1. A nurse is car- ing for a client who has ter- minal pancreat- ic cancer. The client is compe- tent and has re- quested no re- suscitative mea- sures be
... [Show More] tak- en in the event of respiratory or cardiac arrest. Which of the fol- lowing is nec- essary to legal- ly change the client's code sta- tus to do-not-re- suscitate (DNR)? 2. A nurse is caring for a toddler who has acute oti- tis media and is prescribed ben- zocaine (Ameri- caine) ear drops for pain re- lief. Which of the following ac- tions by the nurse is appro- priate when ad- ministering the ear drops? 3. A nurse is car- ing for a client A written prescription from the provider A DNR is typically instituted at the request of a client or family member and should be a written order instead of a verbal prescription. Until a DNR prescription exists. every attempts to revive the client should be made in the event of respiratory or cardiac arrest. A written prescription from the provider is necessary to legally change the client's code status to a DNR Warm refrigerated drops to room temperature prior to instillation. Because of the anatomy of internal ear structures, it is im- portant to remember that the ear is sensitive to extremes in temp. Ear drops should be warmed to room temp prior to instillation to reduce the risk of painful stimuli "What part of your mother's care concerns you?" who has a new colostomy. The client is be- ing discharged and plans to live with her daughter. Which of the following responses by the nurse is appro- priate when the daughter states that she doesn't know how she is going to care for her mother's colostomy? 4. A nurse is car- ing for a client who is diag- nosed with bipo- lar disorder and is taking lithium (Lithane). Which of the follow- ing serum lithi- um levels indi- cates the client's dosage is appro- priate for mainte- nance therapy? 5. A nurse is caring for a client who is scheduled for a lumbar punc- ture. The nurse should teach the 0.75 mEq/L Lithium is a mood-stabilizing medication used in the treat- ment of bipolar I acute and recurrent manic and depres- sive episodes. To achieve a therapeutic range, give 300 mg to 600 mg of lithium during the active phase. The therapeutic serum lithium level is between 0.8 mEq/L and 1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are prescribed lithium for long-term therapy. Because small increments of dosage separate therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for maintenance therapy. Headache A headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture that results from cerebrospinal fluid leakage at the puncture site. These client that which headaches are managed primarily with analgesics, hydra- of the following is tion, and bed rest a post-procedure complication? 6. A nurse is re- inforcing teach- ing about a new prescription for cromolyn sodi- um (Intal) me- tered-dose in- haler (MDI) to a school-age child who has asth- ma. Which of the following state- ments should in- dicate to the nurse that the child needs fur- ther teaching? 7. A nurse is plan- ning to ob- tain blood pres- sure on four clients. On which of the following clients should the nurse per- form an electron- ic blood pressure measurement? 8. A nurse is car- ing for a client who weighs 132 lb and "I will use my cromolyn inhaler before using my albuterol inhaler." When both cromolyn and albuterol are prescribed, al- buterol should be inhaled first to open the airways because it is a bronchodilator. After waiting a few minutes, the cromolyn can then be inhaled and will reach further into the lungs because of the dilatory effects of albuterol. A client who is recovering from a cardiac catheterization Electronic blood pressure measurement is attained through a sensor that detects vibrations caused by blood rushing through the arteyr, is appropriate for use when the blood pressure must be monitored frequently, and should not be taken on clients with conditions that can result in an inaccurate reading. A client who is recovering from a cardiac cath requires frequent blood pressure measure- ments. It is appropriate to perform an electronic blood pressure measurement on this client. 2.5 mL has been pre- scribed gentam- icin (Garamycin) 5mg/kg/day by IV bolus in three equal dos- es. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodi- um chloride. How many mL should the nurse add to the solution per dose? 9. A nurse is pro- viding education to the parent of an infant who is newly diagnosed with biliary atre- sia. The nurse should teach the parent that which of the following is a clinical man- ifestation associ- ated with the ill- ness? 10. A nurse admin- istrator is re- viewing policies and procedures of the facility she works in to ensure confiden- Dark urine Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the liver and being excreted in the urine. The nurse should teach the parent that dark urine is a clinical manifestation associated with the illness Assigning staff members on each shift the same password for accessing medical records If all staff members on each shift have the same password, limitations exist is tracking who is accessing those records, increasing the possibility that someone not involved in the care of a client could access records out of curiosity. This tiality require- ments are be- ing met. Which of the following in- dicates that inter- vention is need- ed to prevent the release of confi- dential client in- formation? 