An assistive personal and a nurse are turning a client onto the right side. which of the following actions by the AP requires the nurse to
... [Show More] intervene
Places the pillow under the clients right arm.
The AP should place pillow under the client's left arm to prevent internal rotation of the left shoulder.
A nurse is assessing a client who has Raynaud's disease. which of the following findings should the nurse except?
Blanching of the fingers and toes.
A client who has Raynaud's disease can have blanching of the fingers and toes in response to exposure to cold or emotional stress. Pallor develops first, then cyanosis, followed by redness or heat as the vessels reperfuse, before the skin returns to the client's baseline tone.
butterfly rash over the cheeks and nose
A client who has lupus erythematosus is likely to have a butterfly rash over the nose and cheeks
a nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. which of the following instructions should the nurse include? (SATA)
A speech pathologist will be performing a swallowing study for you. (client is at risk for aspiration due to difficulty swallowing, which is manifestation of multiple sclerosis)
You should rest before eating a meal. (nurse should encourage the client to rest before each meal due to reported weakness and are easily fatigued).
Thicken your beverages before drinking. (thicken to reduce aspiration due to difficulty swallowing)
a nurse is caring for an older client. which of the following findings should the nurse recognize as a physiological change associated with aging?
decreased lung expansion. (due to decreased mobility of the ribs).
Older adult clients have decreased oral temps, decreased cardiac output, and increased systolic BP with a diastolic pressure that does not change. Increased incidence of orthostatic hypotension.
nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. which of the follow actions should the nurse take first?
measure clients vital signs. (use nursing process to assess the client. The nurse should monitor the client's vital signs every 15 min until stable and then every 4 hr for the next 48 hr.
A nurse is assessing a client who has delirium. which of the following manifestations should the nurse expect?
Rapid speech (delirium: rapid, inappropriate, incoherent, and rambling speech patterns).
administer heparin 5,000 units subcutaneously. Available is 10,000 units/mL. how much should be adminsitered?
0.5ml
Have/Quantity=Desired/X
OR
X=desired x quantity?have
a nurse is caring for a client who states "my boss accused me of stealing yesterday. i was so angry I went to gym and worked out". the nurse recognize the client is demonstrating which of the following defense mechanisms?
sublimation (The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior).
what is used for intermittent catheterization for a client who has urinary retention
Straight urinary catheter.
a client who is 24 hr postoperative following abdominal surgery refuses to ambulate. which of the following actions should the nurse take first?
ask the client to rate their pain level. (first action the nurse should take is to assess the client's level of pain. If indicated, the nurse should administer an analgesic, then wait 30 to 45 min to allow the analgesic to take effect before encouraging the client to ambulate. Management of the client's pain is a priority for encouraging postoperative activity).
a nurse is teaching the parents of a preschooler about sleep promotion. the parents report that their child is demonstrating reluctance in going to bed at night and states " I am not tired." which of the following statements by the parents indicated an understanding of the teaching?
we should read a story together every night before bedtime.
a nurse is assessing a 2 month old infant during a well-baby examination. which of the following actions should the nurse take to assess the infant's rooting reflex?
stroke the infant's cheek. (causes infant to turn toward that side and suck).
a nurse is providing discharge teaching to a client with cataract extraction. which of the following statements by the client indicates an understanding of the teaching?
"i will bend my knees when picking an object up off the floor". (The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object).
a nurse is caring for a group of clients. for which of the following events should the nurse complete an incident report?
a client's IV pump delivers an inadequate dose of medication. (The nurse should complete an incident report to record occurrences which resulted in a medication error, such as a failure of the IV pump, as part of the quality improvement process. Other situations requiring an incident report include significant complaints about care quality and visitor or client injury).
a nurse is teaching a client who is taking misoprostol and currently is on long term therapy with NSAIDs for arthritis. the nurse provides client with which of the following info?
