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NSG 201 Saunders Review Test 1&2 Questions and Answers,100% CORRECT
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NSG 201 Saunders Review Test1 Questions Answers,100% CORRECT
NSG 201 Saunders Review Test1 Questions Answers 1.ID: 9477033456 A client is being discharged home after a routine hip replacement surgery. The nurse i... [Show More] s instructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply. A. “Limiting fiber is necessary to avoid diarrhea.” Correct B. “I should empty my bladder when I feel the urge.” C. “Avoiding pain medication will prevent constipation.” Correct D. “I should drink plenty of liquids like iced tea or coffee.” Correct E. “I should continue with my physical therapy and walking.” Rationale: Constipation is common after surgery due to pain medication, decreased movement, and anesthesia. Fiber intake should be encouraged as it promotes the prevention of stool retention. Although pain medication can cause constipation, it should not be avoided in the post-operative period. Drinking plenty of fluids is encouraged for both bowel and bladder maintenance, but the client should choose non-caffeinated options. Physical therapy, walking, and exercise will help prevent constipation. Emptying the bladder when the urge is present can help prevent urinary tract infections. Test taking strategy: Note the strategic words need for further teaching. These words indicate a negative event query and the need to select the incorrect client statements. Think about the measures needed for bowel and bladder control to answer correctly. Review: bowel and bladder maintenance. Level of Cognitive Ability: Evaluating Client Need: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Perioperative Care Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health Promotion, Teaching and Learning/Patient Education References: Giddens, J. (2013). Concepts for nursing practice. (p. 143). St. Louis, MO: Mosby. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 969, 1089-1090). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 2.ID: 9477039828 The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the most accurate information? Select all that apply. A. Provide culturally sensitive education. Correct B. Encourage family members to obtain a tuberculosis skin test. Correct C. Provide written instructions in English for the client to reference. D. Encourage the client and family to wash all dishes by hand to prevent the spread of infection. Incorrect E. Urge all family and close contact community members to seek and complete treatment to enhance compliance. Correct Rationale: As always, the nurse must provide culturally sensitive education. Because tuberculosis is highly contagious, all family members and close community members should have a tuberculosis skin test, seek treatment, and remain compliant. A full course of 6-9 months of treatment is needed to prevent re-infection. Instructions written in English are not helpful for the client with limited English skills. Washing dishes by hand is not the best way to prevent infection; rather a dishwasher should be used if available. Test Taking Strategy: Focus on the strategic word most to select correct options that relate to appropriate teaching for both the client and family members. Also, focusing on the data in the question will assist in answering. Review: Tuberculosis Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Fundamentals of Care: Infection Control Priority Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education References: Giger, J. (2013). Transcultural nursing assessment & intervention. (6th ed. p. 445, 455). St. Louis: Mosby. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 533). St. Louis: Mosby. Awarded 1.0 points out of 3.0 possible points. 3.ID: 9477038294 A client with anxiety has just been seen by the health care provider and has been prescribed alprazolam. The client asks the nurse how long it will take for the medication to build up a steady state in her body. If the half life of this medication is approximately 11 hours, approximately how long will it take for this medication to build up and reach a steady state? hours Incorrect Correct Responses A. 55 Rationale: The half life of a medication is the amount of time it takes for 50% of the medication to leave the system. Steady state is the point where the concentration of the medication is equal based on the medication leaving the body system and new medication entering the system. Alprazolam has a half life of 11 hours. For all medications, it takes approximately five times the half life to reach steady state. Therefore the steady state for this medication is 55 hours (11 x 5 = 55). Test taking strategy: Focus on the subject, the time it takes to achieve a steady state of alprazolam in the body. Use the half life of the medication to calculate. Follow the calculation for steady state of five times the half life and verify your answer using a calculator. Review: half life of alprazolam. Level of Cognitive Ability: Understanding Client Need: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Fundamentals of Care: Medications and Administration Priority Concepts: Cellular Regulation, Safety HESI Concepts: Cellular Regulation, Safety References: Rosenjack Burchum, Rosenthal (2016), pp. 374-375 Stuart, G. (2013). Principles and practice of psychiatric nursing (10th ed., p. 526). St. Louis, MO: Mosby. Awarded 0.0 points out of 1.0 possible points. 