ATI PN COMPREHENSIVE EXIT EXAM 2021 |14 DIFFERENT VERSIONS| 100% SUCCESS GUARENTEED

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1 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 ATI PN COMPREHENSIVE EXIT EXAM 2021 14 DIFFERENT VERSIONS 100% SUCCESS GUARENTEED a) 2 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 ATI PN COMPREHEN... SIVE EXIT EXAM VERSION 1 1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take? A. (Unable to read) B. Tell the child they will feel discomfort during the catheter insertion. C. Use a mummy restraint to hold the child during the catheter insertion. D. Require the parents to leave the room during the procedure. 2. A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report? A. Thrill upon palpation. B. Absence of a bruit. C. Distended blood vessels D. Swishing sound upon auscultation. 3. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? A. “I will soak in the tub rather and showering” B. “I will wear loose clothing around my ICD” C. “I will stop using my microwave oven at home because of my ICD” D. “I can hold my cellphone on the same side of my body as the ICD” 4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? a) 3 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 A. “Describe your feelings to me about being pregnant” B. “You should discuss your feelings about being pregnant with your provider” C. “Have you discussed these feelings with your partner?” D. “When did you start having these feelings?” 5. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? A. Encourage a maximum fluid intake of 1,500 ml per day. B. Increase the amount of refined grains in the client’s diet. C. Provide the client with a cold drink prior to defecation. D. Administer a rectal suppository 30 minutes prior to scheduled defecation times. 6. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? A. Administer ondansetron. B. Place the client in a warm shower. C. Apply fundal pressure during contractions. D. Assist the client to a supine position. 7. a nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? A. Below-the knee amputation B. Fractured tibia C. 95% full-thickness body burn D. 10cm (4in) laceration to the forearm 8. a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? a) 4 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 A. Remove the client’s restraint every 4hr B. Document the client’s condition every 15 min C. Attach the restrain to the bed’s side rails D. Request a PRN restrain prescription for clients who are aggressive 9. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit C. Priorities staff request over client needs. D. Provides routine client care and documentation. 10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care. A. Serum sodium 144 mEq/ B. (Unable to read) C. Hba1c 10 % D. Random serum glucose 190 mg/dl. 11. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? A. Chlamydia B. Human papillomavirus C. Candidiasis D. Herps simplex virus a) 5 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 12. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? A. Share personal opinions to help influence the group’s values B. Measure the accomplishments of the group against a previous group C. Yield in situations of conflicts to maintain group harmony D. Use modeling to help the clients improve their interpersonal skills 13. A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) Passover holiday. Which of the following action should the nurse include in the plan of care? A. Provide chicken with cream sauce. B. Avoid serving fish with fins and scales. C. Provide unleavened bread. D. Avoid serving foods containing lamb. 14. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment A. A chest x-ray reveals increased density in all fields. B. The client reports feeling less anxious. C. Diminished breath sounds are auscultated bilaterally D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. 15. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway and initiating an IV, which of the following actions should the nurse do next. A. Monitor the client’s IV site for thrombophlebitis. B. Administer flumazenil to the client. C. Evaluate the client for further suicidal behavior. D. Initiate seizure precautions for the client. a) 6 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 16. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect? A. Hypotension B. Memory loss C. Slurred speech D. Elevated temperature 17. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? A. Loose stools B. Jitteriness C. Hypertonia D. Abdominal distention 18. A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider? A. Hgb 12.5 g/dl B. Platelets 250,000/mm3 C. Hct 40% D. WBC 14,000/mm3 19. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include? A. “The proxy should make health care decisions for the client regardless of the client’s ability to do so.” B. “The proxy can make financial decisions if the need arises.” C. “The proxy can make treatment decisions if the client is under anesthesia.” D. “The proxy should manage legal issues for the client.” a) 7 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 20. A nurse in the PACU is caring for a client who reports nausea. Which of thefollowing actions should the nurse take first? A. Turn the client on their side. B. Administer an analgesic C. Administer antiemetic D. Monitor the client’s vital signs. 21. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? A. Confirm the client’s perception of the event B. Notify the client’s support system C. Help the client identify personal strengths D. Teach the client relaxation techniques 22. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client’s peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client’s condition every 15 minutes. 23. A 24. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the (Unable to read) unit due to a a) 8 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 staffing shortage. Which of the following client should the nurse delegate to the LPN? A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs. B. A client who sustained a concussion and has unequal pupils. C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction. D. A client who fractured his femur yesterday and is experiencing shortness of breath. 25. A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? A. Place the client upright on a donut-shaped cushion B. Teach the client to shift his weight every 15 min while sitting C. Turn and reposition the client every 3 hr while in bed D. Assess pressure points every 24 hr 25. A nurse is caring for a client who is dilated to 10 cm and pushing. Which of thefollowing pain-management (Unable to read) a safe option for the client? A. Naloxone hydrochloride. B. Spinal anesthesia. C. Pudendal block. D. Butorphanol tartrate. 26. C 27. A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the (Unable to read) (Most important?) A. The client changes the subject when future plans are mentioned. B. The client talks about being in pain constantly. C. The client sleeping over 12 hr. each day. a) 9 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 D. The client reports giving away personal items. 28. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply) A. Varicella vaccine. B. Inactivated polio vaccine. C. Tetanus diphtheria and acellular pertussis vaccine D. Rubella vaccine. E. Inactivated influenza vaccine. 29. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child’s medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary glaucoma 30. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. a) 10 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 31. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? A. “I can give you information about respite care if you are interested.” B. “You should consider taking a sleeping pill before bed each night” C. “It must be difficult taking care of someone who is terminally ill” D. “You are doing a great job taking care of your mother” 31. A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s glucose. The nurse should identify this finding as an adverse effect of which of the following medications A. Methylprednisolone. B. Ondansetron. C. Guaifenesin. D. Amoxicillin. 32. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? A. “You should take folic acid to decrease the risk of transmitting infections to your baby” B. “You should consume a maximum of 300 micrograms of folic acid every day”. C. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”. D. “You can expect your urine to appear red-tingled while taking folic acid supplements”. 33. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse’s priority? A. Social relationship with peers. B. Plans for attending school while pregnant. a) 11 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 C. (Unable to read) (Picked this one) Medicaid? D. Understanding of infant care. 34. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? A. Critical pathways have unlimited timeframe for completion B. (Unable to read) decrease health care costs. C. (Unable to read) critical pathway if variances (Unable to read) D. (Unable to read) are used to create the critical pathway. 35. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg(2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and drymouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. a) 12 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 C. Sore throat. D. Blood pressure. 36. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel A. “The nurse is legally responsible for the actions of the AP”. B. “An AP can perform tasks outside of his range if he has been trained”. C. “An experienced AP can delegate to another AP”. D. “An RN evaluates the client needs to determine tasks to delegate” 37. A nurse is assessing a client who is in active labor. Which of the followingfindings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR D. Temperature 37.4C (99.3) 38. A nurse working in a rehabilitation facility is developing a discharge plan for aclient who has left-sided hemiplegia the following actions is the nurse’s priority? A. Consult with a case manager about insurance coverage. B. Counsel caregivers about respite care options. C. Ensure that the client has a referral for physical therapy. D. Refer the client to a local stroke support group. 39. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse’s station? A. A client who has an anxiety disorder and is experiencing moderate anxiety. B. A client who has somatic symptom disorder and reports chronic pain. a) 13 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. 40. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 41. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the client’s TV privileges is the does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the cline in seclusion when he exhibits signs of anxiety 42. A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? A. A client receives his antibiotics 2hr late B. A client vomits within 20min of taking his morning medications C. A client requests his statin to be administered at 2100 D. A client asks for pain medication 1hr early 43. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of the following responses should the nurse make? a) 14 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 A. “Does the doctor know you are eating that?” B. “Why are you eating seaweed soup?” C. “Of course I will heat that up for you” D. “The hospital good is more nutritious” 44. a nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? A. Leaving a nasogastric tube clamped after administering oral medication B. Documenting communication with a provider in the progress notes of the client’s medical records C. Administering potassium via IV bolus D. Placing a yellow bracelet on a client who is at risk for falls 45. a nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Establish a toileting schedule for the client B. Use clothing with buttons and sippers C. Discourage physical activity during the day D. Engage the client in activities that increase sensory stimulation 46. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia. 47. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? a) 15 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 A. “Do you understand that the voices are not real?” B. “Why do you think the voices are talking to you?” C. “Have you tried going to a private place when this occurs?” D. “What helps you ignore what you are hearing?” 48. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? A. Placing a belt restraint on a school-age child who has seizures. B. Securing wrist restraints to the bed rails for an adolescent. C. Applying elbow immobilizers of an infant receiving cleft lip injury D. Keeping the side rails of a toddler’s crib elevated. 49. B 50. A nurse is preparing to mix NPH and regular insulin in the same syringe. Whichof the following A. Inject air into the NPH insulin vial. B. (Unable to read) C. Withdraw the prescribed dose of regular insulin D. Withdraw the prescribed dose of NPH insulin 51. a Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? A. “Let’s talk about how you can change your response to stress.” B. “We should establish our roles in the initial session.” C. “Let me show you simple relaxation exercises to manage stress.” D. “We should discuss resources to implement in your daily life.” 51. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? a) 16 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 52. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following requires intervention by the staff nurse? A. Waits 2 minutes between suctions. B. Encourages the client to cough during suctioning. C. Apply suctioning for 15 seconds. D. Inserts the catheter without applying suction. 53. A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 54. A nurse is providing care for a group of clients. Which of the following client’sshould the nurse identify as having the highest risk for developing a pressure injury? A. A client who has a T-tube following an open cholecystectomy. B. A client who had a knee 2 days ago following a sports injury. C. A client who has dementia and is incontinent of urine and feces D. A client who has a myocardial infarction and is receiving thrombolytic therapy. a) 17 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 55. A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops. Which of the following statements indicates an understanding of the teaching? A. “I will place the eye drops in the center of my eye” B. “I will place pressure on the corner of my eye after using he eye drops” C. “I should expect my tears to turn a red color after using the eye drops.” D. “I should expect the eye drops to appear cloudy.” 