A nurse is performing an ECG on a client who is scheduled for surgery the following morning. What location should the nurse place the V1 electrode? -
... [Show More] correct answer The nurse should identify that the V1 electrode should be placed in the 4th intercostal space just right of the sternum.
A nurse is collecting data from a 55 year old female client who reports of vaginal dryness and hot flashes. The client is interest in trying hormone replacement therapy (HRT). What should the nurse recognize as a contraindication to HRT? - correct answer History of treatment for blood clots.
A nurse is reinforcing discharge teaching with a client who has cirrhosis. What instructions should the nurse include? - correct answer Consume foods low in sodium
A nurse is caring fro a client who has bacterial meningitis.. Upon monitoring the client, what findings should the nurse expect? - correct answer Red macular rash
A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. What interventions should the nurse include? - correct answer Dangle the extremities off the side of the bed.
A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as a priority? - correct answer Dysrhythmia
A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate what complication? - correct answer Pulmonary embolism
A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What findings should the nurse expect related to hyperkalemia? - correct answer Bradycardia
A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. What intervention should the nurse include in the plan? - correct answer Encourage abdominal breathing
A nurse is caring for a client who has a prescription for phenazopyridine. What finding should the nurse identify as a therapeutic effect of the medication? - correct answer Decreases pain during urination
A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of what? - correct answer Intra-abdominal bleeding
A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. What action should the nurse take first? - correct answer Palpate the abdomen
A nurse is reviewing the lab results of a client who has a chronic kidney failure and is receiving epotein alfa. The nurse should identify what lab value indicates the treatment is effective? - correct answer Hgb 11g/dL
A nurse is caring for a client who has a hx of breast cancer. The client asks the nurse about birth control. What method of birth control is contraindicated for this client? - correct answer Combination oral contraceptives
A nurse is caring for a client who had an acute ischemic stroke 1 day ago. What action should the nurse take to reduce the risk for aspiration? - correct answer Allow 30 minutes of rest before meals
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What finding should the nurse instruct the client to report to the provider? - correct answer Onset of nausea
A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. What action should the nurse take? - correct answer Perform pin site care daily
A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks how to improve the taste of bland food. What should the nurse recommend? - correct answer Lemon juice
A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. What should the nurse include in teaching? - correct answer Increase intake of fiber rich foods
A nurse in a long term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. What finding should indicate to the nurse that the client might have a fecal impaction? - correct answer Small liquid stools
A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate what complication of IV therapy? - correct answer Thrombophlebitis
A nurse is participating in a heath fair for older adult clients. What immunization should the nurse recommend for this age group? - correct answer Herpes zoster
A nurse is monitoring a client who is taking acarbse. What finding should the nurse identify as an adverse effect of the medication? - correct answer Abdominal cramps
Teaching the client with gonorrhea how to prevent reinfection and further spread is an
example of? - correct answer Secondary prevention
Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to? - correct answer Help improve body defenses
The major electrolytes in the extracellular fluid are? - correct answer Sodium and Chloride
What nursing diagnoses might be appropriate as Parkinson disease progresses and complications develop? - correct answer Impaired physical mobility
A teenage client is admitted to the hospital because of tylenol overdose. Overdose of tylenol can precipitate life-threatening abnormalities in what organ? - correct answer Liver
Ill health, malnutrition, and wasting as a result of chronic disease are all associated with? - correct answer Cachexia
Prolonged arching of the back with the head and heels bent backward? - correct answer Opisthotonos
A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period? - correct answer "The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."
The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. What should the nurse do first? - correct answer Check for kinks in the chest drainage system.
The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. What should be included in the plan? - correct answer Pull the earlobe down and back before instilling the ear drops.
Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. What instruction should the nurse reinforce in the client-teaching plan regarding this medication? - correct answer To return to the clinic weekly for serum drug-level testing
The metabolic panel of a client reveals a calcium level of 6.5 mg/dL. Based on this laboratory finding, what additional data specific to this calcium level should the nurse collect? - correct answer -Presence of Chvostek's sign
-Presence of electrocardiogram abnormality
-Presence of tingling in the fingertips and around the mouth
-Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes
An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history? - correct answer Whether the client has had a recent upper respiratory infection (URI)
Administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB? - correct answer Calmette-Guerin Vaccine (BCG)
The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by what action? - correct answer Observing rigid rules and regulations
Enoxaparin sodium (Lovenox) is prescribed for the client following hip replacement surgery. The nurse prepares to have what available in the event that an overdose of the medication occurs? - correct answer Protamine sulfate
A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove what food items that arrived on the client's meal tray from the dietary department? - correct answer Peas
The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by performing what action? - correct answer Monitoring for signs of dyspnea
A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. What findings validate this suspicion? - correct answer -Oliguria
-Restlessness
-Abdominal pain
-Unexplained tachycardia
After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in what appropriate position? - correct answer Prone
The nurse is evaluating the data results of a client with sepsis and acute kidney injury with related azotemia and oliguria. What are the primary features of azotemia and oliguria? - correct answer -Increase in serum creatinine
-Increase in blood urea nitrogen (BUN)
-Urine output less than 0.5 mL/kg/hour
A client with ascites is scheduled for a paracentesis. The nurse is assisting the health care provider in performing the procedure. What position should the nurse assist the client into for this procedure? - correct answer Upright
"The disease is transmitted by contact with nasal or oral fluids, so any items contaminated with these types of fluids, such as a drinking cup, should not be used by your other children." - correct answer Roseola infantum
The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). What method should be used to monitor the client for crepitus? - correct answer Palpating for the leakage of air into the subcutaneous tissues
The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find what sign/symptoms of lithium toxicity associated with this level? - correct answer -Incoordiantaion
-Mental confusion
-Muscle hyper irritability
The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if what is documented in the client's history? - correct answer Pancreatitis
A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid what fruit? - correct answer Bananas
The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate what potential complication? - correct answer Infection of a central catheter site can lead to septicemia
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On data collection of the client, the nurse expects to note what finding? - correct answer Rhythmic respirations with periods of apnea
The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make what observation while caring for the neonate? - correct answer The neonate cries incessantly.
In caring for a preterm newborn's skin, what special characteristics should the nurse expect to note? - correct answer Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture
Heparin sodium is prescribed for the client. What laboratory result indicates that the heparin is prescribed at a therapeutic level? - correct answer Activated partial thromboplastin time (aPTT) of 55 seconds
A client with lung cancer is receiving a high dose of methotrexate (Rheumatrex). Leucovorin (citrovorum factor, folic acid) is also prescribed. The nurse who is assisting in planning care for the client understands that administering the leucovorin is for what purpose? - correct answer Preserve normal cells.
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that what has probably occurred? - correct answer Infiltration
Primary belief of psychiatric mental health nursing is? - correct answer Every person is worthy of dignity and respect
What fetal heart monitoring pattern can indicate cord compression? - correct answer Variable deceleration
What is the HEELP Syndrome? - correct answer This is pre-eclampsia with liver involvement
How many arteries and veins are in the umbilical cord? - correct answer 2 arteries, 1 vein
The click that is heard or felt when the infant is supine and knees are flexed and hips are abducted (hip dyslpasia) is called? - correct answer Ortilani's sign
What is ptosis? - correct answer Drooping
What cranial nerve is optic? - correct answer Cranial nerve 2
What sign is the softening of the cervix? - correct answer Goodell's
What is the normal Lithium value? - correct answer Normal= less than 1.5 mEq/L
Toxic= greater than 2 mEq/L
Antidote for acetaminophen? - correct answer Mucomyst (Nacetylcysteine)
Dietary considerations for Celiac disease? - correct answer -No gluten
-Increase calories
-Increase protein
What is a continuous seizure that must be interrupted by emergency measures? - correct answer Status epilepticus
Meds most often used to treat status epilepticus? - correct answer -Diazepam (Valium)
-Phenytoin (Dilantin)
-Phenobarbitol (Luminol)
Supine with legs straight and elevated at the hips and head is slightly raised (increases blood flow to heart and brain) - correct answer Modified Trendelenburg
-Called the "Shock" position
Amount of blood ejected by the heart in any one contraction is called? - correct answer Stroke volume
Do Mydriatic drops constrict or dilate the pupils? - correct answer Dilate
(myDriatic...D for dilate)
How to mix insulin? - correct answer Clear before Cloudy (NPH)
Normal sodium values? - correct answer 135-145
What is the normal PT value? - correct answer 9.5-12 seconds
Normal creatinine values? - correct answer 0.5-1.5 mg/dl
What is the normal heart and blood flow in the correct order? - correct answer Blood enters, Right atrium, Tricuspid valve, right ventricle, pulmonic valve, left atrium, mitral valve, left ventricle, aortic valve, and out to the body
Normal blood pH? - correct answer 7.35-7.45 [Show Less]