4.ID: 9477033419 The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm (refer to figure). What is the initial nursing action? A. Check for a pulse Correct B. Notify the health care provider C. Obtain a 12 lead electrocardiogram (ECG) D. Begin cardiopulmonary resuscitation (CPR) Rationale: Ventricular tachycardia can be stable or unstable depending on whether the client has a pulse or not. In this case, assessing the client’s pulse is the initial action. Obtaining a 12 lead ECG and notifying the health care provider may be necessary but are not initial actions. Initiating CPR may be necessary of the ventricular tachycardia becomes unstable and cardiac arrest occurs. Test-Taking Strategy: Note eh strategic word, initial. Use the steps of the nursing process and recall that assessment is the first step and the first action to take. Review: Ventricular Tachycardia Level of Cognitive Ability: Analyzing Client Need: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health: Cardiovascular Priority Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 799-800). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 5.ID: 9477032613 A mother brings her 9-month-old child to see the pediatrician and has concerns that the child may have a developmental delay because the child cannot roll over yet. for the nurse should ask the mother about which risk factors associated with a developmental delay? Select all that apply. A. Age B. Race Incorrect C. Income D. Chronic illness E. Low birth weight Correct F. Environmental exposure to toxins Correct Rationale: Developmental delays can occur at any age, however, it is most commonly seen in infancy through adolescence. Developmental delays can occur regardless of race. Children living in poverty, those with chronic illnesses, low birth weight, or exposure to environmental exposure to toxins are at a higher risk for developmental delays. Test taking strategy: Focus on the subject, risk factors associated with a developmental delay. Recall that developmental delays that occur in children are caused by prenatal, birth, social, and health risks. This will help eliminate the incorrect answers of age and race. Review: risk factors for developmental delays Level of Cognitive Ability: Analyzing Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Developmental Stages: Infancy to Adolescence Priority Concepts: Development, Patient Education HESI Concepts: Developmental, Teaching and Learning/Patient Education References: Giddens, J. (2013). Concepts for nursing practice. (p. 4). St. Louis, MO: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 18-19, 432, 777). St Louis: Mosby. Awarded 1.0 points out of 4.0 possible points. 6.ID: 9477043118 The nurse in a pediatric unit is planning the staff assignments for children with developmental delays. When planning the assignment, the nurse decides to assign those children who have social or emotional delays amongst different nurses. Which children should be assigned to different nurses? Select all that apply. A. A child with autism Correct B. An infant with fetal alcohol syndrome Incorrect C. A child with attention deficit disorder D. A child with generalized anxiety disorder Correct E. A child with expressive language disorder Incorrect Rationale: A developmental delay is defined as not meeting the expected developmental level. Social and emotional developmental delays include those affecting personality, emotion, or behaviors. Two examples are autism, and generalized anxiety disorder. Attention deficit disorder and fetal alcohol syndrome are classified as cognitive developmental delays, and expressive language disorder is a communication developmental delay. Test Taking Strategy: Focus on the subject, planning assignments and children with social and emotional developmental delays. Use knowledge of the different types of developmental delays to eliminate those options. Review: developmental delays Level of Cognitive Ability: Creating Client Need: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Developmental Stages: Infancy to Adolescence Priority Concepts: Care Coordination, Development HESI Concepts: Care Coordination, Development References: Giddens, J. (2013). Concepts for nursing practice. (p. 4, 8-9). St. Louis, MO: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 147-148). St Louis: Mosby. McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal- child nursing (4th ed., pp. 1492-1493). St. Louis: Elsevier. Awarded -1.0 points out of 2.0 possible points. 7.ID: 9477035226 The client has been prescribed amoxiciilin 250 mg three times daily for sinusitis. The medication is supplied in a 500 mg tablet. How many tablet(s) would the nurse prepare every 8 hours to administer the correct dose? Fill in the blank. Record the answer using one decimal place. tablet(s) Correct Correct Responses A. 0.5 Rationale: Use the medication calculation formula to calculate the correct dose. Desired 250 mg Available = 500mg Test-Taking Strategy: Focus on the subject, a medication calculation. Once you have performed the calculation, verify your answer with a calculator. Be aware of non-important numbers in the question that can be confusing. In this question, three times a day and 8 hours are not used in the calculation. Lastly, ensure that your answer makes sense. Review: medication calculations. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Fundamental of Care: Medication/IV Calculations Priority Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 486-487). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 8.ID: 9477039851 The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart. H i s t o r y a n d P h y s i c a l La bo rat or y Fin din gs M ed ic at io ns E x p i r Bl oo d pr es Li si no pr il a t o r y r a l e s o n a u s c u l t a t i o n sur e 14 5/ 94 m m Hg 2 0 m g or all y da ily P e r i p h e r a l V a Se ru m Po tas siu m 3. 5 m Eq /L At or va st at in 1 0 m g or all s c u l a r D i s e a s e ( P V D ) (3. 5 m m ol/ L) y at be dt im e A. Expiratory rales B. Atorvastatin prescription C. Peripheral vascular disease D. Potassium level of 3.5 mEq/L (3.5 mmol/L) Correct Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level of 3.5mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should anticipate that the potassium level would drop with the administration of furosemide. Therefore, the nurse should verify continuing the prescription if this potassium level was noted. Expiratory rales are an expected finding with fluid overload and furosemide would be an appropriate treatment. Atorvastatin and peripheral vascular disease are not impacted by the administration of furosemide. Test-Taking Strategy: Focus on the subject, the need to verify continuing the prescription. Note the data in the question and that the client is receiving furosemide. Recall that furosemide is a potassium-losing diuretic. Think about the side and adverse effects of this medication to answer correctly. Review: furosemide Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Analysis Content Area: Fundamentals of Care: Fluids & Electrolytes Priority Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing Care, Safety Reference: Rosenjack Burchum, Rosenthal (2016), pp. 456-457. Awarded 1.0 points out of 1.0 possible points. 9.ID: 9477033433 A nurse employed at a nursing home is caring for a client who has recently been transferred from the hospital to the nursing home. The client is confused and is acting out. The nurse suspects the client is suffering from relocation stress. The nurse should include which helpful actions in the plan of care? Select all that apply. A. Encourage friends and family to visit frequently. Correct B. Establish a trusting relationship with the client as soon as possible. Correct C. Change rooms frequently to prevent the client from becoming bored. D. Ensure the client is an active part of decision making regarding their care. Correct E. Allow the client to move around the halls as desired to decrease the confusion and acting-out. Rationale: Relocation stress can occur when a client is removed from their usual surrounding such as home. In order to provide safe and quality care, encourage friends and family to visit the client often and establish a trusting relationship with the client as soon as possible. It is important for the client to have an active role in decision-making. In order to lessen confusion, the nurse should provide the client time to become familiar with the immediate surroundings such as his or her room before allowing or encouraging ambulation to new surroundings; allowing the client to move around the halls as desired may increase confusion and acting-out behaviors. Likewise, changing the client’s room frequently may increase confusion. Test-Taking Strategy: Focus on the subject, relocation stress. Also note that the client is confused and acting-out. Think about this type of stress and the manifestations and what you might expect from a client who is experiencing relocation stress. Use that knowledge to determine appropriate nursing actions. Review: relocation stress. Level of Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Fundamentals of Care: Safety Priority Concepts: Safety, Stress HESI Concepts: Safety, Stress and Coping References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 19). St. Louis, MO: W.B. Saunders Company. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 70). St. Louis: Mosby. Awarded 2.0 points out of 3.0 possible points. 10.ID: 9477034772 The nurse is caring for a client in the hospital and is reconciling the client’s home medications. The client is taking Lactobacillus, a probiotic over-the counter medication. The nurse is discussing the supplement with the client. What statement by the client would warrant the need for further teaching? Select all that apply. A. “I can take my probiotic at any time of day or night.” Correct B. “Probiotics can be found in yogurt and some juices.” C. “I should take this supplement to prevent gas and bloating.” Correct D. “Because I’m lactose intolerant, a probiotic would not benefit me.” Correct E. “This supplement will help me avoid getting diarrhea from antibiotics.” Incorrect Rationale: Probiotics are live microorganisms that are similar to those found naturally occurring in the gastrointestinal tract. Probiotics should be taken as directed, usually with a meal, and can have a side effect of gas and bloating. If gas an bloating do occur, the client should be advised to try a different type of probiotic. Probiotics are recommended for those clients who are lactose intolerant. Probiotics are found in foods such as yogurts and some juices and can be helpful to treat antibiotic-associated diarrhea. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select he incorrect client statements. Use knowledge of probiotic supplements to determine the correct options. Review: the uses and effects of probiotics Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Pharmacology: Gastrointestinal Medications Priority Concepts: Client Education, Health Promotion HESI Concepts: Health Promotion, Teaching and Learning/Patient Education References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 10). St. Louis, MO: W.B. Saunders Company. Rosenjack Burchum, Rosenthal (2016), pp. 1325-1326. Awarded 1.0 points out of 3.0 possible points. ...........UP TO 70 QUESTIONS............................. [Show Less]
