylight hours patients with diabetes should keep their A1C at what? - 5% how would you feed a burn victim? - with enteral feedings what type of meal would you recommend for someone with coronary artery disease? - baked salmon what is something that you would teach a patient who is constipated? - [Show Less]
A nurse is performing a nutrition assessment on a client. Which of the following clinical findings are suggestive of malnutrition? Select all that apply. ... [Show More] Poor wound healing Impaired coordination Weak hand grips Dry hair Blood pressure 130/80 mm Hg - Poor wound healing Impaired coordination Weak hand grips Dry hair A nurse is teaching a group of female clients about risk factors for developing osteoporosis. Which of the following risk factors should the nurse include? Select all that apply. Family history Cigarette smoking Hyperlipidemia Obesity Inactivity - Family history Cigarette smoking Inactivity A nurse is educating a client who has anemia about dietary intake of iron. Which of the following is a non-heme source of iron? TurkeyGround beef Salmon Dried beans - Dried beans A nurse is discussing how the body processes food with a client during a routine provider's visit. Which of the following statements should the nurse include? The liver converts unused glucose into glycogen. The body uses glycogen for fat before using available ATP. Glycerol can be broken down into glucose for use by the body. Excess fatty acids are stored in the muscle tissue - The liver converts unused glucose into glycogen. A nurse is conducting a nutrition class at a local community center. Which of the following information should the nurse include in the teaching? Limit cholesterol consumption to 400 mg/day. Progress toward limiting saturated fat to 7% of total daily intake. Normal functioning cardiac systems depend upon B-complex vitamins. Good bowel function requires 35 g/day of fiber for females. - Progress toward limiting saturated fat to 7% of total daily intake. A charge nurse is conducting a nutritional class for a group of newly licensed nurses regarding basal metabolic rate (BMR). The charge nurse should inform the class that which of the following factors increases BMR? Select all that apply. Puberty Malnutrition Prolonged stressLactation Age older than 60 years - Puberty Prolonged stress Lactation A school nurse is teaching a group of students how to read food labels. Which of the following is a required component of food labels that the nurse should include in the teaching? Select all that apply [Show Less]
What is a precursor? - A substance that is used to synthesize another compound. What is a chief function of the B vitamins? - Coenzyme participation Whic... [Show More] h of the following diets is most likely to lead to beriberi? - High intakes of white rice A deficiency of what vitamin produces a characteristic cracking and redness at the corners of the mouth? - Riboflavin When the diet contains an adequate amount of protein, what amino acid can be used by the body to synthesize niacin? - Tryptophan Which of the following is a feature of niacin nutrition? - High doses may lower blood cholesterol. Which of the following is a feature of pantothenic acid in nutrition? - It functions in the metabolism of amino acids, glucose, and fatty acids. Biotin can be synthesized by - intestinal bacteria A common drug for the treatment of tuberculosis is known to markedly interfere in the metabolism of vitamin - B6 Research has shown that the risk for neural tube defects is lowered by taking supplements of - folate What vitamin is involved mainly with the replacement of red blood cells and digestive tract cells? - folate What is the most likely reason for development of a vitamin B12 deficiency? - Inadequate absorptionThe absorption of which of the following vitamins is most affected by the disorder atrophic gastritis? - Vitamin B12 Which of the following is a feature of choline in nutrition? - Average intakes in the United States are lower than recommended. The synthesis of collagen requires both vitamin C and - iron Which of the following is an early sign of vitamin C deficiency? - Bleeding gums Which of the following food groups is a rich source of vitamin C? - Fruit Groups Which of the following food substances can be converted to vitamin A in the body? - Beta-carotene. Which of the following describes the primary function of vitamin A in bone health? - It assists enzymes that degrade certain regions of the bone, thereby allowing remodeling to occur. Why does vitamin A status depend on the person's protein status? - Transport of the vitamin within the body requires sufficient protein to synthesize retinol-binding protein. The main function of vitamin D is to promote [Show Less]
