NCLEX RN 2022 Review.
A client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the following referrals is
... [Show More] appropriate for the nurse to make currently?
1. Physical Therapist
2. Speech Pathologist
3. Registered Dietitian
4. Occupational Therapist
A client who has chronic progressive dementia exhibits symptoms of malnutrition. Which action is needed at this time?
1. Notify social services about concern for abuse.
2. Initiate a consult for physical therapy to visit daily.
3. Ask home care services to provide written instructions.
4. Arrange a meeting with the interprofessional team to coordinate care?
A nurse should recognize which of the following clients are likely to need rehabilitation services after hepatization? (SATA)
1. School-age child who is recovering from an appendectomy.
2. Client who had a cesarean delivery for a breech presentation.
3. An adult client who has left hemiplegia after a stroke.
4. An adult client who is recovering from Guillain-Barre syndrome.
5. An older adult client who had a left hip replacement.
6. An adolescent client who required hospitalization due to asthma.
A nurse is assigned to a group of clients. Which of the following has an increased risk of aspiration while eating? (SATA)
1. A client who has a new diagnosis of gastroesophageal reflux disease.
2. A client who has admitted with a diagnosis of cerebrovascular accident.
3. A client who is 4 hr. post-op and received general anesthesia.
4. A client who is 8 hr. following traumatic laryngeal nerve damage.
5. A client who continually experiences prolonged coughing episodes.
A client is receiving packed RBCs and becomes tachypneic. The client's temperature changes from 36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions should the nurse perform first.
1. Give 750 mg acetaminophen orally.
2. Collect blood and urine specimens for analysis.
3. Administer and IV infusion of 0.9% sodium chloride.
4. Stop the infusion and return the blood to the lab.
A nurse receives a request from four clients at the same time. Which of the following clients should the nurse address first? A client who
1. Needs to void 1 hr. after removal of an indwelling urinary catheter.
2. Reports restlessness and shortness of breath following surgery for a fractured femur.
3. Asks for a stool softener 2 days following surgery.
4. Demands to take prescribed insulin early the spouse is bringing dinner..
After receiving the report, a nurse should plan to access the clients in which priority order?
1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.
2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter.
3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.
4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter.
A nurse received the report and should plan to see which of the following client first?
1. A client at 39 weeks of gestation who is having contractions over 5 min lasting45 to 60 seconds.
2. A client who is pregnant and has a blood glucose level of 150mg/dl.
3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV.
4. A client 1 day postpartum who has changed perineal pads twice in the last 7 hr.
After receiving the report, which of the following clients should the nurse see first?
1. A client who was admitted with kidney stones and is crying with back pain.
2. A client who had chest discomfort prior to admission and is now requesting coffee.
3. A client who is scheduled for surgery and needs the linen changed.
4. A client who is to receive one unit of packed RBCs today and needs an IV restarted.
The nurse should triage which of the following clients first?
1. Vomiting, photosensitivity, and stiff neck.
2. Elevated temperature, sore throat, and fatigue.
3. A guarded gait and a bruised, edematous ankle.
4. Cloudy urine with painful urination.
5 Rights of Delegation
Scope of Practice
RN -
LPN -
UAP -
A nurse is organizing care for four clients, which of the following tasks should the nurse instruct the UAP to perform?
1. Measure the urine output from a client who was recently admitted with dehydration.
2. Bathe and shampoo hair for a client who was just admitted after a motor vehicle crash.
3. Help a client who is requesting a bedpan after a lumbar puncture.
4. Decrease the oxygen on a nasal cannula for a client who is being discharged with COPD.
Which of the following tasks should a nurse assign to the experienced unlicensed assistive personnel (UAP)? (SATA)
1. Completing intake and output measurements.
2. Feeding a client who has early dementia.
3. Explaining oral hygiene to a client receiving chemotherapy.
4. Bathing a client two days after a cerebrovascular accident.
5. Ambulating a client who is one-day post-hysterectomy.
6. Assisting a client who has hypertension select low-sodium snacks.
A nurse is supervising care delegated to a UAP. The nurse should take corrective action if which of the following is observed?