56. A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency 57. A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make? A. “I would recommend sharing your feelings with a psychologist”. B. “I can give you information about making end of life decisions”. C. “You should discuss your end life decisions with your family” D. “Everyone feels this way at first. You will start feeling better soon”. 58. A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? a) 18 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 A. Keep client’s calcium gluconate at the client’s bedside B. Monitor blood pressure every 2 hr. C. (Limit or remove?) IV bag from exposure to light. D. Attach tan inline filter to the IV tubing. 59. A nurse is caring for a client who is experiencing mild anxiety. Which of thefollowing findings should the nurse expect? A. Feelings of dread B. Heightened perceptual field C. Rapid speech D. Purposeless activity 60. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. 61. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1hr if unable to fall asleep B. Take 1 hr nap during the day C. Perform exercise prior to bed D. Eat a light snack before bedtime 62. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam a) 19 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 C. Colchicine D. Codeine. 63.A nurse is caring for a client following insertion of a chest tube 12 hr. ago. The(Unable to read) following actions should the nurse take? A. Assess the amount of drainage in the collection chamber. B. Clamp the chest tube during ambulation. C. Report continuous bubbling in the water seal chamber. D. Strip the chest tube every 4 hr. to maintain patency. 64. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every4 hr. PRN. The nurse should monitor for which of the following adverse effects? A. Productive cough. B. Urinary retention. C. Rhinitis D. Fever. 65. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so quickly.” Which of the following by the nurse is therapeutic? A. “Can you talk about what happens with your partner at home?” B. “Why do you think your partner’s symptoms are progressing so quickly?” C. “You should make sure your partner takes the prescribed medication.” D. “You did the right thing by bringing your partner in for treatment.” 66. A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching? a) 20 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 A. “I will put my child on a gluten-free diet”. B. “I will administer digestive enzymes with meals and snacks”. C. “Provide my child with some high fiber foods.” D. “I will give my child whole wheat toast and milk for breakfast”. 67. A nurse is caring for a client who is to receive a transfusion of packed RBCs.Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. 68. A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of continuous infusions should the nurse initiate? A. 0.9% normal saline. B. NPH insulin. C. Glargine insulin. D. 0.45% saline. 69. A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching? A. Drink 1.5L fluids each day. B. Take mineral oil at bedtime. C. Increase exercise activity D. Decrease insoluble fiber. a) 21 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 70. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? A. “Drink 2 liters of warm water per day”. B. “Empty your bladder every 6 weeks.”. C. “Soak in a warm bath everyday”. D. “Take an oral estrogen tablet”. 71. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes and a hemoglobin A1C of 6.8% 72. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? A. Consume food high in bran fiber B. Increase intake of milk products C. Sweeten foods with fructose corn syrup D. Increase foods high in gluten 73. A nurse is caring for a 1-day-old newborns who has jaundice and is receivingphototherapy. Which of the following actions should the nurse take? A. the infant 30 ml (1 oz) glucose water every 2 hr. a) 22 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 B. Keep the infants head covered with a cap. C. Ensure that the newborn wears a diaper. D. Apply lotion to the newborn every 4 hr. 74. a nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. “(Unable to read) I feel to be in his best health care decision” B. “I will intervene if there is conflict between a client and his provider” C. “I should not advocate for a client unless he is able to ask me himself” D. “I will inform a client that his family should help make his health care decisions.” 75. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? A. Raise the side rails on both sides of the client’s bed during repositioning. B. Reposition the client without assistive devices. C. Discuss the client’s preferences for determining a reposition schedule. D. Evaluate the client’s ability to help with repositioning. 76. A 77. A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension D. Increased intracranial pressure\ a) 23 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 78. a nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? 78. A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? A. A statement that participants can leave the study at will. B. An assignment of the participant to either the experimental or control group. C. A list of the clients participating in the study. a) 24 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 D. A description of the framework the researchers will use to evaluate the data. 79. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 80. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? A. The client’s pulse oximetry level is 96%. B. (Unable to read) C. The client develops hiccups. D. The ECG shows pacing spikes after the QRS complex. 81. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? A. Personal blogs about managing the adverse effects of diabetes medications B. Food label recommendations from the Institute of Medicine C. Diabetes medication information from the Physicians’ Desk Reference D. Food exchange lists for meal planning from the American Diabetes Association 82. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. “The PCA will deliver a double dose of medication when you push the button twice.” B. “You can adjust the amount of pain medication you receive by pushing on the keypad.” a) 25 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 C. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” D. “You should push the button before physical activity to allow maximum pain control.” 83. A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? A. Glargine insulin. B. Regular insulin. C. NPH insulin. D. Insulin aspart. 84. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which ofthe following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. 85. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? A. Administer a refrigerated feeding. B. Increased the amount of water use to flush the tubing. C. (Unable to read) rate of the client’s feedings. D. Instruct the client to move onto their right side. a) 26 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 86. A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing.Which of the following actions is the nurse’s priority? A. Monitor the client’s ECG B. Take the client’s vital signs. C. Administer oxygen D. Insert an IV line. 87. A nurse is caring for a client who has Raynaud’s disease. Which of the followingactions should the nurse take? A. Provide information about stress management. B. Maintain a cool temperature in the client’s room. C. Administer epinephrine for acute episodes. D. Give glucocorticoid steroid twice per day. 88. A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client’s medical history should identify as a risk factorfor angina? A. Hyperlipidemia. B. COPD C. Seizure disorder D. Hyponatremia. 89. A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? A. Bisacodyl 10 mg rectal suppository. B. Magnesium hydroxide 30 ml PO. C. Famotidine 20 mg PO. D. Loperamide 4 mg PO. a) 27 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 90. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? A. Contact the client’s family about the incident. B. Notify the client’s provider about the incident. C. File a complaint with the facility’s ethics committee. D. Report the incident to the AP’s charge nurse. 91. A nurse is planning care for a client who is receiving hemodialysis. Which of thefollowing actions should the nurse include in the plan of care? A. Withhold all medications until after dialysis B. Rehydrate with dextrose 5% in water for orthostatic hypotension. C. Check the vascular access site for bleeding after dialysis. D. Give an antibiotic 30 min before dialysis. 92. A nurse in the emergency department is caring for a client who reports intimate partner violence. Which of the following interventions is the nurse’s priority? A. Develop a safety plan with the client B. (Unable) options for reporting the incident. C. Refer the client to a community support group. D. Determine if the client has any injuries. 93. A nurse is caring for a client who is in active labor and note the FHR baselinehas been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal fever B. Fetal anemia C. Maternal hypoglycemia D. Chorioamnionitis a) 28 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 94. A nurse is assessing a school-age child who has a urinary tract infection. Whichof the following findings should the nurse expect? A. Periorbital edema. B. Decreased frequency of urination. C. Enuresis. D. Diarrhea. 95. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation therapy C. A client who is receiving heparin for deep-vein thrombosis D. A client who is 1 day postoperative following a vertebroplasty 96. A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number) 6 mL/hr 97. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching? A. “This test should be performed after your baby is 24 hours old.” a) 29 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 B. “A nurse will draw blood from your baby’s inner elbow.” C. “Your baby will be given 2 ounces of water to drink prior to the test.” D. “This test will be repeated when your baby is 2 months old.” 98. A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching? A. “My stool will become fully formed within 3 weeks” B. “My skin will need to be cleaned with alcohol before I apply a new pouch” C. “I should avoid eating popcorn and fresh pineapple” D. “I should expect bruising around the stoma” 99. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse’s priority? A. Refer the client to a speech language pathologist. B. Monitor the client’s prealbumin levels C. Measure the client’s weight. D. Place the client on NPO status. 100. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 101. A nurse is planning a teaching session for a client who is postoperative following a colon resection. Which of the following actions should the nurse take first? a) 30 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 A. Providing written material for the client to read B. Plan a short instruction about coughing and deep breathing. C. Determine the client’s current pain level. D. Instruct the client about dietary restrictions. 102. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. 103. A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? A. “I cannot be a witness for your consent to donate.” B. “Your name cannot be removed once you are listed on the organ donor list.” C. “Your desire to be an organ donor must be documented in writing.” D. “You must be at least 21 years of age to become an organ donor.” 104. A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? A. The client takes a hot bubble bath every day. B. The client wipes back to front when toileting. C. The client washes her perineum first when bathing. D. The client brushes her teeth twice daily. a) 31 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 108. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these finding to which of the following members of the interdisciplinary team? A. Dietitian B. Infection control nurse C. Nephrologist D. Cardiologist 109. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? A. Return unopened equipment to the supply center B. Leave the unused infusion pump in the room until discharge C. Stock the room with a 2-day supply of disposable diapers D. Being in formula as needed 108. A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider? A. Hear rate 100/min B. Temperature 37.8C (100F) a) 32 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 C. Albumin level 4.0 g/dL. D. WBC count 14,000 mm3 109. A nurse is preparing education material for a client. Which of the following techniques should the nurse use in creating material? A. Emphasize important information using bold lettering. B. Use 7 th grade reading level. C. Avoid using cartoons in the teaching material. D. Use words with three or four syllables. 110. A nurse is creating for a client who has aids. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide? A. “Add salt to season” B. “Ice chips” C. “Rinse your mouth with an alcohol-based mouthwash” D. “Eat foods served at hot temperatures” 111. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions 112. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. a) 33 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 113. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance) A. Identify family needs interventions using the nursing process. B. Record information about the home visit according to agency policy. C. Contact the family to determine availability and readiness to make an appointment D. Discuss plans for future visits with the family. E. Clarify the reason for the referral with the provider’s office. E C A B D (My choice) 114. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing” 115. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration? A. A residual of 65mL 1 hr postprandial B. A History of gastroesophageal reflux disease C. Sitting in a high-Fowler’s position during the feeding D. Receiving a high osmolarity formula a) 34 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 116. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? A. Take magnesium hydroxide for indigestion B. Drink at least 3L of fluid daily C. Eat 1g/kg of protein per day D. Consume foods high in potassium 118. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. First degree AV block B. Premature ventricular contraction. C. Sinus bradycardia. D. Atrial fibrillation. 