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NSG 201 Saunders Review Test 2 Questions and Answers,100% CORRECT
NSG 201 Saunders Review Test 2 Questions and Answers 1.ID: 9476801282 The nurse is caring for a woman who is starting medroxyprogesterone injections fo... [Show More] r birth control. What statements by the client would indicate a need for further teaching? Select all that apply. A. “I may experience some weight gain.” Incorrect B. “I may not have regular periods while taking this medication.” C. “I should return in approximately 6 months for my next injection.” D. “Because it is highly effective, I can use this medication for many years.” E. “Depression is a side effect, and I should let my doctor know if I experience any mood changes.” Incorrect Rationale: Medroxyprogesterone is an injectable progestin given every 3 months to prevent ovulation and pregnancy. It suppresses ovulation for 15 weeks, and therefore, timing of the next injection is very important and should be no longer than exactly 3 months. Although medroxyprogesterone is highly effective, it should not be taken for more than 2 years due to the risk of osteoporosis. Weight gain, irregular periods, and depression are all known side effects. Test-Taking Strategy: Note the strategic words, “need for further teaching.” These words indicate a negative event query and the need to select the incorrect client statements. Specific knowledge about this medication is needed to answer correctly. Remember that it needs to be given every 3 months and should not be taken for more than 2 years due to the risk of osteoporosis. Review: medroxyprogesterone injections Level of Cognitive Ability: Evaluating Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Pharmacology: Reproductive Medications Priority Concepts: Client Education, Reproduction HESI Concepts: Sexuality/Reproduction, Teaching and Learning/Patient Education Reference: Rosenjack Burchum, Rosenthal (2016), pp. 760-761. Awarded -1.0 points out of 2.0 possible points. 2.ID: 9476801218 Following thyroid surgery, the nurse notes this response (refer to figure) when taking the client’s blood pressure. On further assessment, which laboratory finding would the nurse expect to find? A. Serum calcium of 8.4 mg/dL (2.1 mmol/L) B. Correct C. Sodium level of 138 mEq/L (138 mmol/L) D. Serum potassium of 5.1 mEq/L (5.1 mmol/L) E. F. Thyroid Stimulating Hormone (TSH) of 1.5 mU/L Incorrect Rationale: Hypocalcemia is characterized by tetany, or sustained muscle contractions. Chvostek’s sign is facial contractions seen after a light tap of the facial nerve in front of the ear. Trousseau’s sign is carpal contraction when a blood pressure cuff is inflated. These two signs are observed in hypocalcemia. Test-Taking Strategy: Focus on the subject, thyroid surgery and the signs of hypocalcemia. Use knowledge of signs of muscle contractions and its association with a low calcium level. Note that hypocalcemia is a known complication after thyroid surgery and serum calcium levels should be closely monitored. Review: hypocalcemia. Level of Cognitive Ability: Synthesizing Client Need: Physiological Integrity Integrated Process: Nursing Process/Analyzing Content Area: Fundamentals of Care: Fluids & Electrolytes Priority Concepts: Cellular Regulation, Fluid and Electrolytes HESI Concepts: Cellular Regulation, Fluids and Electrolytes Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 298-299). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 3.ID: 9476805570 The charge nurse on a women’s health unit is making a client room assignment. Which clients would be least appropriate to assign to share a room with a woman who is pregnant? Select all that apply. A. A client with hepatitis B Correct B. A client with herpes zoster Correct C. A client with pyelonephritis Incorrect D. A client with hashimotos thyroiditis Incorrect E. A client with a urinary tract infection Rationale: Viral infections such as hepatitis B and herpes zoster can be very serious for the mother and fetus if exposed and clients with these conditions should not share a room with a pregnant client. Pyelonephritis, hashimotos thyroiditis, and urinary tract infections can all have adverse effects on a pregnant woman, however, these are not contagious conditions, and therefore clients with these conditions can safely room share with a pregnant woman. Test taking strategy: Focus on the strategic words least appropriate and select the clients that should not share a room with a pregnant female. Think about the infectious factors of each disorder in the options to answer correctly. Review: risks of pregnancy Level of Cognitive Ability: Creating Client Need: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Maternity: Antepartum Priority Concepts: Care Coordination, Infection HESI Concepts: Care Coordination, Infection Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 626-628). St. Louis: Elsevier. Awarded -1.0 points out of 2.0 possible points. 