___ is the study •These nutrients must be obtained t •The body will make these nutrients Name the 6 nutritive sources for the 1. Carbohydrates & Fi... [Show More] ber 2. Fats 3. Proteins 4. Vitamins 5. Minerals and Electrolytes 6. Water CALORIC VALUES •1g of carbohydrates yields _4__ cal •1g of proteins yield _4_ calories •1g of fats yield _9_ calories - C: [Show Less]
Coronary Heart Disease Nutrition - Low fat (saturated fat)= < 7% of daily caloric intake Low CHL = <200/daily Avoid saturated Fat Decreasing Red meat ... [Show More] Decrease Homocystine levels--> deficiencies in folate and vitamins B6 and B12 increase the levels Red Wine Increased Fiber--> oats, beans, fruit, vegetables, whole grains, berley, and flaxseed Increased Carbohydrate Increased intake of omega-3 fatty acids Exercise and weight management Smoking cessation Omega-3 Fatty Acids - Fish, Flaxseed, soy beans, Canola, and Walnuts HDL - Females= 35 to 80 mg/dl Males= 35 to 65 mg/dl LDL - <130 mg/dl Metabolic Syndrome: The presence of three of five of the following - Abdominal obesity- men > 40 inch waist, Female>35 inch waist Triglycerides >150 mg/dl Low HDL- Men <40 mg/dl , Female <50 mg/dlIncreased BP-- 130/85 Fasting BG > than or equal to 110 mg/dl How to lower CHL and saturated fats (teaching) - Trim visible fat from meats Limit red meats and choose lean meats (Turkey, chicken) Remove the skin from meats Broil, bake, grill, or steam foods. Avoid frying foods. Use a low-fat or nonfat milk, cheese, and yogurt Use spices in place of butter or salt to season foods Avoid trans fat as it increases LDL. No hydrogenatede products. Read Labels Hypertension Dietary Approaches to Stopping Hypertension (DASH) [Show Less]
What type of food allergy reactions would the nurse assess prior to administering epi? - -nausea -vomiting -dyspnea -itching -dizziness -headache al... [Show More] so: gasping for air, clenching throat, severe swelling on the face, etc. -these all indicate severe anaphylaxis Diet Management for an older adult with heart failure will include teaching to: - -limit sodium (Na) to 2000 mg/day or less -monitor (possibly restrict to 1.5 L/day) fluid intake -small meals to decrease effort of eating -electrolytes may be messed up due to diuretics: potassium, sodium, zinc (except spinrolactone=K sparing) A person with heart failure should have a daily sodium intake of: - 2000 mg or less Foods high in potassium: - apricots bananas potatoes tomatoesavocado fish spinach beans Daily cholesterol intake should be less than: - 200 mg DASH diet for HTN: - -low sodium -high potassium -high calcium A client with diabetes that may be experiencing hypoglycemia should be instructed to: - eat 15-20 g of carbs such as juice, soda, candies, honey, glucose tablets, etc. General nutritional guidelines for a client with diabetes: - Carbs: 130 g/day from grains, fruits, legumes, milk. No simple carbs. Fats: sat fat less than 7% of total calories, trans fatty acid less than 1% of total daily caloric intake, limit fried foods. Cholesterol: 200-300 mg/day Fiber: 14 g per 1000 calories from beans, oats, veggies, whole grains Protein: 15-20% total caloric intake from meats, eggs, fish, nuts, beans, & soy products NO TOBACCO, LIMIT ALCOHOLHyperlipidemia? NO ALCOHOL Artificial sweeteners okay, except preggo! sucrose (table sugar) can be included in diabetic diet as long as adequate insulin is available A nurse is reinforcing diet teaching to a client who has type 2 DM. Which of the following should the nurse include in the teaching? Select all that apply. A. Carbs should comprise 55% of daily caloric intake B. Use hydrogenated oils for cooking [Show Less]
The nurse is assessing a client who has type 2 diabetes mellitus. The nurse should recognize which of the following as a manifestation of hypoglycemia? - ... [Show More] Confusion A nurse is a clinic is reviewing the laboratory findings of a client who recently began a Dietary Approaches to Stop Hypertension (DASH) diet. Which of the following laboratory findings indicates the client has reached one fo the goals of the DASH diet? - Total cholesterol 190 mg/dL Range should be less than 200 A community health nurse is planning to teach a class about weight management for cardiovascular health. Which of the following statements should the nurse plan to include? - Plan to lose weight gradually at 1/2 to 1 pound per week A nurse is assessing a client who has diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia? - Diaphoresis (sweating) -Diaphoresis, irritability, and tremors -Tachycardia and hunger A nurse is caring for a client who has undergone a radical head and neck resection to treat cancer and is receiving radiation therapy. The nurse should monitor for which of the following potential adverse effects? - Changes in the production of saliva A nurse is creating a lan of care for a client who has mucositis following head and neck radiation therapy to treat cancer. Which of the following interventions should the nurse include in the plan? - Increase fluid intake to 2 L per day -Client with mucositis should increase fluid intake to promote hydration and peristalsis A nurse is caring for a client who is receiving TPN and is prescribed an oral diet. The client asks the nurse why the TPN is being continued since he is now eating. Which of the following responses should the nurse make? - Consume at least 60% of diet orally before TPN dicontinued.A nurse is caring for a client who adheres to a kosher diet. Which of the following food choices would be appropriate for this client. - Vegetable salad with cheese - Can't eat dairy and meat together -Dont eat pork -No shellfish A nurse is assessing a client who has an elevated BP, headache, and is sweating. The client recently started taking an MAOI. The nurse should question the client regarding the consumption of which of the following foods. - Chedder Cheese -Clients who take MAOI