1. Allowing a client to sit in a bedside chair while discarding bathwater.
2. Pulling the curtain partially around the bed while performing perineal care.
3. Raising the bed and lowing the side rail while repositioning a client.
4. Answering a call that rings the hospital telephone while the client is away.
A nurse delegates hygiene care for a client hospitalized with COPD to unlicensed assistive personnel. Which of the following is the most appropriate instruction for the nurse to give?
1. Delay hygiene care until one hour after breakfast.
2. Allow the client to nap with the lead of the bed elevated.
3. Encourage the client to participate in hygiene care.
4. Teach the client to breathe slowly and deeply.
An LPN reports the following data to the supervising RN regarding data collection for a client who has congestive heart failure: Pulse oximetry 85%, respirations 48/min and labored. What is the priority action at this time?
1. The LPN will administer IV Furosemide.
2. The respiratory therapist will be notified.
3. The client will be prepared for a chest x-ray.
4. The care of the client will be reassigned to an RN.
A nurse from the adult medical unit is assigned to the pediatric unit. Which of the following would be an appropriate assignment?
1. A toddler admitted with epiglottitis.
2. A school-age child scheduled for excision of a Wilms tumor.
3. An infant who is recovering from repair of a cleft lip and palate.
4. A preschooler who had surgical fixation of a fractured humerus
A nurse coordinates care for a client who had a cerebrovascular accident. Which of the following tasks should be addressed by the Physical Therapist? (SATA)
1. Completing self-care.
2. Thickening clear liquids.
3. Using devices for walking.
4. Transferring from chair to bed.
5. Administering Albuterol treatment.
A client is recovering from a cerebrovascular adducent and has orders to be transferred to a rehabilitation center. Which of the following date should the nurse include in the verbal report? (SATA)
1. The client has been married three times.
2. The client is moving all extremities well.
3. The client is being treated for hypertension.
4. The client has three children who visit daily.
5. The client has an unrepaired aortic aneurism.
6. The client initially received the wrong IV fluids.
A nurse contract the provider and questions the prescription of enoxaparin for a client who is allergic to heparin. The provider directs the nurse to give the medication as prescribed. Which of the following should be the priority action by the nurse?
1. Submit an incident report to the nurse manager.
2. Decline to administer the medication.
3. Document datils of the conversation in the medical record.
4. Immediately report this situation to the charge nurse.
A client was recently placed in seclusion after exhibiting behaviors of acute mania. What is the appropriate nursing action?
1. Review medical history for potential contraindications of seclusion.
2. Obtain a verbal prescription now and request a medical evaluation with 12 hr.
3. Maintain seclusion if the client continues to exhibit signs of delirium.
4. Administer propofol 80 mg IV and repeat as needed.
A client who is admitted with an epidural hematoma attempts to leave the hospital without a discharge prescription from the provider. After notifying the provider. After notifying the provider, which action should the nurse take?
1. Explain risk to the client.
2. Notify the legal department.
3. Provider discharge instructions.
4. Administer prescribed medications.
A nurse prepares to ask a client to sign a consent for an elective surgical procedure and notes the client received midazolam hydrochloride 1 hr. ago. Which of the following actions should the nurse take?
1. Ask a family member to sign the consent.
2. Obtain the client's signature if alert and oriented.
3. Send the client to the operating room with documentation.
4. Notify the provider ad operating room staff to cancel the procedure.
A nurse plans care for a client who is pregnant and practices the theory of hot and cold. Which food sections may be served? (SATA)
1. Cereal and milk
2. Yogurt and fruit
3. Steak and potato
4. Chili and crackers
5. Hot tea with ginger
A nurse provides discharge teaching to an older adult about fall prevention measures in the home. Which instructions should be included? (SATA)
1. Install grab-bars in the shower.
2. Wear shoes inside the house.
3. Use small rigs in the bedroom.
4. Mark stairs-step edges with colored tape.
5. Keep frequently used items within reach.
A nurse provides care to a client who has celiac disease. Which of the following choices would be an appropriate snack?