4.ID: 9476805554 The home health nurse is caring for an older client recovering from pneumonia. A concerned family member believes that the client is no longer capable of caring for self effectively. The nurse conducts an assessment of the client’s basic activities of daily living (BADLs). What activities would the nurse assess? Select all that apply. A. Eating Correct B. Bathing Correct C. Cooking Incorrect D. Dressing Correct E. Taking medications Incorrect F. Balancing a checkbook Rationale: ADL’s are basic activities that assess functional ability. Daily activities such as eating, bathing, and dressing are considered basic every day needs. Activities such as cooking, taking medication, and balancing a checkbook are considered more complex, instrumental activities. Test-taking Strategy: Focus on the subject, basic activities of daily living. Select the answers that require the most basic care for completion. In addition, specific knowledge of those activities that are basic and those that are instrumental will assist in answering correctly. Review: Activities of Daily Living. Level of Cognitive Ability: Applying Client Need: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fundamental Skills: Safety Priority Concepts: Functional Ability, Safety HESI Concepts: Functional Ability, Safety References: Giddens, J. (2013). Concepts for nursing practice. (p. 12). St. Louis, MO: Mosby. Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., pp. 259-260). St. Louis: Mosby. Awarded 1.0 points out of 3.0 possible points. 5.ID: 9476807948 The nurse is caring for a client who has recently undergone a right-sided mastectomy for stage 3 breast cancer. When giving report to the next shift, what information would be essential to communicate to the oncoming nurse? Select all that apply. A. Elevate the right arm on a pillow. Correct B. Monitor skin color and for the presence of edema. Correct C. Educate that a medical alert bracelet is being worn. Correct D. Ensure the client refrains from any physical activity. Incorrect E. Take blood pressure measurements on the right side only. Incorrect Rationale: After a mastectomy, the nurse must assess for peripheral tissue perfusion. Therefore it is important to assess skin color and for the presence of edema. Elevation of the extremity will decrease venous pressure and decrease edema. A medical alert bracelet should be worn at all times. A medical alert bracelet should be worn to alert others and prevent anyone from using the affected extremity for blood pressure, intravenous (IV punctures), or blood draws because this could increase the likelihood of infection or decreased tissue perfusion. Although the client should avoid heavy lifting, activity should be encouraged and the client should participate in physical therapy unless contraindicated. Test-Taking Strategy: Note the strategic word essential when considering what information should be included in shift change report. Think about what information would be necessary for safe care of the client to help select the correct answer. Also noting the words, any and only in options 4 and 5 will assist in eliminating these options. Review: mastectomy Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Adult Health: Oncology Priority Concepts: Care Coordination, Tissue Integrity HESI Concepts: Care Coordination, Tissue Integrity Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1254-1255). St. Louis: Mosby. Awarded -1.0 points out of 3.0 possible points. 6.ID: 9476793886 A client informs the nurse that she has recently started taking the herbal supplement black cohosh for her menopausal symptoms. When reviewing the client’s medical record, what finding would warrant the need for follow-up? Refer to chart. H i s t o r y a n d P h y s i c a l Laboratory Results M e di c at io n s R e n a l I n Thyroid Stimulating Hormone (TSH) 2.45 mIU/L Gl ipi zi de 5 m g s u f f i c i e n c y or al on ce da ily H e a r t f a i l u r e B-type natriuretic peptide (BNP) 204 pg/ml Si m va st at in 4 0 m g on ce da ily A. TSH result B. BNP result C. Heart failure D. Glipizide prescription Correct Rationale: Black cohosh is an herbal product used to treat hot flashes, irritability, and palpitations. It potentiates insulin, oral hypoglycemic agents, and anti- hypertensive agents. Therefore, follow-up would be necessary if the client was taking glipizide, a sulfonlyrea oral hypoglycemic agent. The TSH result is a normal finding. The BNP result would be expected with a known diagnosis of heart failure and additionally would not be affected by black cohosh. Test-Taking Strategy: Note the strategic words need for follow-up when considering what information provided in the chart is important. The options of heart failure and the BNP result are comparable or alike options, and therefore should be eliminated. Next, note that the TSH level is normal to eliminate this option. Review: interactions associated with black cohosh Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Analysis Content Area: Fundamental of Care: Safety Priority Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 1317 ). St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1285). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 7.ID: 9476797805 A client is admitted to hospital for treatment of a respiratory infection. The client was treated with an intravenous (IV) course of ampicillin and is ready to be discharged home on oral antibiotics. What information present in the chart would warrant the nurse to provide further teaching? Hist ory and Phy sica l Labo rator y and Diag nosti c Findi ngs Medi catio ns Ane Ches t X- Ray: norg esti mate mia cons olida tion in left uppe r lobe and ethin yl estra diol oral once daily Poly Cys Pota Metf tic ssiu ormi Ova m n rian level 500 Syn of mg dro 4.5 oral me meq/ twice (PC L daily OS) A. Anemia B. Potassium result C. Chest X-ray result Incorrect D. Norgestimate and ethinyl estradiol prescription Correct Rationale: Broad-spectrum antibiotics such as ampicillin are commonly used to treat upper respiratory infections. These medications can decrease the effectiveness of oral contraceptive medications and the client should be advised to use alternative birth control options. Anemia has no impact on the use of ampicillin. The chest x-ray results, although abnormal, are expected with a respiratory infection. Serum potassium level is within normal limits. PCOS and the use of metformin is not affected by the oral antibiotic. Test-Taking Strategy: Focus on the strategic words, provide further teaching. Use knowledge of board spectrum antibiotics to answer correctly. Remember that antibiotics can cause a decrease in the effectiveness of oral contraceptive pills. Review: broad spectrum antibiotics. Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analysis Content Area: Fundamentals of Care: Safety Priority Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Rosenjack Burchum, Rosenthal (2016), pp. 1022, 1024. Awarded 0.0 points out of 1.0 possible points. 8.ID: 9476797864 The charge nurse is making a client assignment for the upcoming shift. In order to create a safe assignment, the charge nurse plans to assign those clients requiring airborne precautions amongst different nurses. Which clients should be assigned to different nurses? Select all that apply. A. A client with measles. Correct B. A client with C. difficle. C. A client with influenza. Incorrect D. A client with pneumonia. E. A client with tuberculosis. Correct Rationale: Airborne precautions are used for those clients that are diagnosed with or suspected to have a condition spread through airborne transmission. Measles and tuberculosis are transmitted via airborne transmission. A client with influenza should be placed on droplet precautions. A client with C. difficile should be placed in contact and enteric precautions and a client with pneumonia only requires standard precautions. Test Taking Strategy: Focus on the subject of the question, airborne contact precautions. Think about how each disease identified in the options is transmitted in order to help select the correct option. Review: all types of transmission-based precautions Level of Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Fundamentals of Care: Infection Control Priority Concepts: Care Coordination, Infection HESI Concepts: Care Coordination, Infection References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 440). St. Louis, MO: W.B. Saunders Company. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 173). St. Louis: Mosby. Awarded 1.0 points out of 2.0 possible points. 9.ID: 9476801200 The nurse at an outpatient clinic is performing a health assessment on a 67 year-old client. Her health history includes chronic obstructive pulmonary disorder (COPD) and diabetes mellitus and she currently has no complaints. On assessment, the client tells the nurse that she has not received any vaccinations other than a tetanus vaccine four years ago. Which routine vaccinations should be recommended given the client’s age? Select all that apply. A. Tetanus vaccine Incorrect B. Shingles vaccine Correct C. Influenza vaccine Correct D. Rotavirus vaccine Incorrect E. Pneumococcal vaccine Correct Rationale: The Centers for Disease Control (CDC) recommends that a healthy individual over the age of 65 years old should receive the shingles vaccine, an annual influenza vaccine, and a pneumococcal vaccine. Rotavirus is given to infants and the client is not due for a tetanus booster. Test-Taking Strategy: Focus on the data in the question and recall the recommended immunization schedule. Also focus on the client’s age to assist in answering. Review: immunization schedules Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process: Implementation Content Area: Developmental Stages: Health Assessment/Physical Exam Priority Concepts: Health Promotion, Immunity HESI Concepts: Health Promotion, Immunity Reference: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 16). St. Louis, MO: W.B. Saunders Company. Awarded -1.0 points out of 3.0 possible points. 