119. A nurse is supervising an assistive personnel (AP) who is feeding a client. Thenurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next? A. Provide the client with an instructional handout about swallowing exercises. B. Ask a speech therapist to evaluate the client’s ability to swallow. C. Discuss the manifestations of impaired swallowing with the AP. D. Listens to the client’s lung sounds. 120. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Ask the client directly what he is hearing B. Encourage the client to lie down in a quiet room C. Avoid eye contact with the client a) 35 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 D. Refer to the hallucinations as if the are real 120. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? A. “If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease” B. “There is no need to have genetic counseling if I know that I have a family history of mental illness.” C. “My family has genetic risk for breast cancer, so I am considering a total mastectomy” D. “Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to current medical treatments.” 121. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? A. “The cord stump will fall off in 5 days.” B. “Contact the provider if the cord stump turns black.” C. “Clean the base of the cord with hydrogen peroxide daily.” D. “Keep the cord stump dry until it falls off.” 122. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? A. “I have my eyes examines annually” B. “I take a calcium vitamin supplement daily” C. “I limit my intake of foods with potassium” D. “I constantly take my medication between 8 and 9 each evening” a) 36 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 123. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching? A. Stands with feet together when lifting a client up in bed. B. Raises the client’s head of bed before pulling the cline up. C. Uses a mechanical lift to move client from bed to chair. D. Places a gait belt around the client’s upper chest before assisting a client to stand. 124. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? A. “Your bladder should be full prior to me performing this test B. “If this test is positive you will be required to have a non-stress test. C. “This test will determine if there is leaking amniotic fluid” D. “I will be taking a blood sample to test for changes in your hormones levels” 125. A Nurse is assessing a client who has hyponatremia and is receiving IV fluidtherapy. Which of the following findings indicate the client is developing a complication of therapy? A. Peripheral edema B. Increased thirst. C. Flattened neck veins. D. Hypotension 126. A nurse is conducting a home visit for a family who has two young children.The nurse notes several welts across the backs of the legs of one of the children.Which of the following actions should the nurse take first? A. Document clinical findings. B. Contact child protective services. C. Refer the parents to a self-help group. a) 37 of 640 ATI PN COMPREHENSIVE EXIT EXAM 2021 D. Instruct the parents about methods of discipline. 127. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? A. Encourage the client to floss daily. B. Remove fresh flowers from the client’s room. C. Provide the client what a stool softener. D. Avoid serving the client raw vegetable. 128. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. 129. (Unable to read) A. Use NPH insulin to treat ketoacidosis. B. Administer NPH insulin 30 minutes before breakfast. C. (Unable to read) I think this answer was 0.9% sodium chloride D. Discard the NPH insulin vial if the medication is cloudy. 131. A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take? A. Maintain the client’s oxygen saturation level at 89%. B. Place the client’s lower extremities on two pillows. C. Recommended that the client follow a 3g sodium diet. D. Place the client in high fowler’s position. a) 38 of 640 132. A charge nurse is teaching a newly licensed nurse about the administration of total parenteral nutrition. Which of the following should the charge nurse include? A. “You will need to monitor the client’s electrolytes daily” B. “You will need to change the IV dressing site once per week” C. “You will need to warm the solution in the microwave before administration” D. “You need to weigh the client twice per week” 133. A nurse is teaching a prenatal class about infection at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” B. “I can clean my cat’s litter box during my pregnancy.” C. “I should take antibiotics when I have a virus.” D. “I should wash my hands for 10 seconds with hot after working in the garden.” 133. A nurse is caring for a client who has end-stage liver cancer. Which of the following statements should the nurse make to support the client’s right to autonomy? A. “You should trust that your care team has your best interest at heart” B. “I will not share any personal information without your permission C. “The health care team will do their best to keep any promise we make to you” D. “We encourage you to participate in all decisions about your treatment” 134. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. a) 39 of 640 136. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. 137. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violet. Which of the following risk factors should the nurse include as the best predictor of future violence? A. Previous violent behavior B. A history of being in prison C. Experiencing delusions D. Male gender 137. A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? A. Inform clients about the action of each medication prior to administration. B. (Unable to read) two times prior to administration. C. Complete an incident report if a client vomits after taking a medication. D. Avoid preparing medications for more than two clients at one time. 138. A charge nurse is evaluating the time management skills of a newly licensed nurse. For which of the following actions by the newly licensed nurse should the charge nurse intervene? a) 40 of 640 A. Takes assigned breaks at regular intervals B. Documents the clients care tasks at the end of the shift. C. assisting with ADLs to perform time sensitive activities D. Gather necessary supplies before beginning a dressing change. 139. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. 140. A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the following locations should the nurse expect to palpate the client’s fundus? C a) 41 of 640 142. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. “The client might act seductively.” B. “The client is overly concentrated about minor details.” C. “The client exhibits impulsive behaviors.” D. “The client is exceptionally clingy to others.” 142. A nurse is caring for a client who has a prescription for warfarin. When reviewing the client’s current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply) A. Aspirin B. Magnesium sulfate C. Gingko biloba. D. Cetirizine E. Ibuprofen. a) 42 of 640 143. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Ritual behavior B. Suspicious of others C. Exhibits separation anxiety D. Preoccupied with aging 144. A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg(165.3 lb) and is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client’s BMI value as which of the following? A. 23 B. 42 C. 32 D. 8 145. A nurses is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding? A. The child expresses curiosity about the death process. B. The child refuses to talk about death. C. The child believes the person will return. D. The child focuses on his own mortality. 146. A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first? a) 43 of 640 Exhibit 1 Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl Glucose 35 mg/dl Cloudy in appearance Exhibit 2 History and Physical Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic. Exhibit 3 Vital Signs BP 166/96 mm Hg Respiratory rate 24/min Pulse rate 112/min Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9 A. Place the client on a cooling blanket. B. Administer an analgesic. C. Obtain arterial blood gas levels. D. Elevate the head of the client’s bed 30 degrees. 147. A client is caring for a client following a paracentesis. Which of the followingfindings should the nurse identify as an indication of a complication? A. Decreased hematocrit. B. Increased blood pressure. C. Tachycardia. D. Hypothermia. 148. A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? A. “Use a vein in the middle of the lower arm to insert a PICC.” B. “Flush a PICC using a 3-milliliter syringe.” a) 44 of 640 C. “Informed consent is required prior to PICC placement.” D. “Position the client’s arm in adduction for PICC placement.” 149. A nurse is reviewing admission prescriptions for a group of clients. Which ofthe following prescriptions should the nurse identify as complete? A. Furosemide 20 mg BID B. Nitroglycerin transdermal patch. C. Aspirin 1 tablet daily. D. Metoprolol 5mg IV now. 150. A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussion on the child B. Perform the procedure twice a day C. Administer a bronchodilator after the procedure D. Perform the procedure prior to meals 151. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1.8 D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L 152. A nurse is caring for a client who is postpartum and request information about contraception. Which of the following instructions should the nurse include? A. “The lactation amenorrhea method is effective for your first year postpartum” B. “You can continue to use the diaphragm used before your pregnancy” C. “Place transdermal birth control patch on your upper arm” D. “I should avoid vaginal spermicides while breast feeding.” a) 45 of 640 153. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. “Staff will apply identification band after first bath” B. “I will not publish public announcement about my baby’s birth” C. “I can remove my baby’s identification band as long as she is in my room” D. “I can leave my baby in my room while I walk in the hallway” 154. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? A. Restrict the client’s total fluid intake to 250 mL/hr B. Give the protamine if signs of magnesium sulfate toxicity occur C. Monitor the FHR via Doppler every 30min D. Measure the client’s urine output every hour 155. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. “Morphine 3 mg SQ every 4 hr. PRN for pain.” B. “Morphine 3 mg Subcutaneous (Unable to read) C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” D. “Morphine 3 mg SC q 4 hr. PRN for pain.” 156. A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client’s ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis. a) 46 of 640 157. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. 158.recieves a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the provider? A. “Have your child lie down and turn their head to their side for 10 minutes” B. “Use your thumb and forefinger to apply pressure to the (Unable to read) of your child’s nose” C. “Place a warm wet washcloth over your child’s forehead and the bridge of their nose” D. “Tell your child to blow their nose gently and then sit down and tilt your head back” 159. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client’s blood type with the type and cross match specimens. B. Confirm the provider’s prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client’s identification band matches the number on the blood unit. a) 47 of 640 160. A nurse is transcribing new medication prescriptions for a group of client. For which of the following prescriptions should the nurse contact the provider for clarifications? A. Zolpidem 10mg PO one tablet at bedtime B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Lorazepam .5mg PO one tablet daily 161. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? A. Offer fluids every 2hr. B. Document the client’s behavior prior to being placed in seclusion. C. Discuss with the client his inappropriate behavior prior to seclusion. D. Assess the client’s behavior once every hour. 162. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. “Dehydration is treated with calcium supplements” B. “Dehydration can increase the risk of preterm labor” C. “Dehydration associated gastroesophageal reflux D. “Dehydration is caused by a decreased hemoglobin and hematocrit” 163. A nurse is using an IV pump for a newly admitted client. Which of thefollowing actions should the nurse take? A. (Unable to read) B. (Unable to read) C. Grasp the IV pump cord when unplugging it from the electrical outlet. a) 48 of 640 D. (Unable to read) outlet has two prongs for the IV pump. 164. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the following interventions should the nurse anticipate? A. Clamp the (Unable to read) B. Administer fluid bolus. C. Obtain a urine specimen for culture and sensitivity D. Initiate continuous bladder irrigation. 165. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? A. Heart rate 58/min B. Fasting blood glucose 100 mg/dL C. Hgb 14 g/dL D. WBC count 2,900/mm3 166. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) 167. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? a) 49 of 640 A. Serotonin syndrome B. Tardive dyskinesia C. Pseudo parkinsonism. D. Acute dystonia. 168. A client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse nutritional requirements? A. (Unable to read) (Chose this one) B. Keep a calorie count for food and beverages. C. Schedule meals at 6 hr. intervals D. Provide low-protein high carbohydrate diet 169. D 170. A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine. The nurse should collect additional (Unable to read) for which of the following client prior to administering the vaccine? A. (Unable to read B. Client has (Unable to read) HIV/AIDS C. Client has a sensitivity to eggs. D. Client is experiencing seasonal allergies. 171. A nurse is providing teaching about digoxin administration to the parents of a toddler which as heart failure. Which of the following statements should the nurse include in the teaching? A. “Limit your child’s potassium intake while she is taking this medication.” B. “You can add the medication to a half-cup of your child’s favorite juice.” C. “Repeat the does if your child vomits within 1 hour after taking the medication.” D. “Have your child drink a small glass of water after swallowing the medication.” a) 50 of 640 171. A nurse is teaching about preventing sudden infant syndrome (SIDS) to parent of a 1-month-old infant. Which of the following indicates that the parent understands how to place the infant in the crib at bed time? B a) 51 of 640 172. A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? A. Obtain the specimen immediately upon the client waking up. B. Wait 1 day to collect the specimen if the client cannot provide sputum. C. Ask the client to provide 15 to 20 ml of sputum in the container. D. Wear sterile gloves to collect specimen from the client. 