1. Corn chips and salsa.
2. Pretzels and hummus.
3. Pastrami with rye bread.
4. Cheese spread on crackers.
A nurse assists an older adult client with selecting kosher foods from the dietary menu. Which options should the nurse expect the client to choose? (SATA)
1. Orange
2. Milkshake
3. Shrimp salad
4. Chili with beef
5. Hardboiled egg
The school nurse suspects that a junior high student may have anorexia nervosa. This eating disorder is characterized by:
1. A lack of control over overeating patterns.
2. Self-imposed starvation.
3. Binge/purge cycles.
4. Excessive exercise.
After a surgical procedure, the client is advanced to a full liquid diet. The nurse is able to recommend which one of the following foods for this client?
1. Custard.
2. Pureed meats.
3. Soft fresh fruit.
4. Canned soup.
The nurse is speaking with parents of a child at a day-care center. The parents ask the nurse about the nutritional needs of their toddler. An appropriate ginger food that is identified by the nurse is:
1. Nuts.
2. Popcorn.
3. Cheerios.
4. Hot dogs.
When introducing a feeding to a client with an indwelling gavage tube for enteral nutrition, the nurse should first:
1. Irrigate the tube with normal saline solution.
2. Check to see that the tube is properly placed.
3. Place the client in a supine position.
4. Introduce some water before giving the liquid nourishment.
An older adult client is scheduled for intermittent tube feedings by syringe. To ensure client safety during administration of the feeding, the nurse should take which of the following actions?
1. Unclamp the feeding tube and then connect the syringe to it.
2. Heat the formula before administering the feeding.
3. Verify there is no more than 300 mL residual prior to the feeding.
4. Pour the formula into the syringe, raising or lowering it as needed.
ANTIDOATE FOR:
Acetaminophen
ANTIDOATE FOR:
Benzodiazepine
ANTIDOATE FOR:
Curare
ANTIDOATE FOR:
Cyanide Poisoning
ANTIDOATE FOR:
Digitalis
ANTIDOATE FOR:
Ethylene Poisoning
ANTIDOATE FOR:
Heparin and Enoxaparin
ANTIDOATE FOR:
Iron (
ANTIDOATE FOR:
Lead
ANTIDOATE FOR:
Magnesium Sulfate
ANTIDOATE FOR:
ANTIDOATE FOR:
Side effects and adverse reactions for:
Side effects and adverse reactions for:
Side effects and adverse reactions for:
Side effects and adverse reactions for:
Side effects and adverse reactions for:
Side effects and adverse reactions for:
Side effects and adverse reactions for:
Furosemide
Side effects and adverse reactions for:
Lithium
Side effects and adverse reactions for:
Tobramycin
Side effects and adverse reactions for:
Valacyclovir
Therapeutic & Toxic Drug Levels
Digoxin
Toxic
> 2.4 ng/mL
Therapeutic & Toxic Drug Levels
Lithium
Toxic
> 2.0 mEq/mL
Therapeutic & Toxic Drug Levels
Phenytoin
Toxic
> 30 mcg/mL
Therapeutic & Toxic Drug Levels
Magnesium Sulfate
Toxic
> 9 mg/dL
Medication Categories "ending"
ACE Inhibitors
Medication Categories "ending"
Antivirals
Medication Categories "ending"
Antifungals
Medication Categories "ending"
Antilipidemic
Medication Categories "ending"
Angiotensin II receptor blockers (ARBs)
Medication Categories "ending"
Beta-Blockers
Medication Categories "ending"
Calcium Channel Blockers
Medication Categories "ending"
Erectile Dysfunction
Medication Categories "ending"
Histamine receptor antagonists
Medication Categories "ending"
Proton Pump Inhibitors
A nurse prepares to perform a heel stick to evaluate blood glucose for an infant. Which action should be used to minimize pain?