10.ID: 9476801225 The nurse at a long-term care facility is conducting a medication review of a newly admitted older client with dementia, hypertension, diabetes mellitus, and depression. Which medication prescription would warrant the need to contact the health care provider? Select all that apply. A. Lisinopril 10 mg orally once daily. B. Furosemide 20mg orally once daily. C. Fluoxetine 20 mg orally once daily. Correct D. Metformin 500mg orally twice daily. E. Cyclobenzaprine 5mg every 8 hours as needed. Correct Rationale: A close review of medications is necessary for safe care of any client client but because the aging process affects physiological functioning, medication prescriptions for the older client need to be carefully monitored. The use of fluoxetine and cyclobenzaprine are considered inappropriate in the older client according to the Beers criteria and should not be used. All other medications listed would be appropriate. Test-Taking Strategy: Focus on the subject of this question, appropriate medication use in the elderly population. Think about physiological changes that occur with aging when selecting the correct option. Also, specific knowledge of medications in the Beers criteria and the classifications of the medications in the options will assist in answering correctly. Review: Beers criteria Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Analysis Content Area: Fundamental of Care: Medications and Administration Priority Concepts: Collaboration, Safety HESI Concepts: Collaboration, Safety References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 20-21). St. Louis, MO: W.B. Saunders Company. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 74). St. Louis: Mosby. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, The American Geriatrics Society 2012 Beers Criteria Update Expert Panel; http://www.americangeriatrics.org/files/documents/beers/2012BeersCriter ia_JAGS.pdf Awarded 1.0 points out of 2.0 possible points. 11.ID: 9476801253 The nurse is assisting in the examination of a five year old child who was removed from an abusive home. The social worker alerts the nurse that there is a history of violence in the child’s home, which has resulted in the removal of the child and siblings. Which behaviors should the nurse expect the child to express? Select all that apply. A. Smiling during the exam. B. Blaming the abuser for the injury. C. A need to find and protect a sibling. Correct D. Feeling guilty for causing the abuse to occur. Correct E. Aggressive behavior towards the nurse and health care provider. Correct Rationale: In homes where intimate partner violence (IPV) occurs, children are exposed to that violence at the very least and often become additional recipients of that violence. IPV usually predates abuse of the child. Younger children seem to have more behavioral problems when exposed to intra-family violence. For instance, they often have problems with anxiety, depression, and aggression. They often experience many fears and worries that are developmentally inappropriate. Expressing the need to find and protect a sibling is an example of worry that is developmentally inappropriate for a five year old child. Guilt is another aspect that abused children frequently struggle with, as children often blame themselves for abuse. The nurse would expect the child to portray aggressive behaviors out of fear. Due to the history of violence that this child has been subjected to, the nurse would not expect the child to smile and be receptive to the exam, or blame the abuser for the injury. Another issue of concern that the nurse should be aware of is post-traumatic stress disorder (PTSD). Associated features of PTSD may be more detrimental than the violence itself. Test-Taking Strategy: Focus on the subject, “behaviors of an abused child”. Determine which behaviors an abused child would show during interaction with the nurse. Eliminate options 1 and 2, because the child is likely to be afraid and unsure of the nurse and exam. Review: Behaviors of the abused child. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity. Integrated Process: Nursing Process/Assessment Content Area: Leadership/Management Giddens Concepts: Caregiving, Interpersonal Violence HESI Concepts: Developmental/Family Dynamics, Violence References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 353). St. Louis: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 565-566). St Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 12.ID: 9476797879 The nurse is examining an infant with burns that are suspicious for child abuse. Which findings should the nurse report as highly suspicious for abuse? (Select all that apply). A. A burn mark on the child’s finger. B. Circular burn marks on the infant’s buttocks. Correct C. A bright pink coloring on the infant’s cheeks. D. A dark brown marking on the infant’s lower back. Incorrect E. A stocking pattern of burn marks on the infant’s feet and legs. Correct Rationale: Examination findings for interpersonal violence range from subtle to obvious. Some may manifest as old or new injuries that may seem mild to more significant and may not raise concern. For this reason, it is critical to consider the history in relation to injuries seen. The nurse should also maintain a high degree of awareness for injuries that are not typically seen in the context of day- to-day living—such as unusual patterns of bruising or burn marks. Findings during the physical assessment that would raise suspicion for the nurse are circular burns or burns that occur in a stocking pattern. A burn mark to the finger should be questioned, but is not highly suspicious for child abuse. Bright pink coloring to the checks is typically normal in infants. Dark brown markings located on the lower back or buttocks are known as Mongolian spots. ...............UP TO 70 QUESTIONS,,,,,,...................... [Show Less]
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