173.A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which of the following laboratory results should the nurse withhold the medication and notify the provider? A. Digoxin 0.8 ng/ml B. Sodium (Was out of range) C. BUN 15 D. Potassium 3.1 mEq/L. 174. A nurse is caring for a client who wears glasses. Which of the followingactions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 175. A school nurse is teaching a parent about absent seizures. Which of the following information should the nurse include? A. “This type of seizure can be mistaken for daydreaming.” B. “This type of seizure lasts 30 to 60 seconds.” C. “The child usually has an aura prior to onset.” D. “This type of seizure has a gradual onset.” a) 52 of 640 176. A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Removal of vaginal packing B. Insertion of an indwelling urinary catheter C. Ambulation four times daily D. Maintenance of NPO status until therapy is complete 177. A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy. Which of the following tests should the nurse use to monitor and regulate the dosage of the medications? A. aPTT. B. Pyro (Unsure if that’s the writing) C. Platelet count. D. INR. 178. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation? A. Identify solutions prior to negotiation B. Focus on how the conflict occurred C. Attempts to understand both sides of the issue D. Personalize the conflict 179. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client’s children to provide interpretation. a) 53 of 640 B. (Answer was the nurse was going to do the interpretation) C. Offer client’s translation services for a nominal fee. D. Evaluate the clients’ understanding at regular intervals. 180. A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of the following findings should the nurse identify as an indication of intercranial pressure? A. Tachycardia. B. Narrowed pulse pressure. C. Hypotension. D. Increasingly severe headache. VERSION 2 ATI RN Comprehensive Predictor 2020 1. A nurse on a med surg unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP? A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk with a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer Answer: C 2. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating a) 54 of 640 D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning Answer: B C D 3. An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24 hr postop to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift C. providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump Answer: D 4. A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances Answer: B VERSION 3 ATI COMPREHENSIVE EXAM C E a) 55 of 640 1. A nurse is performing tracheostomy care for a client who is postop following a laryngectomy. Which of the following actions take when suctioning the client’s airway? a. Apply suction for 10 seconds 2. A nurse is preparing to administer a long acting insulin to a client who has DM. Which of the following actions should the nurse take first? a. Check the correct dose with another licensed nurse 3. A nurse is caring for an older adult client in the PACU following gen anesthesia. Which of the following should the nurse report to the provider? a. Audible stridor 4. A nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? a. The family can have the child in an open casket without fearing that the organ donation might disfigure the child’s body. 5. Math 0.6mL 6. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff’s acceptance of this change, which of the following actions should the nurse manager take first? a. Provide information about scheduling issues to the staff 7. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? a. Low back pain 8. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? a. Decreased central vision 9. A nurse who is working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury? a. Recent weight loss a) 56 of 640 10. A nurse is teaching about TPN and IV lipid emulsion with a client who has an extensive burn injury. Which of the following information should the nurse include? a. “you will receive finger sticks for blood glucose testing.” 11. A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The nurse should identify which of the following findings as an indication of fluid volume deficit? a. Orthostatic hypotension 12. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? a. Continue observing the fetal heart rate 13. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? a. Involve the client in the selection of a physical therapy provider 14. A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? a. Hematuria 15. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? a. I should have my child avoid sun exposure between 10am and 2pm 16. A nurse is caring for four clients at the beginning of a shift. After receiving change of shift report, which of the following clients should the nurse attend to first? a. A client who is confused and has been attempting to get out of bed. 17. A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority? a. Confusion a) 57 of 640 18. 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? a. Notify the incident commander 19. A nurse is planning care for a client who is receiving hemodialysis via an established AV fistula in the right arm. Which of the following interventions should the nurse include in the client’s plan of care? a. Auscultate the affected extremity for a bruit 20. A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? a. There is a protocol for reviewing your medical record, and I can initiate the process 21. A nurse is assessing a client who has OSA. For which of the following complications should the nurse monitor? a. Hypertension 22. Math heparin 0.5 23. A nurse in an ED is assessing a client who reports taking MDMA. Which of the following should the nurse expect? a. Diaphoresis 24. A nurse is caring for a client who has a terminal illness and requests no lifesaving measure if a cardiac arrests occurs. Which of the following statements should the nurse make? a. I will provide you with information about medical treatment to include in your living will 25. A nurse is administering cyclophosphamide orally to a school-aged child who has neuroblastoma. Which of the following actions should nurse take when administering this medication? a. Maintain hydration with liberal fluid intake 26. A nurse is reviewing the UA report of a client who has glomerulonephritis. Which of the following findings should the nurse expect? a. Protein 27. A nurse is providing colostomy care for a client using a two piece pouching system. Which of the following actions should the nurse take? a) 58 of 640 a. Place the skin barrier over the stoma and hold it for 30 seconds 28. A nurse is administering meds to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? a. Flush the clients gastrostomy tube with 30 mL of water before administering the medication 29. A night shift nurse is giving change of shift report to the day shift nurse who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? a. The client needs assistance when transferring from the bed to a wheelchair 30. A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following food should the nurse include in the teaching? a. Oranges 31. An RN is planning care for a group of clients and is working with a LPN and AP. Which of the following tasks should the RN delegate to the LPN? a. Insertion of nasogastric tube 32. A nurse is caring for a newborn who has HSV. Which of the n=following isolation precautions should the nurse initiate? a. Contact 33. A nurse is performing gastric lavage for a client who has GI bleeding and an NG tube in place. Which of the following actions should the nurse take? a. Use NS for irrigation of the NG tube 34. A nurse is providing discharge instructions to a client following total hip arthroplasty. Which of the following instructions should the nurse include? a. Install a raised toilet seat at home 35. A nurse is reviewing lab findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following lab values indication cellular injury of myocardial tissue? a. Troponin a) 59 of 640 36. A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client’s partner should the nurse identify as the priority? a. My husband doesn’t know that I’ve already moved out and filed for divorce 37. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client’s safety, which of the following actions should the nurse take first? a. Determine the client’s perception of the personal impact of the crisis 38. An AP and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? a. places a pillow under the client’s right arm 39. a community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? a. A client who has significant head trauma and agonal respirations 40. A nurse is caring for a client who has MRSA in an abd wound. Which of the following precautions should the nurse implement? a. Contact 41. A nurse is teaching a client about foods high in vitamin A. which of the following foods should the nurse recommend as having the highest amount of vitamin A? a. 1 medium raw carrot 42. a nurse is caring for a client who has a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? a. Assess the client for functional limitations 43. A nurse is conducting visual acuity testing using the Snellen letter chart for a school aged child who has eyeglasses. Which of the following instruction s should the nurse give to the child? a. You should keep both eyes open during the testing a) 60 of 640 44. A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect? a. Persistent uterine contractions 45. A nurse is assessing a client who raynaud’s disease. Which of the following findings should the nurse expect? a. Blanching of the fingers and toes 46. A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take? a. Inject 20 units of air into the NPH insulin vial 47. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? a. Withhold administering the varicella vaccine to the child 48. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the of the following techniques should the nurse use to maintain surgical aseptic technique? a. Set the catheter tray on the overhead table at waist height 49. A home health nurse is assessing a 2 week old newborn who has a birth weight of 3.64 kg and is being breastfed. Which of the following findings indicates effective breastfeeding? a. The newborn has 6-8 wet diapers per day 50. A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which clients as having a nationally notifiable infectious condition? a. An adolescent client who has foodborne botulism 51. A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? a. Move the client to a quiet place away from others a) 61 of 640 52. A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder and asks the nurse to recommend a nonpharm therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? a. Guided imagery 53. A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse requests an inter-professional care conference a. A client who has DM and has had repeated hospitalizations for diabetic ketoacidosis 54. A nurse is caring for a client who states, “My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out.” The nurse should recognize the client is demonstrating which of the following defense mechanisms? a. Sublimation 55. A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? a. Decreased lung expansion 56. A client who is 24 hr postop following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? a. Ask the client to rate their pain 57. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as indication that the client understands the teaching? a. I should report change in the color in my stools 58. A nurse is providing discharge teaching to a new parent about care seat safety. Which of the following statements should the nurse include in the teaching? a. Secure the retainer clip at the level of your baby’s armpits 59. A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? a. Explain to the client to a social worker for counseling a) 62 of 640 60. A nurse is teaching a client who has a new prescription for digoxin about manifestations for toxicity. Which of the following should the nurse include in the teaching? a. Nausea 61. A nurse is providing dietary teaching to the parents of a 6-month =-old infant. Which of the following instructions should the nurse include? a. Introduce new foods one at a time over 5 to 7 days. 62. A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? a. Boggy uterus 63. A nurse is caring for a client who has end-stage Alzheimer’s disease. The adult child of the client says to the nurse, “I don’t know why I bother to visit my mother anymore.” Which of the following responses should the nurse take? a. It seems like you feel your visits are a waste of time.” 64. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following should the nurse include in the plan of care? a. Elevate the affected leg 65. A nurse is an acute mental health facility os 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? a. Supervise the client during and after eating 66. A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching? a. I should watch for common reactions like dry mouth and constipation 67. A nurse manager is assisting with the orientation fo a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? a. Tells the hospital chaplain a client’s diagnosis 68. A nurse is caring for a client who is int ehfirst trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following a) 63 of 640 statementss by the clients indicates that this therapy is having the desired effect? a. I have not vomited as much recently 69. A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis a. Investigate environmental factors that might be contributing to client injury during these hours. 