1. Warm the lateral surface to the foot for 5 minutes.
2. Apply a eutectic mixture of location anesthetic (EMLA) 1 hour before the procedure.
3. Allow the skin to dry after cleansing with mild friction.
4. Encourage the mother to breastfeed the infant during the procedure.
A dietitian instructs a client who has a transdermal fentanyl patch about food choices to minimize constipation. Which of the following should be included? (SATA)
1. Eggs
2. Barley
3. Raisins
4. Oatmeal
5. White rice
6. Fresh celery
When coordinating home discharge for a client who has a recent spinal cord injury, the nurse plans to promote and maintain health by which of the following actions? (SATA)
1. Reducing fluid intake
2. Assessing food choices
3. Evaluating bowel training
4. Promoting a daily exercise program
5. Recommending annual immunizations
Eight hours after a vaginal delivery, a client is unable to void. What should the nurse's initial action be?
1. Offer PO medication for pain.
2. Demonstrate use of sitz bath.
3. Assist the woman to the bathroom.
4. Pour warm water for the perineum.
A nurse cares for a client who speaks a different language. Which of the following are correct statement regarding communication? (SATA)
1. Written material is given in English and primary language.
2. Hospital personnel may interpret if fluent in client's primary language.
3. Communication is directed to the client even if an interpreter is present.
4. Interpretation provided by family member s is strongly discouraged.
5. Language access services are required in all hospitals that receive federal funding.
During a facility disaster drill for a mass casualty incident, the nurse should correctly assign a yellow tag to which client?
1. A client reporting severe chest pain and shortness of breath.
2. A client who has superficial chemical burns to both hands and arms.
3. A client who has a traumatic amputation of the left leg above the knee.
4. A client transported via ambulance for asystole nonresponsive to epinephrine.
A client reports smoke is coming from a wall socket. in what order should the nurse take the following actions? (put in order)
Close all doors
Point extinguisher hose to base of fire
Squeeze the trigger
Remove client from area
Initiate emergency response system
A nurse initiates emergency protocol on the medical unit during a fire. Which client should be evacuated first? A client who is
1. receiving mechanical ventilation
2. prescribed continuous oxygen therapy
3. recovering from a below the knee amputation
4. schedule for cholecystectomy the following day.
A unit educator evaluates teaching for the staff about the transfer of an obese client who is unable to assist from the bed to ta wheelchair. Which method is best o complete this task?
1. Gait belt
2. Mechanical lift
3. Bear hug technique
4. Two personnel to assist
A client who lives in a long-term care facility is at high risk for falls. Which actions should the nurse implement? (SATA)
1. Place the client's walker at the foot of the bed.
2. Keep all four side rails up throughout the night.
3. Maintain a clear bath from bed to the bathroom.
4. Put items on the beside table within easy reach.
5. Check the client every four hours to ensure safety.
6. Ask the client o use the call light before getting up.
A unit manager provides an update from the quality improvement report. Which standards of care should be followed for a client who requires mechanical restraints? (SATA)
1. Vital signs
2. Toileting needs
3. Range of motion
4. Behavior changes
5. Neurovascular checks
A client who has a latex allergy is admitted to a medical-surgical unit for elective surgery. Which action should the nurse implement? (SATA)
1. Verify surgery is schedule last.
2. Bring a latex-free cart to the room
3. Use of stopcocks to inject IV medications
4. Alert the perioperative team of allergy
5. Place monitor devices in a stockinet
A nurse reviews the following admission prescriptions for a client who has pneumonia. Which action should be implemented? (SATA)
- Vital Signs every 4 hrs.
- Regular Diet
- Ceftriaxone 500 mg IV BID
- Continue regimen for insulin
1. Determine any known allergies
2. Ensure an identification bracelet is in place.
3. Verify all medications currently being taken.
4. Store home medications at the bedside.
5. Validate the client's understanding related to the purpose of each medicine.
A client has a sealed radiation implant. Which action should the nurse implement? (SATA)
1. Save linens in the client room.
2. Assign client to a private room
3. Limit each visitor to 30 minutes a day.
4. instruct friends to stand 3 feet from client.