should avoid consumption of most cheese and other foods high in tyramine. Can lead to hypertensive crisis O Home A nurse is planning dietary teaching for a client who has dumping syndrome following a gastrectomy. Which of the following interventions should the nurse include in the client's plan of care? - Select grains with less than 2 g fiber per serving. -Clients at risk for dumling syndrome better toleratr low fiver grains thst contain less than 2g fiber per serving to slow gastric emptying -Eat small frequent meals -Lie down after eating to slow mobement -Avoid simple sugars and sugar alchols A nurse is reviewing the introduction of solid foods with the guardian of a 4-month-old infant. Which of the following statements by the guardian indicates an understanding of the teaching? - "I will introduce a new solid food every 5 days." - New food items introfuced every 4-7 days to monitor food allergies -Fruit juice introduced at 6 months limited to 120 ml and in cup -Recieve most calories from formula or breast milk -1 to 2 teaspoons of solid food at each feeding A nurse is providing dietary teaching to a client who is postoperative following a gastric bypass procedure. Which of the following instructions should the nurse include? [Show Less]
Nutritional screening is used in some settings to identify - at-risk or malnourished patients nutrition screenings are required for all patients within - ... [Show More] 24 hours of admission In other healthcare settings, such as outpatient or community-based clinics, the clinician determines whether or not - nutritional screening is warranted Unintended weight loss alone is an important indicator of - nutritional status Recent weight loss of more than __% in 30 days or __% in 180 days requires a complete assessment. - - 5% -10% Nutritional assessment is an in-depth analysis of nutritional status that focuses on _________ to ________ risk patients with suspected or confirmed _________ _______ malnutrition - - moderate - high - protein- energy malnutrition In general, though, a complete nutritional assessment focuses on five major areas: - - anthropometry (measurements such as weight/height and waist circumference) - BMI and IBW calculations - laboratory tests - dietary and health history - clinical observation - patients' expectations. Nutritional Screening tools- 1. Height, weight, recent weight change, patient's primary diagnosis, and presence of other factors that increase risk for nutritional deficits 2. The Subjective Global Assessment Tool 3. The Mini Nutritional Assessment Tool 4. The Malnutrition Screening Tool Nursing Assessment Questions [Show Less]
dysphagia swallowing precautions - tilt head FORWARD place food on UNAFFECTED SIDE OF MOUTH palpate throat high calcium foods - almonds! and yogurt a... [Show More] norexia pts - assign privleges based on direct weight gain when enteral feeding stops.. - flush with warm water increase fiber - eat fruit with skin parental nutrition allergy indications - eggs to absorb iron well, increase - vitamin c! ex. tomato juice copd diet - high calorie and protein soft, easy to eat nausea/ abdominal cramping indicates low - sodiumfasting questions – 1 exempt from illness? 2 refrain from liquids? 3 during certain hours? 4 certain type of food? macular degeneration diet - increase LUTEIN , vitamin a folate high foods - chicken liver increase absorption of calcium by increasing - vitamin d stomatitis foods should be - room temperature zinc foods - [Show Less]
Which Carbohydrates are the best - Polysaccaride How much Protein Should you have in a day - 10-35% How much fat should you have in a day - 20-35% How m... [Show More] uch cholesterol should you have daily - 200-300mg Ground Beef is high in what? - Zinc When should a mom first breastfeed? - within one hour of delivery How can you prevent aspiration of a tube feeding - Check Residuals A high fiber diet will result in what? - Lowered Cholesterol What age does osteoporosis start at? - 35 years old Low residue diet means - Low amount of stool Beriberi is a Thiamin deficiency what food can help - Bread whole grains Examples of complete proteins - meats and animal products Examples of incomplete proteins - Plant sourcesChicken liver is high in what - Folate What is lutein important for? - Eye health Nutrition for Gastric Bypass patients - begin meal with protein have five meals a day sop eating when full eat over thirty to sixty minute period Clear Liquid Diet - coffee Jell-O hard candy not ice cream soda juice tea water ginger ale clear juice Somogyi phenomenon - hyperglycemia in the morning how to give intermittent tube feedings - increase the volume slowly over feedings to lose one pound how many calories do you need to lose a week - 3500 calories to lose two pounds how many calories do you need to lose a week - 7000 calories How to use breast milk - if it is thawed can be used in 24 hours do not put in microwave can store in the fridge up to five to eight days What to do if there is no new T P N bag - hang ten percent dextrose bag What should you take calcium with - Vitamin D What should you take iron with - fruit juice, orange juice not milk or calcium One gram of fat is equal to how many calories - nine calories If a tube feed patient is distended [Show Less]
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