70. A nurse is caring for a client who is immediately post op following a total vaginal hysterectomy. Which of the following actions should the nurse take first? a. Measure the client’s vital signs 71. A nurse is assessing a client who is 2 hr postop following a cardiac cath. Which of the following information should the nurse report to the provider? a. Neurologic status 72. A nurse is caring for a client who is 12 hr post op, is receiving PCA for pain control, and requires a blood pressure check in 10 min. which of the following staff members should the nurse assign to collect this information? a. An AP who is assisting a client to return to bed. 73. A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the following actions should the nurse plan to take? a. Clear objects from the client’s walking area. 74. A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? a. I should pull the top of the ear upward and back while instilling the medication 75. A nurse is assessing a preschooler who has CF and has been receiving O2 therapy for the nurse the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? a. Substernal pain a) 64 of 640 76. A nurse working on a med surg unit receives a phone call requesting the status of a client from an individual who identifies themselves as the client’s parent. Which of the following actions should the nurse take? a. Ask the caller for verification of their identity 77. A nurse is assessing a client who has a skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? a. Upper chest petechiae 78. A charge nurse overhears two staff nurses in the hallway discussing the nutrional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? a. Tell the nurses to stop the discussion 79. A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? a. Lack of remorse 80. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the nurse take first to provide teaching about chest tubes? a. Ask the nurse about their knowledge of the procedure 81. A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder for 24 hours. Which of the following assessment findings should the nurse identify as the priority? a. The clients heal is redden and tender. 82. A nurse is caring for a client who has a potassium level of 3mEq/L. for which of the following manifestations should the nurse monitor? a. Decreased deep tendon reflexes 83. A nurse is caring for a client who is 4 hour postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? a. Massage the uterus to expel clots 84. A charge nurse observes a staff nurse document a dressing change in client’s chart that was not performed. Which of the following actions should the charge nurse take first? a. Gather more information about the nurse’s actions a) 65 of 640 85. A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client’s prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? a. Maybe this is better for our child because we don’t want any suffering through chemotherapy treatments 86. A nurse is assessing a client who has schizophrenia and is chlorpromazine. Which of the following findings is the priority for the nurse to report to the provider a. Temperature 39.4 87. A home health nurse is providing teaching to a client who has hep A. which of the following instructions should the nurse include? a. Use hydrogen peroxide to clean kitchen surfaces 88. A nurse manager is preparing a newly licensed nurse’s performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse’s time management skills? a. Maintain regular notes about the nurse’s time management skills 89. A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection a. Periumbilical area 90. A nurse is assessing a client who has multiple sclerosis. Which of the following should the nurse expect? a. Nystagmus 91. A nurse is reviewing the ABG results of client who has COPD. The results include a ph of 7.3, Pa O2 56mmHg, CO2 54, HCO3 26, O2 87 a. Uncompensated respiratory acidosis 92. A nurse is caring for a newborn whose parent asks why the baby is receiving vit k. the nurse should explain to the parent that the newborn should receive vit k to prevent which of the following? a. Bleeding 93. A nurse should is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? a. Initiate oral rehydration therapy for the toddler a) 66 of 640 94. A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following should the nurse expect? a. Facial flushing, nasal congestion, headache 95. A nurse in a clinic receives a call form a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following should the nurse make? a. When crusts have formed on every lesion 96. A nurse is caring for a client who si at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? a. The enlarged uterus compresses the intestines and causes constipation 97. A nurse is initiating dc planning for a client who has a stroke and is experiencing right-sided weakness. Which of the following actions should the nurse take first? a. Request a referral for the client to receive physical therapy 98. A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter. Which of the following information should the nurse include in the teaching? a. You should keep the catheter clamped when not in use 99. A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? a. Clang association 100. A nurse is taking caring of a child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? a. Place the child in a side lying position 101. A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the actions should the nurse plan to take? a. Enter the plasma product number into the client’s medical record 102. A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury at home? a. Mark the edges of stairs for contrast a) 67 of 640 103. A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? a. A speech pathologist, should rest before eating meal, thicken beverages before drinking 104. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take? a. Dry the newborn 105. A home health nurse is proving teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? a. I will walk short distances throughout the day 106. A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? a. You should complete advanced directives in the event you cannot express your own wishes 107. A nurse is teaching a client who has anew prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? a. Headaches 108. A nurse in an emergency department is preparing to dc a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? a. Develop a safety plan with the client 109. A nurse is caring for a client who is the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect? a. Grandiose delusions 110. A charge nurse is observing a newly licesnsed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. Keeps the HOB elevated to 45 degrees for 1 hr after feedings 111. A nurse is proving client education to a post partum client who has decided to bottle feed the nwborn. Which of the following instructions should a) 68 of 640 the nurse include in the teaching to help prevent the discomfort of engorgement? a. Place ice packs on the breasts for 15 min several times aday 112. A nurse is preparing to perform an intermittenet urinary cath for a client who has urinary renteion. Which of the following images indicates the catheter the nurse should use? a. Straight cath 113. A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? a. Sedation is a common adverse effect of this medication 114. A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? a. Provide a staff member to stay with the client continuously 115. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should be reported to the provider? a. Axillary temp 36.2 116. A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following instructions? a. Complete a serum pregnancy test before taking the medication 117. A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? a. Place the BP cuff in a labeled bag to send it for decontamination 118. A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend? a. Double bag soiled dressings in plastic bags for disposal 119. A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an on going problem, and the charge nurse previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? a) 69 of 640 a. Inform the nurse manager of the issue. 120. A nurse is providing discharge teaching to a client with who has colorectal cancer and a new colostomy. The client states, “Im worried about being discharged because I live alone, and my insurance does not cover ostomy supplies.” a. Refer client to community based social worker, initiate a consult with a home health care provider, give the client information about local support group 121. A nurse is caring for a client who has hypertension and it taking captopril. Which of the following tasks should the nurse delegate to an assistive personal? a. Obtain the client’s blood pressure before the nurse administers medication 122. A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? a. A client’s IV pump delievers an inadequate dose of medication 123. A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? a. Diced steamed carrots 124. A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? a. Establish the termination date of therapy 125. A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? a. Set your hot water heater temp at or below 120 degrees F 126. A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? a. Partial-thickness skin loss 127. A nurse on a mental health unit is caring who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? a. Document the client’s refusal of the medication a) 70 of 640 128. A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler’s plan of care? a. Encourage the parents to bring toys from home 129. 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? a. Initiate fall precautions 130. A client is receiving lorazepam IV for panic attacks and develops a resp rate of 6/min and a BP of 90/44 mmHg. Which of the following medications should the nurse anticipate administering? a. Flumazenil 131. A nurse is assessing a 2-month old during a well-baby exam. Which of the following action should the nurse take to assess the infant’s rooting reflex? a. Stroke the infant’s cheek 132. 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? a. The newly licensed nurse writes detailed notes while performing the head-to-toe assessment 133. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? a. The cervix transitions to an anterior position 134. A nurse is performing an admission assessment of a preschooler who is in the acute phase of kawasaki disease. Which of the following findings should the nurse expect? a. Fever unresponsive to antipyretics 135. A nurse is caring for client who is receiving TPN solution by continuous IV infusion at 60mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? a. Provide dextrose 10% in water solution using manual drip tubing at 60ml/hr a) 71 of 640 136. 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, “im not tired.” Which of the following statement by the parents indicates an understanding of the teaching? a. We should read a story together every night before bedtime 137. A nurse is caring for four clients. Which of the following should the nruse assign to an AP to assist with meals? a. A client who has Alzheimer’s disease and is demonstrating aphasia. 138. A nurse is providing teaching to a parent of a child who has a permanent trach tube. Identify the sequence of steps to the parent should follow to perform trach care. a. Remove inner cannula, remove soiled dressing, clean stoma, change trach collar 139. A nurse is caring for a client who has a closed head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? a. Mannitol 140. A nurse on a med-surg unit is caring for a client prior to surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? a. The client is able to accurately describe the upcoming procedure 141. When caring for a child, a nurse plans to use nonpharm interventions to enhance the effectiveness of pain medications. Which of the following strategies incorporates visualization techniques to help decrease the child’s discomfort? a. Blowing bubbles with liquid soap to “blow the hurt away” 142. A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? a. Performing a rapid needs assessment 143. A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client’s plan of care a. Avoid venipunctures when possible a) 72 of 640 144. A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? a. WBC count 2,800/mm3 145. A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? a. Pulsus paradoxus 146. A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? a. Identify health-related issues within the community 147. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an unerstadning of the teaching? a. I will bend at my knees when picking an object off the floor 148. A nurse is preparing to insert an indwelling urinary cath for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? a. Latex allergy 149. A nurse is assessing a school aged child who has CF. which of the following findings is the priority for the nurse to report to the provider? a. Hemoptysis 275mL/hr 150. A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? a. Rapid speech VERSION 4 ATI COMPREHENSIVE ATI A 1. A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the end of the hallway. The client appears to be anxious &agitated. What action should the nurse take? a) 73 of 640 ANS: Escort the client to a quiet area on the nursing unit. - A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease agitation. They will be unable to follow instructions/commands. 2. A nurse is assisting with the plan of care for a client who has a continent urinary diversion. Which intervention should the nurse plan to implement to facilitate urinary elimination? ANS: Use intermittent urinary catheterization for the client at regular intervals. - A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client’s pouch. 3. A nurse is assisting with an education program about car restraint safety fora group of parents. Which statement by the parent indicates an understanding of the instructions? ANS: “My 12YO child should place the shoulder-lap seatbelt low across his hips.” - When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips rather than over the abdomen to reduce risk for injury during motor vehicle crash. 4. A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which instructions should the nurse include in the teaching? ANS: Drink high-protein and high-calorie nutritional supplements. - The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that leads to hypermetabolism and wasting of the client’s muscle mass. 5. When removing PPE after direct care for a client who requires airborne & contact precautions, which PPE is removed first? ANS: Gloves a) 74 of 640 - The greatest risk is contamination from pathogens that might be present on the PPE; therefore, the priority action for the AP is to remove the gloves, which are considered the most contaminated. 