5. Place a "Caution: Radioactive Material" sign on door.
Ten days after chemotherapy, a client's WBC is 1000/mm3. Which discharge instructions should the nurse provide? (SATA)
1. Sanitize your personal toothbrush daily.
2. Avoid cleaning cages of household pets.
3. Wear a mask when around other people.
4. Increase intake of raw fruits and vegetables.
5. Avoid using the public transportation system.
Four clients enter the emergency department and require immediate admission. Only one private room is available. Which client should the nurse place in the private room.
1. A client who has a steel rod protruding from the chest.
2. A client who is coughing up coffee ground color emesis.
3. A client who has a low-grade fever and dry cough.
4. A client who is referred for admission due to sever viral conjunctivitis.
A child who has a rash and fluid-filled blisters across the face and chest is confirmed to have varicella. Which action should the nurse take?
1. Administer amoxicillin P.O. TID
2. Give one dose of the varicella vaccine.
3. Implement airborne and contact precautions.
4. Place the client in a private room and provide positive airflow.
A nurse provides care for a client who has a WBC of 900mm3. Which actions increase the risk for harm? (SATA)
1. Bathe client every other day.
2. Use plastic cup kept at the bedside.
3. Wash hands with antimicrobial soap.
4. Place fresh plants at least 3 feet from client.
5. Dispose of any beverage serviced to client after 8 hours.
6. Limit number of personnel who may enter the room.
A woman who has a premature rupture of membranes is admitted for observation. Which finding should concern the nurse?
1. Cloudy amniotic fluid
2. Fetal heart rate 160/min
3. Irregular uterine contractions
4. Maternal temperature 37.2*C(99*F)
A client remains in the intensive care unit 48 hr. post-intubation. The nurse recognizes which interventions are needed to assist in prevention of ventilator-associated pneumonia? (SATA)
1. Turn ever 2 hrs.
2. Wearing a face mask.
3. Frequent hand hygiene.
4. Client positioned supine.
5. Clean oral suction device.
6. Oral care with disinfectant.
A nurse provides teaching about preventing sudden infant death syndrome to the parent of a newborn. Which statement indicates understand?
1. I will offer the baby a pacifier at sleep time.
2. Only one stuffed animal should be kept in the crib.
3. The baby's head should be covered while napping.
4. A pillow can be used to maintain a side-lying position.
The client is to apply a topical corticosteroid to an area of atopic dermatitis. When teaching the client about his drug the nurse should tell the client to
1. Apply the medication often during the day
2. Avoid stopping the medication abruptly
3. Use gloves for application
4. Expect that the problem will worsen before it improves
The client is going to the beach. Which of the following suggestions regarding protection form the sun is accurate?
1. Use a sunscreen with the lowest SPF number.
2. Use a sunscreen, even on overcast days.
3. Sitting in the shade will protect you from sun exposure.
4. Wear light-colored, loosely woven clothes.
The client developed herpes simplex. The nurse documents that the client has which of the following types of skin lesions?
1. Vesicle
2. Pustule
3. Nodule
4. Wheal
If an area of skin is indurated, it means that it is?
1. reddened
2. hardened
3. inflamed
4. draining
A client has iron-deficiency anemia. The nurse anticipates that which of the following abnormalities will be present during the inspection of the nailbeds?
1. Pint color
2. cyanosis
3. jaundice
4. pallor
The nurse is bathing a client. When the nurse lifts the client's foot to clean it, the nurse notices that is is cool to the touch. Which of the following action would be most appropriate for the nurse to take first?
1. Document the finding on the client's chart.
2. Place the extremity under a blanket and continue the bath.
3. Inspect hair distribution on the lower half of the leg.
4. Compare the temperature of the foot with the client's other foot.
The client is to undergo a surgical excisional biopsy of a skin lesion o his arm. Which of the following should the nurse include in preoperative teaching?