Complete a serum pregnancy test before taking medication. (Misoprostol can induce uterine contractions. Clients of childbearing age must rule out pregnancy before taking misoprostol.)
tends to cause diarrhea. reduces gastric acid secretion so ulcers can heal and reduces risk of new ulcer development. Magnesium containing antiacids increase the risk of diarrhea and the client should avoid these when taking misoprostol.
a nurse is caring for a client who is at 28 weeks of gestation. the client asks the nurse to explain what causes her to have constipation. which of the following responses should nurse make
enlarged uterus compresses the intestines and causes constipation. (During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation)
small intestine absorbs more iron due to increased maternal needs, leading to constipation.
intestine absorbs more water from the stool during pregnancy, leading to constipation.
estrogen and progesteron levels increase during pregnancy causing decreased peristalsis and constipaiton.
a nurse is caring for a client who has a fractured femur and has a fiberglass leg cylinder cast for 24 hours. which assessment finding should be priority
the client's heel is reddened and tender. (The greatest risk to this client is injury from a pressure injury. Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel).
a nurse is a mental health facility is planning care for a client who has anorexia nervosa. which of the following interventions should the nurse include in the client's plan of care?
supervise the client during and after eating. (The nurse should monitor the client during and for 1 hr after meals to prevent the client from hiding food or purging).
The nurse should establish specific meal times as part of a structured meal plan. The nurse should offer the client a structured meal plan to ensure appropriate caloric intake and adequate nutrition. encourage conversation that does not focus on the theme of food during meal times. The nurse should emphasize eating as a social activity.
which foods are highest in vitamin A
1 medium raw carrot (The nurse should identify that 1 medium raw carrot contains 2,025 mcg/dL of vitamin A and is therefore the best food to recommend to the client).
(1 raw carrot (2,025 mcg/dL), 1/2 cooked spinach (737 mcg/dL), 1/2 cup cooked butternut squash (714 mcg/dL), 1 cup sliced cantaloupe (516 mcg/dL))
advanced directives
You should complete advanced directives in the event you cannot express your own wishes.
lithium carbonate. which of the following assessment findings should the nurse identify as priority?
Confusion (early manifestation of lithium toxicity. The nurse should monitor the client for additional indications of lithium toxicity, including coarse hand tremors, incoordination, ECG changes, and sedation.
polyuria is expected.
fine hand tremors are expected.
lethargy is expected.
a case manager is reviewing the medical records of several clients. for which of the following clients should the nurse request an interprofessional care conference?
a client who has diabetes mellitus and has had repeated hospitalization for diabetic ketoacidosis. ( A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support).
a community health nurse is assisting with the development of a disaster management plan. the nurse should include which of the following nursing responsibility in the disaster response stage of the plan?
performing a rapid needs assessment. (Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage).
new prescription for estradiol. which adverse effects should the nurse instruct client to monitor and report to the provider?
headaches (Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events).
Hypertension,
swelling and tenderness due to fluid retention, and genitourinary candidiasis.
a charge nurse is observing a newly licensed nurse performing a physical assessment on a client. which of the following actions by the nurse indicates that the charge nurse should intervene?
the newly licensed nurse writes detailed notes while performing a head to toe assessment (record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment).
macular degeneration expected findings
decreased central vision. due to bleeding into the macula or yellow spots under the retina).
double vision (cataracts)
floating dark spots (retinal detachment)
intraocular pressure increased (glaucoma)
colostomy care for a client with two piece pouching system.
cleanse skin at stoma site using washcloth and warm water to reduce risk of skin irritation.
throughly dry skin around stoma using a patting motion before applying skin barrier.
activate adhesive in the skin barrier by holding it in place over the stoma for 30 seconds.
nurse should cut the skin barrier opening no more than 0.3 cm (0.13in) larger than the stoma to reduce risk of skin irritation.
An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN?
A. Collection of a stool specimen
B. Preparation of a client's postoperative bed
C. preparation of teaching plan about pneumonia
D. Insertion of a nasogastric tube
D. insertion of nasogastric tube.
a nurse is preparing a sterile field in order to insert indwelling urinary catheter for a male client. which of the following should nurse do to maintain surgical aseptic technique?
set catheter tray on the overbed table at waist height. (To maintain sterility, the nurse should place the catheter tray on a work surface at or above waist level).