6. A nurse is inspecting the skin of a newborn. Which finding should the nurse report to the PCP? ANS: Generalized Petechiae - Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, & also anywhere on the head of infants who had a nuchal cord, w/c is an umbilical cord around the neck. However, petechiae all over the newborn’s body can indicate infectionor decreased platelet count and should be reported to the provider. 7. A nurse is contributing to a teaching plan for a group of male adolescents about the A/E of anabolic steroid use. Which manifestations should the nurse include? ANS: Reduced height potential - Use of anabolic steroids in adolescence can lead to premature epiphyseal closure, thus reducing full height potential. A/E includes: Liver disorders, hyperlipidemia, breast enlargement, acne, and edema. 8. A nurse is reinforcing teaching with an older adult client who has severe L-sided HF. Which statement should the nurse make? ANS: Rest for 15 minutes between activities. - The nurse should instruct to increase his activity gradually & to rest for a period of 15 min if he becomes tired. Clients who have HF should balance activity c rest to reduce cardiac workload. 9. A nurse in a LTC facility is documenting the care of an older adult client. Which information should be included in weekly nursing care summary?ANS: Hydration Status - Older adult client are at risk for dehydration. Therefore, the nurse should be vigilant about monitoring the client’s hydration status & include this information in the weekly nursing care summary. a) 75 of 640 10. A nurse is caring for a client who has a head injury. Using the Glasgow ComaScale to collect data, the nurse should obtain which information? ANS: Motor Response - The nurse should collect data about the client’s motor response & assign the response a score of 1-6, according to the Glasgow Coma Scale. 11. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which instruction should the nurse include? ANS: Apply the stocking in the morning. - The nurse should instruct the client to apply the elastic stocking in the morning and remove them at the end of the day before bedtime. 12. A nurse is obtaining health hx from a client who is scheduled to undergo cardiac catheterization in 2 days. Which questions is the priority for the nurse to ask? ANS: “Do you know if you’re allergic to iodine?” - The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. 13. A nurse is planning to administer nystatin oral suspension to a client who has oral candidiasis. Which instructions should the nurse give? ANS: “Hold the medication in your mouth for several minutes prior to swallowing” - The client should swish & hold the liquid in the mouth for at least 2 min to facilitate contact of the medication with the organism. The client should then swallow or spit out the medication. 14. A nurse is preparing to care for the assigned clients on her upcoming shift. Which time management strategies should the nurse plan to use? ANS: Prepare a priority list of client needs for the shift. - The nurse should prepare a client priority-to-do list, which could include administering time-critical medications. This will allow the nurse to determine which clients should receive care first. 15. After witnessing the consent, what action should the nurse take next? ANS: Ask client what he understands about the procedure. a) 76 of 640 16. Which task should the nurse assign to an AP for a pt 2 days post-op ff Total knee arthroplasty? ANS: Reapply antiembolitic stockings to the client ff a shower. 17. A nurse is reinforcing teaching with a client who is receiving radiationtherapy for cancer of the larynx. Which statement made by the client indicates understanding of the teaching? ANS: “I will wear a soft scarf around my neck when I am outside” - Wash it with plain water without soap. NO heat source therapy. Only use electric razor if necessary, for shaving. 18. A nurse is using FLACC scale to determine the level of pain for an 11-months-old infant who sis port-op. Which factor should the nurseconsider when using this pain scale? ANS: Level Of Activity - The nurse should consider the infants level of activity when using FLACC painscale. The FLACC is determined by five categories of behavior: Facial Expression, Leg Movement, Activity, and Consolability. 19. A nurse is collecting data from a 5YO child at a well-child visit. Parent reports that the child is having frequent nightmares. Which statements by the parents indicates to the nurse that the child Is experiencing sleep terrorsrather than nightmares? ANS: “My child goes back to sleep right away.” - The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than nightmares. A child who is experiencing nightmare has difficulty returning to sleep because of continued fear. 20. A nurse is assisting with the care of a school-age child immediately ffsurgery. The child weighs 21.8 kg (48 lb) & has a chest tube applied tosuction. Which finding should the nurse report to PCP? ANS: 250 mL of sanguineous drainage over the last 3 hr - More than 3 mL/kg/hr of sanguineous drainage occurs for more than 2-3 consecutive hr ff surgery. It indicates active hemorrhaging. a) 77 of 640 21. A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which instructions should the nurse include? ANS: Apply capsaicin cream 4x/day - Apply it topically to provide warmth & relieve joint pain. 22. A nurse is reinforcing teaching about managing manifestation of anxiety with a client who has generalized anxiety disorder. Which information should the nurse include? ANS: Say the word “STOP” when upsetting thoughts occur. 23. A nurse in a LTC facility is collecting data form a client who has beenreceiving betaxolol to treat glaucoma. Which findings is an A/E if thismedication? ANS: Bradycardia - Betaxolol is a beta blocker that can produce systemic effects, including bradycardia. 24. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client ff a lithotripsy for uric acid stones. Which instructions should thenurse plan to include? ANS: Strain the urine to collect stone fragments. 25. A nurse in a provider’s office is reinforcing teaching with a client who is tofollow a 2,000 mg sodium-restricted diet. Which client food selections indicates understanding of the teaching? ANS: Canned Peaches. 26. A nurse is preparing to perform a bladder scan for a client. Which action should the nurse take? ANS: Tell the client she should not experience any discomfort. 27. A nurse is contributing to the plan of care for a client who has a prescription for ROM exercises of the shoulder. Which exercise should the nurse recommend promoting shoulder hyperextension? ANS: Move her arm behind her body with her elbow straight. 28. A nurse is collecting data from an older adult client who has a gastric ulcer. Which finding should the nurse identify as a complication to report to the provider? a) 78 of 640 ANS: Hematemesis 29. A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which statement by the newly licensed nurse indicates understandingof this method of pain control? ANS: “I should report leaking at the insertion site to the anesthesiologist” 30. A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation immediately ff a transurethral resection of the prostate (TURP). Which of the ff interventions should the nurse include? ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color. 31. A nurse is caring for a client who is scheduled for a mastectomy the ff day. The client is tearful & tells the nurse that she is not ready to have this procedure done at this time. What response should the nurse give? ANS: “Would you like for me to talk to the surgeon with you?” 32. A nurse is collecting data from a school-age child who has hypoglycemia.What is the manifestation to expect? ANS: Sweating 33. A nurse is assisting with a community education program for parents of preschoolers about recommended activities to promote physical development. Which of the ff statement should the nurse make? ANS: “You should provide unorganized play activities for your child each day.” 34. A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which findings indicates the client is experiencing a therapeutic response to this medication? ANS: Report of a decrease in the number of stools. - Pancrelipase is administered as a replacement therapy for a deficiency in pancreatic enzymes, which results in steatorrhea, or fatty stools. 35. A nurse is caring for a client who is 12-hour post-op ff total knee arthroplasty. What action should the nurse take? ANS: Place an abduction wedge between the client’s legs when he is in bed. a) 79 of 640 36. A nurse is reinforcing teaching regarding puberty with a group of prepubescent female clients. Which information should the nurse include in the teaching? ANS: “You will gain weight before you start to get taller.” 37. NO ORAL CONTARCEPTIVES for CAD 38. A nurse is caring for a client who is at 34 weeks gestation and has mild preeclampsia. Which finding indicates a progression from mild to severe preeclampsia? ANS: Client reports of blurred vision. 39. A nurse is reinforcing teaching with a client who has asthma & has a prescription of theophylline. What statement should the nurse make? ANS: Discontinue drinking caffeinated beverages. 40. A/E of metronidazole: Reddish-brown urine. 41. A home health nurse is collecting data from an older adult client who has generalized anxiety disorder. The client lives at home with her partner & sibling. Which responses by the client’s partner is the priority for the nurse to address? ANS: “Her prescription isn’t generic, so we can’t afford it anymore.” 42. Patient having difficulty using eating utensils. Refer patient to OT. 43. Child who have ingested full bottle of acetaminophen, instruct parents to take the child to the ER 44. A client requesting information from a nurse about creating a health care proxy. Which statement should the nurse make? ANS: “The person you appoint will make health care decisions for you if you cannot do so yourself.” 45. Venipuncture = antecubital fossa 46. The nurse should stop the infusion if the patient is having edema above the catheter insertion site. 47. A nurse is contributing to the plan of care for a client who has pneumonia. Which entries should the nurse include in the plan? ANS: “Client prefers bathing in the evening.” a) 80 of 640 48. Strategies to teach parents about pediculosis capitis (Head lice) management: ANS: Store child clothing in a separate cubicle when at school. Boil brushed and combs in water for 10 min. Dry bed linens & clothing in a hot dryer for at least 20 min. 49. Caring for a client who has GTube. What actions should the nurse take? ANS: Flush the tube with 50-60 mL of warm water if the tube becomes clogged. 50. Caring for client who is 4 hr post-op ff GI surgery & NG is placed for decompression. Which action should the nurse take? ANS: Keep the plugged tube above the level of the stomach when the clientis ambulating. 51. Reinforcing teaching with a client who is scheduled for an exercise electrocardiography (ECG) stress test. What instruction to give? ANS: Recommend the client wear comfortable shoes during the test. - Informed consent must be signed, Instruct client to eat 2-3 hr before test and then remain NPO to prevent GI upset during test. 52. A client who is Orthodox Judaism with terminal illness. The nurse shouldassure the client family member will stay with his body after death. 53. A client who has pneumonia and is currently receiving oral antibiotic may be discharged to have more rooms for new admission patient. 54. Avoid Ibuprofen when taking “PRIL” medications. 55. A nurse observes a client in labor. What interventions should the nurse recommend? ANS: Squatting using a birth ball, Counter pressure to the sacral area, & leaning forward while kneeling. 56. Sitting and leaning forward using both hands for support is an expected finding for a 7-month old infant. 57. Type 1 DM, patient indicates understanding of patient teaching when he/she states that, “I will dispose of my needles in a plastic laundry detergent container”. - It is puncture-proof! a) 81 of 640 58. Offer client a whole grain cracker before bedtime if they are having difficulty sleeping. 59. Red meat = iron 60. Peanut butter = protein 61. External rotation is a clinical manifestation to expect to a client with hip fx 62. “Let’s give the medication to your doll first” is an action the nurse should take prior to performing an immunization to a preschooler. 63. Dark green and viscous is the stool to expect 24 hrs after birth of an infant. 64. Atorvastatin A/E: Muscle Pain 65. Suggest walking outside with a staff member to a patient with bipolar disorder & in a manic phase. 66. An infection with gonorrhea may result to infertility. STI pt teaching 67. Physical neglect indication when collecting a from a toddler is when “the toddler is inadequately dressed for the weather” 68. Overdose digoxin? Check VS 69. Anorexia Nervosa care plan? Record I&O 70. Documenting client care in the medical record, entries to include would be “Client remains NPO until X-Ray procedure is complete” 71. To initiate Babinski reflex? Stroke the sole of the infant’s foot upward & toward the great toe. 72. Report an ECG result with PR interval 0.24 seconds. 73. When patient report of nuchal rigidity, H/A, along with fever & chills. Thenurse should anticipate the MD to order what diagnostic tests? ANS: Cerebrospinal fluid analysis - The client findings are consistent with bacterial meningitis. A lumbar puncture should be performed to obtain cerebrospinal fluid to confirm the diagnosis. 74. Post-Op Lumbar puncture: Instruct patient to increase fluid intake. 75. The client must take montelukast once daily at bedtime. 