1. Discussion of general anesthesia
2. Remaining NPO after midnight
3. Avoidance of aspirin 48 hours prior to surgery
4. Need for postoperative antibiotics.
A nurse initiates IV therapy for an older adult. Which of the following actions should be implemented?
1. Slap the extremity gently to visualize veins.
2. Ensure that the tourniquet is applied tightly for a brief time.
3. Use an inflated blood pressure cuff in place of a tourniquets.
4. Insert the IV catheter at higher angle to help avoid rolling veins.
After insertion is completed a nurse should perform which of the following assessments prior to infusing antibiotics through a client's tunneled central venous catheter. (SATA)
1. Observe the antecubital fossa for edema
2. Aspirate the IV port for a brisk blood return
3. Validate there is no resistance when flushing the line with normal saline.
4. Evaluate the client's discomfort level at the insertion site when the infusion begins.
5. Review the radiology report to confirm the catheter tip rests in the superior vena cava.
A client is receiving total parental nutrition (TPN) and lipids. The nurse should recognize which of the following measures should be implemented? (SATA)
1. Change TPN infusion tubing every 24 hrs.
2. Discontinue infusion of lipids after 12 hrs.
3. Clean the IV injection port before and after each time it is used.
4. Increase the rate if the infusion falls behind schedule.
5. Monitor blood glucose levels before meals and at bedtime.
A client develops swelling of the eyes, face, tongue, and lips after administration of intravenous penicillin. Which action should the nurse perform first?
1. Give diphenhydramine 25 mg IV
2. Administer epinephrine 0.2 mL IM
3. Raise dead of bed to 45* or higher
4. Prepare to administer a 1-liter fluid bolus.
A provider prescribes amoxicillin 500 mg orally every 12 hrs. for a client. The nurse should be concerned if the client reports a history of an allergic reaction to which of the following classification of medication?
1. Macrolides
2. Quinolones
3. Sulfonamides
4. Cephalosporins
A client diagnosed with pneumonia received ceftriaxone 1g IV every 12 hrs. for 4 days. Which of the following statement should be of most concern to the nurse?
1. My IV site is a little tender
2. I still have a productive cough
3. I feel nauseated ever time I eat
4. I have had runny diarrhea all day
A nurse reviews discharge documentation written by the provider for a client who takes clopidogrel daily. Which of the following information should be clarified before speaking with the client? (SATA)
1. Schedule INR each moth.
2. Use saline nasal spray as needed.
3. take 81 mg aspirin each morning.
4. Instruct client to report any usually bleeding or bruising.
5. Rotate self-injection sites to include abdomen and deltoid area.
A nurse cares for a client who is prescribed alteplase. The concurrent us of which medication should be of concern?
1. Warfarin
2. Metoprolol
3. Furosemide
4. Levothyroxine
A nurse is providing discharge teaching to a client prescribed ferrous sulfate. Which client statement indicates a need for additional teaching?
1. I will dilute the medicine in juice or water
2. I will eat more food high in fiber every day
3. I will take the medicine before eating breakfast
4. I will call the doctor if my stools are dark green or black
A nurse provides discharge teaching to a client who has a diagnosis of chronic kidney disease and a new prescription for metoprolol. Which action is most important for the client to accomplish?
1. Identify symptoms of uremia
2. Verbalize how to obtain a daily weight
3. Create a list of low sodium food options.
4. Demonstrate ability to check heart rate.
A nurse should advise a client to discontinue lisinopril and see the provider immediately if which of the following manifestations occur?
1. A persistent dry cough
2. Dizziness when standing
3. A rash on the torso and neck
4. Swelling of the tongue and lips
A client is newly prescribed isosorbide mononitrate. Upon review of the client's admission history, which of the following findings should concern the nurse most?