The nurse is providing dietary teaching to the parents of a 6-month old infant. which instruction should the nurse include?
introduce new foods one at a time over 5 to 7 days. (to identify potential food allergies).
NO WHOLE MILK.
100% fruit juice to not exceed 120 to 180 ml per day, after age 6 month.
planning care for a client who is receiving heparin to treat DVP of left lower leg. which intervention should the nurse include in the plan of care.
elevate the affected leg. (The nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency).
place warm compression on affected area to reduce swelling and promote comfort.
encourage 2-3 L of fluid daily to decrease platelet aggregation and prevent dehydration.
encourage patient to ambulate once anticoagulant is initiated.
TPN (total parenteral nutrition)
Highly concentrated, hypertonic lots of minerals less water
Calories, fluids & nutrients
Central venous access device required you have to have a central line not a peripheral line it would burn the tissue* also you will use a filter
A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring.
Check patient for egg allergy, intolerance of the lipid solution and many lipids are composed of egg phospholipids.
a nurse is teaching a group of guardians about child safety measures. which shows understanding of the teaching?
i should have my child avoid sun exposure between 10am and 2pm. (To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400.
Can skateboard from age 5<
a nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure sensitive valve. which of the following info should the nurse include in the teaching?
keep the catheter clamped when not in use. (The adolescent should keep the catheter clamped to prevent blood backflow. Not all tunneled catheters have a pressure-sensitive valve that prevents blood reflux.)
change dressing at least every 5-7 days.
flush catheter daily with heparin when not using it regularly.
cystic fibrosis has been receiving oxygen therapy for past 36 hrs. indication of oxygen toxicity?
substernal pain (manifestation of oxygen toxicity due to the increased work of breathing, such as in a preschooler who has cystic fibrosis).
oxygen toxicity can have crackles too.
a nurse is planning care for a client who is receiving hemodialysis via an established AV fistual in the right arm. which of the following interventions should the nurse include in the client's plan of care
auscultate the affected extremity for a bruit. (The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present, which indicates patency.
Should report absence of a thrill to the provider.
a nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. which should nurse take first?
massage the uterus to expel clots.
a nurse is planning care for a child who has acute lymphoid luekemia and an absolute neutrophil count of 400/mm3. which interventions should the nurse include in the plan?
withhold administering the varicella vaccine to the child. (A child who has severe immunodeficiency should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed).
nurse is providing teaching to a client about newborn safety. which of the following statements should the nurse include in the teaching?
set your water heater temperature at or below 120 degrees fahrenheit. (The nurse should instruct the client to set the maximum hot water temperature to no more than 49° C (120° F). The nurse should also instruct the client to test the temperature of the bath water with her elbow prior to bathing the newborn).
a nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. which of the following actions should the nurse take?
initiate fall precautions for the client. (common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy).
a nurse manager is on a planning committee to develop an emergency preparedness plan. the nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan?
notify the incident commander. (notify the incident commander to initiate the command hierarchy and maintain order).
a nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. which actions should the nurse take when suctioning the client's airway?
apply suction for 10 seconds. (suction for only 5 to 15 seconds to minimize oxygen loss)
advance catheter 1 to 2 cm to prevent damaged bronchial tissues.
closed head injury, which medication is used to reduce intracranial pressure?
mannitol. (The client should receive mannitol, an osmotic diuretic, to reduce intracranial pressure caused by cerebral edema).
child has varicella. when can they return to school?
when crusts have formed on every lesion.
(no longer contagious after crusts have formed on all lesions.)
immediate postpartum period. which finding requires immediate intervention by the nurse?
boggy uterus. (can indicate hemorrhage).
initiating discharge planning for a client who had a stroke and is experiencing right sided weakness. which action should nurse take first?
request a referral for the client to receive physical therapy. (The greatest risk to this client is injury from falls. Therefore, the first action the nurse should take is to request a referral for physical therapy).
conducting visual acutiy testing using the snellen letter chart for a school age child who has eyeglasses. which instructions should the nurse give to child?
you should keep both eyes open during the testing (this is for visual acuity).
child should stand 10 ft away
correction glasses first then again without visual correction.
need 4-6 symbols to pass the line correctly.