11. A school nurse has requested the school board remove a piece of playground equipment due to a documented in- crease in injuries that can be linked back to it. The nurse's actions are an example of which of the fol- lowing? 12. A nursing super- visor is determin- ing bed place- ment for four clients. Which of the following clients should be placed on droplet precautions? 13. A nurse is as- signed to care for four clients. procedure is not appropriate and requires intervention to prevent the release of confidential information. Advocacy Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a person, group, or community. The nurse made the request to remove the playground equipment on behalf of and to benefit the children of the school. This is an example of advocacy. A client who has rubella NG tube to suction The client with which of the fol- lowing drainage tubes is at an in- creased risk for hypokalemia? 14. A nurse is caring for a school-age client who was diagnosed with sickle cell ane- mia and has been admitted for a vaso-occlu- sive crisis. Which of the follow- ing findings has the highest prior- ity?c 15. A nurse is col- lecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. Which of the fol- lowing findings requires further intervention? 16. A nurse is re- inforcing teach- ing about the diet for dump- ing syndrome to a client who Slurred speech Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of sickle cell ane- mia. The blockage of blood vessels in the brain by sickled cells results in cerebral infarction, which leads to neuro- logical impairment. Because a CVA threatens the life of the client, this is highest priority finding. Abdominal distension Toast with peanut butter Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and mani- fests as a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations. is postoperative following a gas- trectomy. Which of the following food selections by the client indi- cates the teach- ing was effec- tive? 17. A nurse is collecting data on a client who is diag- nosed with schiz- ophrenia and is taking clozapine (Clozaril). Which of the follow- ing findings indi- cates the client is experiencing an adverse effect of the medication? 18. A nurse is car- ing for a client who is postop- erative following a wedge resec- tion of a lung and has a chest tube with a water seal chest tube drainage system. The client re- ports a burning pain in his chest. Which of the fol- Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some foods and includes others as appropriate food choices re- duces the occurrence and severity of dumping syndrome. Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome. WBC 2,800/mm3 Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis, which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal. Be- cause of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3 indicates the client is experiencing an adverse effect of the medication. Assist the client to a side-lying position. lowing actions by the nurse is ap- propriate? 19. A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) of 23. When asked by the client how much weight she should gain dur- ing the preg- nancy, which of the following re- sponses by the nurse is appro- priate? 20. A nurse is car- ing for a client who is experienc- ing night sweats and hemoptysis and is suspect- ed to have active pulmonary tuber- culosis. Which of the following tests is used to confirm this diag- nosis? 25 to 35 lb Sputum culture for acid-fast bacillus Once infected, the bacteria multiply freely after reaching the bronchi or alveoli. Typically, acquired immunity pro- tects individuals from attaining active tuberculosis. Infec- tion is most common among those who are immunocom- promised and those who have been in repeated, close contact with someone who has an undiagnosed case of active tuberculosis. The lungs are primarily involved, but the infection can spread to other organs. Symptoms of pulmonary tuberculosis include productive cough, fever, fatigue, weight loss, hemoptysis, and night sweats. In cases of active pulmonary tuberculosis, the organism is transmitted through the air because it is found in the sputum and secretions. The presence of acid fast bacillus in the sputum, secretions, or tissues of the client is the only method to confirm the diagnosis of active tuberculosis. [Show Less]