1. Use of vardenafil
2. Administration of metoprolol
3. Report of frequent headaches
4. History of myocardial infarction
A client is receiving digoxin. The nurse should instruct the client to notify the provider of which of the following finding? (SATA)
1. Blurred vision
2. Muscle weakness
3. Nausea and vomiting
4. Irregular heart rhythm
5. Increased urine output
A nurse provides discharge instruction to a client receiving simvastatin. Which of the following symptoms should the client immediately report to the provider?
1. Headaches
2. Dyspepsia
3. Sore throat
4. Weakness
A nurse provides teaching to a client prescribed furosemide. Which of the following client statements indicates effective teaching?
1. I will take one pill every day at bedtime
2. I will avoid eating high-potassium foods
3. I will skip the next dose if my feet tingle
4. I will call the doctor if my legs feel weak
A nurse cares for a client who takes insulin lispro for the management of type 1 diabetes mellitus. Which of the following instructions would be a priority for teaching?
1. Schedule eye examinations at least once each year.
2. Medication can be administered immediately after eating.
3. A medical alert bracelet should be worn where it can be easily identified.
4. Rotate injection sites systematically within the designated region.
A client is prescribed levothyroxine. Which of the following symptoms should concern the nurse most?
1. Weight loss
2. Palpitations
3. Heat intolerance
4. Increased appetite
A nurse provides care to a client receiving methylprednisolone sodium succinate for status asthmaticus. The nurse should monitor for which of the following adverse effects?
1. Blurred vision
2. Loss of energy
3. Hyperglycemia
4. Compression factures
A client is receiving magnesium sulfate 1 g per hr. The nurse is unable to elicit a patellar deep tendon reflex and respirations are 10/min. Which of the following is the priority nursing action?
1. Review previous laboratory results.
2. Verify infusion rate of medication.
3. Prepare to administer calcium gluconate.
4. Arrange for an emergency cesarean birth.
A client has excessive bleeding during the third stage of labor. Which of the following pre-existing medical conditions should cause the nurse to question a prescription for methylergonovine?
1. Chronic depression
2. Transfusion reaction
3. Migraine headaches
4. Gestational hypertension
The following pattern is observed on the fetal monitor for a client who is receiving oxytocin: multiple contractions with short resting period, duration of contractions is 100 to 115 seconds and the fetal heart rate baseline is at 100 beats/min. Which of the following actions should the nurse perform first?
1. Notify the provider
2. Administer oxygen by face mask
3. Discontinue the oxytocin infusion
4. Prepare to administer terbutaline
Twenty four hours ago, a client who is Rh-negative delivered and infant which is Rh-positive. Which medication should the nurse prepare to administer to the mother.
1. Vitamin K
2. Rubella vaccine
3. Methylergonovine
4. RHo(D) immune globin
A nurse provides teaching to an older adult prescribed patient-controlled analgesia (PCA). Which of the following should the nurse include?
1. Press the button 15 minutes prior to physical therapy.
2. Allow at least 60 minutes between doses.
3. Maintain regular time interval for using pump.
4. Large doses of the medication will be infused on a preset cycle.
A nurse provides care for a client who has received an epidural analgesia. Which of the following finding requires immediate intervention?
1. Inability to urinate
2. Reports of a headache
3. Bilateral upper extremity itching
4. Decrease level of consciousness
A client who has Parkinson's disease is prescribed selegiline. The nurse should provide dietary teaching that includes avoiding which foods? (SATA)
1. Red wine
2. Soy sauce
3. Watermelon
4. Aged cheese
5. Cured sausage
A nurse reviews the medication record of several clients. Which of the following clients should be of most concern if taking sertraline? A client who
1. takes phenelzine daily.
2. has a decline in sexual libido.
3. is prescribed furosemide daily.
4. reports a 20-pound weight gain this month.
A nurse provides discharge teaching to a a client prescribed clozapine. Which of the following instructions should the nurse include?
1. Schedule weekly lab tests.
2. Decrease fiber in the diet.
3. Monitor blood pressure for hypertension.
4. Avoid consuming aged cheeses and win.
ANEMIA
Aplastic
ANEMIA
Hemolytic
ANEMIA
Pernicious
ANEMIA
Iron Deficiency
Hemophilia
What should a nurse monitor, teach, and assess?