39 weeks of gestation, during second week of labor nurse observes early decelerations on the monitor tracing. which action should nurse take?
continue to observe fetal heart rate. (Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing).
nurse is providing discharge teaching to a parent about care safety. which statement is correct.
secure the retainer clip at the level f your baby's armpits.
performing gastric lavage for a client who has GI bleeding and an NG tube in place.
use 0.9 Sodium chloride for irrigation of the NG tube. (The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube.)
solution should be room temperature.
volumes of 200-300ml at a time to reduce risk of injury to client.
school-age child, administering ear drops
i should pull the top of the ear upward and back while instilling the medication.
children younger than 3 years of age should pull pinna downward and back.
multiple sclerosis. which manifestation is expected
nystagmus. (Nystagmus is involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis).
MRSA (methicillin-resistant Staphylococcus aureus)
contact precautions.
Autonomic Dysreflexia. which findings are expected
facial flushing.
nasal congestion.
headache.
signs of true labor
cervix transitions to an anterior position and begins to dilate in preparation for birth.
contraction felt in lower abdomen and back
contractions increase with ambulation
cervix progressively shortens and thins
placing tracheostomy tube (steps)
remove inner cannula.
remove soiled dressing.
clean the stoma with 0.9% sodium chloride irrigation
change tracheostomy collar.
Digoxin toxicity symptoms
nausea, vomiting, diarrhea, vision changes, arrythmias, anorexia, abdominal pin. bradycardia, muscle weakness.
client has schizophrenia and is taking chlorpromazine. which finding is a priority to report to provider
temperature of 39.4C (102.9F). (neuroleptic malignant syndrome)
a nurse is assessing a newborn who is 2 hours old. which finding should nurse report to provider?
expected axillary temperature for newborns is between 36.5-37.5 (97.7F to 99.5F)
apical pulse (80 to 100 when asleep and up to 180 when crying.
RR -> 30-60/min
a nurse in ED has a client with cardiac tamponade. which assessment finding is expected.
Pulsus paradoxus (a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension).
acute glomerulonephritis. what is expected finding
protein. (A client who has glomerulonephritis has increased glomerular permeability, which allows protein to filter into the urine. Therefore, the nurse should expect proteinuria on the urinalysis report).
Amitriptyline
i should watch for common reactions like dry mouth and constipation (increase dietary fiber, fluid intake, and chewing sugar free gum can alleviate anticholinergic effects).
vitamin k for newborn
to prevent bleeding of newborn.
37 weeks of gestation and experiencing abruptio placentae. Which is an expected finding?
persistent uterine contractions and dark red vaginal bleeding.
a nurse is administering cyclophosphamide orally to a school-aged child who has neuroblastoma. which action should nurse take when administering this medication?
maintain hydration with liberal fluid intake. to prevent hemorrhagic cystitis.
an elevation of which laboratory value indicates cellular injury of myocardial tissue?
troponin T
a nurse is caring for a patient who requires PT following discharge. which action should nurse take?
involve the client in selection of a physical therapy provider.
toddler has infectious gastroenteritis. which action should nurse take
initiate oral rehydration therapy for the toddler. (Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed).
blood transfusion, which finding should indicate to the nurse that the client is having a hemolytic transfusion reaction?
low back pain.
Expect tachycardia
expect hypotension
HSV (herpes simplex virus)
contact precautions.
cranial nerve 2
optic nerve
Thrombocytopenia
avoid venipunctures when possible. due to decreased platelet count and are at risk for bleeding. avoid to reduce risk of bleeding.
TPN solution at 60l/hr. pump stopped working, what should nurse do while waiting for a new infusion pump?
provide dextrose 10
% in water solution using manual drip tubing at 60ml/hr. [Show Less]