Sickle Cell Anemia
What should a nurse avoid, manage, and assess?
A child who has hemophilia is being discharge home. The nurse should teach the parents to use which measures if a child sustains an injury? (SATA)
1. Pace ice over the injured tissue
2. Provide passive range of motion
3. Apply pressure directly if bleeding
4. Soak the affected area in warm water
5. Keep injured extremity above the heart
6. Administer replacement clotting factors
An older adult client who has heart failure reports feeling short of breath two hours after a blood transfusion is started. The nurse should suspect fluid overload based on which assessment finding?
1. Bilateral crackles in the lungs
2. Jugular venous distention is absent
3. BP decreased from 135/79 to 110/62 mmHg
4. Potassium level changes from 4.8 to 3.7 mEq/L
A nurse recognizes which client statements demonstrate effective teaching regarding stomatitis after radiation therapy? (SATA)
1. I should try to ignore the sores
2. Food choices do not make a difference
3. My toothbrush should be replaced often
4. Alcohol-based mouth rinses should be avoided
5. My provider may prescribe medicine if sores develop
After radiation treatment, a client reports dryness, redness, and scaling within the designated radiation markings. how should the nurse respond?
1. Leve it alone because the area should not be touched
2. Wash the area with mild soap and water, and pat dry
3. Powders, ointment or creams can be used as needed
4. A heating pad will improve blood flow and help the area heal
M. O. N. A.
This stands for?
A nurse provides care to a client who underwent an aortic femoral bypass yesterday. Which finding should the nurse immediately repot to the surgeon?
1. Limited range of motion of the affected extremity
2. Manual brachial BP of 160/88 mmHg
3. Serosanguineous drainage on the abdominal dressing
4. Lower extremity pulse 1+ with warmth, redness, and edema
One hour after a client has a cardiac catheterization and stent placement using an approach via the left femoral artery, the nurse should be most concerned about which findings?
1. Left pedal pulse 1+, right pedal pulse 2+, left leg slightly cooler than the right
2. Client rates discomfort of 3, on a scale of 0 - 10, in the left groin area
3. Cardiac monitor shows 1 to 2 premature ventricular contractions (PVCs) per minute
4. Vital signs include pulse rate 120 bpm, BP 90/60, respirations 22, and temperature 99*F
What heart rhythm?
What heart rhythm?
What heart rhythm?
What heart rhythm?
What heart rhythm?
What heart rhythm?
What heart rhythm?
A client reports a "racing" heart, restlessness, and anxiety. The blood pressure is 140/68 mmHg and respirations 32/min. The nurse should recognize which finding may explain the cardiac rhythm?
1. Anemia
2. Carotid massage
3. Diabetes Mellitus
4. Valsalva maneuvers
A client is alert and oriented, but anxious and short of breath. After vagal maneuvers and medication administration the cardiac rhythm has not changed. The nurse should prepare to assist with which procedure?
1. Defibrillation
2. Cardioversion
3. Echocardiogram
4. Pacemaker insertion
A nurse provides discharge teaching to a client about management of an implantable cardioverter/defibrillator (ICD). Which statement requires clarification?
1. Strenuous exercises should be avoided
2. The ICD identification card is in my wallet
3. Exposure to a metal detector will active the device
4. I can talk on my cell phone using the ear opposite of the ICD
A nurse prepares to insert a peripheral intravenous catheter. Which actions will be included? (SATA)
1. Done sterile gloves for the procedure
2. Prime tubing after the catheter is inserted
3. Insert catheter with the bevel up at 10* to 30* angle (*=degrees)
4. Use chlorhexidine to cleanse the skin before insertion
5. Apply a tourniquet 4 to 6 inches above the selected insertion site
A nurse in the PACU admits a client who had gastric surgery. Which sign indicates postoperative hypovolemia?
1. Dyspnea
2. S3 gallop
3. Confusion
4. Tachycardia [Show Less]