76. Perform daily gum massage when taking phenytoin as a measure to assist with the possible A/E. a) 82 of 640 77. Lung sound: Wheezes 78. Morphine A/E: Respiratory Rate of 10/min 79. Document findings as a variance 80. pH 7.5 is a complication of mechanical ventilation 81. Recent confirmation of pregnancies 82. Spaghetti with red meat sauce 83. Urine specific gravity of 1.002 for pt with DI VERSION 5 Kawasaki Disease intervention- monitor cardiac rhythm Know McBurney’s Point for appendicitis HOT SPOT- RIGHT side of abdomen Donepezil and Memantine for Alzheimer’s- to slow down progression of disease Clozapine- Agranulocytosis Omeprazole long term side effect- Osteoporosis Omeprazole teaching effectiveness- take 30 mins before meal Priority- Thyroidectomy with feeling of lump in back of throat Priority- Thyroidectomy with stuporous Priority- Abdominal pain with coffee ground emesis Exhibit question: Patient on Heparin- apt 100 seconds- Hold/DC Heparin Simvastatin adverse effect- muscle weakness Ferrous sulfate given to a school age child- give with OJLab to determine nutritional status- Serum Albumin Wound care specialist recommended for a stage 4 pressure ulcer. Which finding would necessitate change in plan of care…? Client weight lost (5 lbs) Pregnant woman asking for risk factor for DM- BMI of 28 How to dispose syringes- use aluminum can, secure and put in high area Vaso-occlusive crisis interventions- Start IV fluid replacement Patient with peripheral inserted central catheter care- measure arm with above the insertion a) 83 of 640 Patient post gastric bypass intervention- measure abdominal girth daily Characteristic of anti-social personality- lack of remorse Older client with difficulty swallowing, refer to- Speech Therapist Enoxaparin (Lovenox)- Platelet 90,000 Client who can’t afford medication, refer to- Social Worker C-Diff patient client care- Wear gown when giving care Caring for a client with implanted radiation device- Wear a dorsimeter badgeClient 12 weeks gestation, how to listen to fetal heart tone- put Doppler by symphysis pubis Hyperthermia intervention- Initiate seizure precaution Active Herpes Simplex Virus during pregnancy, appropriate nursing response-C-Section is done Priority- Patient on peritoneal dialysis with cloudy diasylate MRI procedure- Skin patches will need to be removed Niagele’s rule Client last menstruation March 31, what is the expected delivery date- January 7 Scoliosis manifestation- Uneven curvature (shoulders, hips) Prevent neural tube defect- Folic Acid Alpha-fetoprotein test- Spina Bifida Osteoporosis- Weight bearing exercises Priority- Hip arthroplasty with pain in calf Intervention for stomatitis- Use soft bristle to brush teeth Intervention for mucositis- Rinse with 0.9% Normal SalineAcarbose for DM- Weight lose (?) Suspected elderly abuse, what to do first- Interview in a private room Carbidopa/Levodopa intervention/side effect- monitor for hypotension HIV retroviral medication effectiveness- decrease in HIV RNA Oxytocin with prolonged contraction- D/C infusion Fat embolism manifestation- Petecheae in chest and abdomen Manifestation of ICP (picture)- Pupils unequal (one is constricted) AP delegation- Apply condom catheter Toddler on isolation, cost effective care- Bring formula in room as needed a) 84 of 640 Intervention of a client following radial mastectomy with drain- Deflate/compress suction drain Captopril adverse effect to report- Sore throat Patient doesn’t speak English- Find female interpreter in facility Signs of dehydration in toddler- Oliguria Blood glucose control understanding- HgA1C less than 7% Proper d/c planning after hip replacement- “I will not cross my legs” Priority- Patient receiving blood transfusion and complaining of lower back pain Tonsillectomy discharge teaching- report for frequent swallowing Priority- Patient with full thickness burn to faces and chest Safety for frayed cord in patient’s room- Take malfunctioning equipment out ofthe room Fire in facility, who to rescue first- ambulatory patient with oxygen Wound care nurse seeking plan of care, which information to go to- DRGs (?) AFib complication- Widening Pulse Pressure (?) Home Health nurse responsibility when taking care of a patient with Lyme diseaseMake sure CDC is informed Skin care with radiation therapy- Wash area with water, DO NOT REMOVE TRACE MARKS, DO NOT APPLY WARM COMPRESS, DO NOT APPLY LOTION Newborn assessment- Newborn breathing 70 breaths per minute Study adverse effect of Methotraxate Study advance directives Study diet for Crohn’s disease, patient with high level of uric acid, nephrotic syndrome Know therapeutic communications with psych patients Study Misoprostol (Cytotec) and intervention during insertion for induction of labor Know appropriate delegations to assistive personal (AP) Know risk factors for hypoglycemia in newborn Know pediculosis capitis mode of transmission, life expectancy and how it survives Know umbilical stump cord care Know stages of Alzheimer’s disease and manifestations a) 85 of 640 Know proper body alignment for turning a patient with Thoracic spinal injury Know contraindication of Latex allergy Know manifestation of Mild Anxiety VERSION 6 ATI COMPREHENSIVE EXIT FINAL 1) A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statements should the nurse include in the assessment? a) Tell me about your siblings b) Tell me what kind of music you like c) Tell me how often do you drink alcohol d) Tell me about your school schedule 2) *A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to intervene? a) Holding the newborn in an en face position b) Asking the father to change the newborn's diaper c) Requesting the nurse take the newborn nursery so she can rest d) Viewing the newborn’s actions to be uncooperative 3) A nurse is caring for client who is taking levothyroxin . Which of the followingfindings should indicate that the medication is effective? a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism) b) Decreased blood pressure c) Absence of seizures d) Decrease inflammation a) 86 of 640 4) A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching? a) Contact provider if the cord still turns black ( it’s going to turn black) b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser ) c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection) d) The cord stump will fall off in five days ( cord falls off in 10-14 days) 5) A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? a) Shivering b) Oliguria c) Bradypnea d) Constricted pupils 6) A nurse is assisting with mass casualty triage : explosion at a local factory.Which of the following client should the nurse identify as the priority ? a) A client that has massive head trauma b) A client has full thickness burns to face and trunk c) A client with indications of hypovolemic shock d) A client with open fracture of the lower extremity 7) A nurse is a receiving report on four clients. Which of the following clientsshould the nurse assess first? a) A client who has illeal conduit and mucus in the pouch b) Client pleasant arteriovenous additional vibration palpated c) A client whose chronic kidney disease with cloudy diasylate outflow a) 87 of 640 d) A client was transurethral resection of the prostate with a red tinged urine in the bag 8) A nurse is caring for a client just received the first dose of lisinopril. Thefollowing is an appropriate nursing intervention? a) Place’s cardiac monitoring b) Monitor the clients oxygen saturation level c) Provide standby assist with the client from bed d) Encourage foods high in potassium 9) A nurse is caring for a client who is in labor and his seat is receiving electronicfetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse expect? a) Feta hypoxia b) Abrupto placentae c) Post maturity d) Head Compression 10) A nurse is caring for a client who has chronic kidney disease . The nurse should identify which of the following laboratory values as in an indicationfor hemodialysis ? a) glomerular filtration rate of 14 mL/ minute b) BUN 16 mg/DL c) serum magnesium 1.8 mg mg/dl d) Serum phosphorus 4.0 mg/dL 11) A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take? a) Placed infant under radiant warmer b) Move the probe site every 3 hours a) 88 of 640 c) Heat the skin one minute prior to placing the program d) Placed a sensor on the index finger 12) A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first? a) Client placed in restraints to the aggressive behavior b) A new limited client pleasures history of 4.5 kg weight loss in the past two months c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety d) Applied he’ll be receiving his first ECT treatment today 13) A nurse working at the clinic is teaching a group of clients who are pregnant onthe use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor? a) Hypnosis focuses on the biofeedback as a relaxation technique b) Hypnosis promotes increased control of her pain perception during contractions c) Hypnosis uses therapeutic touch to reduce anxiety during labor d) Hypnosis provides instruction to minimize pain 14) A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation ? ( rxn formation is when you use opposite feelings; ex: being super nice to someone you dislike) a) I steal things because it’s the only way I can keep my mind off my bad marriage b) I can’t believe I was accused of something I didn’t do c) I don’t want talk about my feelings right now. We will talk more next time a) 89 of 640 d) I think that people just you’re just lazy and should earn money honestly 15) A nurse is obtaining the medical history of a client who has a new prescription for isosorbide monotitrate . Which of the following should thenurse identify as a contraindication to medication? a) Glaucoma b) Hypertension c) Polycythemia d) Migraine headaches 16)? 17)The nurses is caring for a client recovering from an acute myocardial infarction . Which following intervention should the nurse include in the point of care? a) Draw a troponin level every four hours b) Performance EKG every 12 hours c) Plant oxygen tent fell over minutes via rebreather mask d) Obtain a cardiac rehabilitation consult 18)A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy . Which of the following laboratory values shouldnurse report to provider? a) WBC 3,000/mm3 b) Hemoglobin 14 g/dl c) Platelet 250,000/mm3 d) aPTT 30 seconds 19)Home health nurse is carefully planned for Alzheimer’s disease . To the following action should the nurse include in the plan of care a) 90 of 640 a) Place a daily calendar in the kitchen b) Replace button clothing with zippered items c) Replace the carpet with hardwood floors d) Create variation in daily routine 20)Nurse is performing change of shift assessments on 4 clients. Which of the following findings should the nurse report to provider first? a) The client was cystic fibrosis and has a thick productive clock and reports thirst b) Client who has gastroenteritis and is lethargic and confused c) The Client has diabetes mellitus has morning fasting Legal cost of 185 mgover deal d) The client was sick of signing it reports pain 15 minutes after receiving oral analgesic 21)A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation . Which of the following statements by the nurse is appropriate? Decrease taking vitamins and supplements to every other day a) 91 of 640 Eat 15 g of fiber per day c) Consume 48 ounces of water each day ( need at least 64 oz) d) Drink hot water with lemon juice each morning when you wake up 22)? 23) A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? select all that apply a) I can’t change my instructions once a minute b) My doctor will need to approve my advance directives c) I need an attorney to witness my signature on the advance directives d) I have the right to refuse treatment e) My health care proxy can make medical decisions for me 24) A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac disease . Which of the following positions should the nurse place the client to best promote optimal cardiac output ? a) The chest b) Standing c) Supine d) Left lateral 25) A nurse is caring for a group of clients. Which of the following clients shouldthe nurse assign to an AP? a) Client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry b) Client who has awoken following a bronchoscopy and requests a drink c) Client who had a myocardial infarction 3 days ago reports chest discomfort a) 92 of 640 d) Client who had a cerebrovascular accident two days ago and needs help toileting 26) Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? a) Constipation b) blurred vision c) Fever d) Dry Mouth 27) A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention? a) Providing a high protein snack b) Assisting the child to reposition c) Placing weights as a child’s bed d) Massaging pressure points-causes skin breakdown 28) A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take? a) Determine if the AP is qualified to perform the test. b) Help the AP performed the blood glucose test c) Assign the AP to ask the client is taking his diabetic medication today d) Have AP check the medical record for prior blood glucose test results 29) A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherentspeech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following? a) Alzheimer’s disease b) Schizophrenia a) 93 of 640 c) Substance intoxication d) Depression 30) A nurse is caring for a child who has infectious mononucleosis.. Which of thefollowing findings are associated with this diagnosis? Select all that apply a) splenomegaly b) Koplik spots (this is associated with measles) c) Malaise d) Vertigo e) Sore throat 31)Nurse is performing dressing change for client was a sacral wound usingnegative pressure wound therapy. Which The following actions should the nurse take first? a) Apply skin preparation to wound edges. b) Normal saline c) Don sterile gloves d) Determine pain level 32) A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly? a) Drainage fluid is greenish-yellow b) aspirate pH of 3 c) Abdominal rigidity d) air bubbles noted in the NG tube 33) A nurse is preparing to administer TPN with added fat supplements to a clientwho has malnutrition. Which of the following action should the nurse take? a) 94 of 640 a) Piggyback 0.9 sodium chloride with TPN solution b) Check for an allergy to eggs c) Discuss the TPS solution for 12 hours d) Monitor for hypoglycemia 34) A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? ( A/C?) a) Systemic analgesic effect b) increase in your metabolism c) Decreased capillary permeability d) Vasodilation 35)Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to Perform weight bearing exercises Avoid crossing the legs beyond the midline c) Avoid sitting in one position for prolonged periods d) Split affected area 36)A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority? a) The client has surgical hypoparathyroidism and positive Trousseau’s sign b) A client who was Clostridium difficile with acute diarrhea c) A client who is acute kidney injury and urine with a low specific gravity d) The client who has oral cancer and reports a sore on his gums 37)Nurses caring for a client was congestive heart failure . Which of the following prescriptions for the provider should the nurse anticipate ? a) Call the provider to clients respiratory rate is less 18/min a) 95 of 640 b) Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr c) Give the client enalapril 2.5 mg PO twice daily d) Call the provider if the clients pulse rate is less than 80/min 38) A nurse is caring for a client who has a prescription for sertraline to treat depression . Which of the following statements by the client indicates an understanding of the medication treatment plan? a) I will be able starting this medication with feel better b) I can expect to urinate frequently while on this medication c) I understand I may experience difficulty sleeping on this medication d) I should decrease my sodium intake while on this medication 39) A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing intervention?” a) Offer to speak to the client’s husband regarding his abuse behavior. b) Help the client to recognize the signs of escalation of abuse behavior c) Assist the client to identify personal behaviors that trigger abusive behavior d) Assist the client to Reports abusive behavior to the proper authority 40) A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses for the nurses appropriate? a) Why do you think your life is not worth it anymore? b) Do you have a plan to end your life? c) I need to know what you mean my misery d) You can trust me and tell me what you’re thinking a) 96 of 640 41) A nurse is caring for a client who has schizophrenia . Which of the followingassessment findings should the nurse expect? a) Decreased level consciousness b) Unable to identify common objects Preoccupation was somatic disturbances 42) A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following action should nurse take? There are 3 tabs that contain separate categories of data. a) Position the client with the affected extremity lower than the heart b) Administration of acetaminophen c) Massage the affected extremity every 4 hrs. d) Withhold heparin IV infusion 43)Is caring for clients was a new prescription for enoxaparin for the prevention of DVT . Which of the following is an appropriate action by the nurse? a) Expel air bubble at the top of the prefilled syringe b) Massage the injection site to evenly distribute the medication c) Inject the medication the lateral abdominal wall d) Administer an NSAID for injection site discomfort 44)Nurses caring for four clients. Which of the following client data should the nurse report to the provider? a) A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing c) Poor problem solving ability d) a) 97 of 640 b) Client was a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hour following surgery c) Client who is 4 hrs postoperative and has a heart rate of 98 per minute d) The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3 45)Nurses caring for client was in end-stage osteoporosis and is reporting severe pain . Clients respiratory rate is 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client? a) Promethazine b) Hydromorphone c) Ketorolac d) Amitriptyline 46) A nurse is caring for a client who has DVT . Which of the following instructionsthe nurse include in the plan of care? a) Live with the clients fluid intake to 1500 mL per day b) Massage place affected extremity to relieve pain c) Apply cold packs of clients affected extremity d) Elevate the client’s affected extremity when in bed 47) A nurse is caring for a client who is receiving oxytocin IV for augmentation oflabor. The client’s contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take? a) Discontinue oxytocin infusion b) Increased oxytocin infusion c) Decreased oxytocin infusion d) Maintain oxytocin infusion a) 98 of 640 48) A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2 . Which of the following questions is most appropriate for the nurse to ask the client? Have your membranes ruptured? How far apart are your contractions? c) Do you have any active lesions? d) Are you positive for beta strap? 49)Nurse is providing teaching for child prescribed ferrous sulfate . Which of thefollowing instructions should the nurse include? a) Take with meals b) Take at bedtime c) Take with a glass of milk d) Take with a glass of orange juice 50)Four clients present to the emergency department. The nurse should plan to see which of the following clients first? a) A 6 year old client whose left shoulder is dislocated b) A 26 year old client for sickle cell disease and a severe joint pain c) A 76 year old client was confused, febrile and has foul smelling urine - uti d) A 50- year old client who has slurred speech, is disoriented, and reports a headache - stroke 51)A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find? a) Leavened bread maybe eaten during Passover. b) Shellfish is commonly consumed in the diet. a) 99 of 640 c) Meat and dairy products are eaten separately. d) Fasting from meat occurs during Hanukkah. 52)? 53)A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the following interventions are appropriate? Select all that apply a) Apply direct pressure to bleeding wounds b) Clean rest last rations and abrasions with hydrogen peroxide c) Cover wounds with a sterile dressing d) Administer 650 mg aspirin PO as needed for pain e) Determine date of last tetanus toxoid vaccination. 54)The nurses reviewing clients admission laboratory results. Which of the findings required further evaluation? a) Sodium 138 b) Creatinine 1.8 c) Hemoglobin 15 d) Potassium 4.2 55)A nurse is providing teaching for a client has a new prescription for methadone . Which of the phone following client statements indicates need for further teaching? a) I understand the methadone tends to slow my breathing b) I understand the methadone may cause me to have difficulty sleeping c) I will avoid alcohol while I’m taking this medication d) I’ll change positions gradually especially from lying down to standing a) 100 of 640 56)Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluation? a) Premature infant with a poor suck reflex and failure to thrive b) An older adults who has difficulty taking in fluids c) Adolescent who anorexia who is cachectic d) A middle aged adults was gastroesophageal reflux disease 57) A nurse is caring for a group of clients. Which of the following clientshould nurse assess first? a) A client whose benign prostatic hyperplasia and is unable to urinate b) The client was heart failure and report shortness of breath while ambulating c) A client who is open cholecystectomy and has green drainage from the T-tube d) A client whose abdominal pain and is vomiting coffee ground emesis 58) A nurse is taking a medication history from client was type II diabetes mellitus is scheduled for an arteriogram. Which of thefollowing medications to the nurses instruct the client to discontinue 48 hrs prior to the procedure? a) Atorvastatin b) Digoxin c) Nifedipine d) Metformin 59)The nurses assessing client with posttraumatic stress disorder . Which of the following findings to the nurse expect to find? a) Dependence on family and friends b) Loss of interest in usual activities c) Ritualistic behavior d) Passive aggressive behavior a) 101 of 640 60) A nurse working in a long-term care facility is caring for an older adult client has dementia . The clients often agitated and frequently wanders the halls . Which of the following intervention should the nurse include in the plan of care? a) Give the client several choices when scheduling activities. b) Confront the client regarding unacceptable behavior c) Maintain Nutritional requirements by offering finger foods d) Stimulate the client by leaving the television on throughout the day 61) A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first? a) A client who has begun to demonstrate catatonic behavior b) The client was compulsive behavior and is frequently drinkingfrom the water fountain c) Client was having auditory hallucinations is becoming agitated d) A client was making sexual comments to clients of the opposite sex 62) A nurse is caring for the full term newborn immediately following birth. Which of the following actions should the nurse take first? a) Instill erythromycin ophthalmic ointment and the newborn’s eyes. b) Place identification bracelets on the newborn. c) Weigh the newborn. d) Dry the newborn 63) A nurse receives report on a group of clients. Which of the following client should the nurse attend to first? a) A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at 1 L per minute via nasal cannula b) A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10 c) The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL a) 102 of 640 d) A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green fluid 64) A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor? a) The client reports the urgeto push b) The cervix is dilated 2 cm c) Contractions are 2 to 3 minutes apart d) The client reports nausea and vomiting 65)The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned ? a) An AP is to calculate intake and output every two hours for client in acute renal failure. b) An AP is to collect vital signs every 30 minutes for client who had a cholecystectomy c) A licensed practical nurse is to check nasogastric tube placement for client list had a bowel resection. d) A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident. 66)A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following findings requires immediate intervention? a) pruiritus under the cast b) Localized stabbing pain upon movement c) paresthesia of the distal extremity d) Edema present when leg is in the dependent position 67)The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of the following is an appropriate a) 103 of 640 nursing action? Click on the links of this below for additional client information a) Offer the child a cup of chicken broth. b) Encourage the child’s intake of gelatin. c) Administer oral rehydration solutions. d) Institute a banana, Rice, applesauce, and toast diet. 68)The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication? a) Serum chlorideb) Uric acid level c) Serum albumin d) Magnesium level 69)A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion? a) Ventricular asystole b) Third-degree AV block Ventricular fibrillation 70)Nurse managers preparing an educational program on infection control measures. Which of the following should the nurse include when discussing contact precautions? a) Scarlet fever b) Herpes simplex c) Varicella d) Streptococcal pharyngitis 71) A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should c) Atrial fibrillation d) a) 104 of 640 the nurse report to the provider immediately? a) The clinic experiences coughing and wheezing after eating. b) The client reports abdominal pain at a five on a scale of 0 to 10. c) The client experience is a drop in oxygen saturation to 91% while eating. d) The client reports a burning sensation in epigastric area. 72) A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP? a) Applying condom catheter for client for spinal cord injury b) Administrative oral fluids to client was dysphasia c) Documenting the report of pain from client who is postoperative d) Reviewing active range of motion exercises with a client who is had a stroke 73)A nurse from the state health department this is instructing a group nurses regarding reportable infections. Which of the following infections should the nurse report to the CDC? a) Candida albicans b) Herpes simplex virus 2 c) staphylococcus aureus d) Lyme disease 74)The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority finding by the nurse? a) A pain score 7 on a scale of 0 to 10 b) Shortness of breath c) New onset of a new enuresis d) Priapism 75)Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which a) 105 of 640 of the following findings requires further assessment by nurse? a) Glascow scale score a 15 b) Blood drainage on initial dressing measuring 3 cm c) Report of dry mouth d) Urinary output greater than fluid intake 76) A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction of the client a) Flexes elbows at 30 degrees when using the handgrips b) Maintains 3 to 4 finger width between the crutch pad and axilla c) Places the crutches 6 inches in front and side each foot when standing. d) Pushes up from a chair with crutches on the unaffected side. 77) A nurse is caring for a toddler who has respiratory syncytial virus.Which of the following actions should the nurse plan to take? a) Use a designated stethoscope when caring for the toddler. b) Wear an N95 respiratory mask while caring for the toddler. c) Remove the disposable gown after leaving the toddler’s room d) Place the toddler in a room with negative air pressure. 78) A nurse is admitting to a client to emergency department and initiates continuous cardiac monitoring. Which of the following ECG with strips indicates sinu stachycardia ? a) 106 of 640 b) 79) A nurse is planning care for client to prevent complications of immobility. With the following actions should the nurse including the plan of care? a) Massage lower extremities daily to prevent DVT b) Limit intake of Food high in calcium to prevent renal calculi. c) Encourage client to lie supine prevent constipation. d) Remove anti embolism stockings for 3 hours each day to decreased skin breakdown. 80) A nurse discovers that the wrong dosage of medication was given to client . When determining what action to take your should recognize that which of the following ethical principles should be applied? a) Utility b) Paternalism c) Veracity d) Fidelity 81) ? 82) A nurse is review in the prescription for doxazosin with a client.Which of the following should be included in the teaching? a) Decrease caloric intake to reduce weight gain. b) Increased dietary fiber to prevent constipation. c) Rise slowly when sitting up from bed. a) 107 of 640 d) Take this medication each morning. 83) Addresses planning to provide teaching to young adult client who is insomnia . Which of the following should the nurse include in the teaching? a) Exercising an hour before bedtime b) Take a short nap today c) Keep bedroom cool at night d) Consume a high carbohydrate snack at bedtime. 84) A nurse is caring for client who has a stool culture that is positive for Clostridium difficile . Which of the following infection control precautions is appropriate? a) Wear a face shield prior into entering the room. b) Place the client private room. c) Place the client in a negative pressure room. d) Use alcohol based hand rub following client care. 85) A nurse is planning care for a child who has increased intracranial pressure with a decreased level of consciousness. Which of the following intervention should the nurse including the plan of care? a) Perform active range of motion exercises. b) Perform neurological checks every 4 hours. c) Suction the airway frequently. d) Maintain the head at a midline position. 86) The nurse is assessing a client is receiving radiation therapy.Which of the following findings should the nurse expect? a) White blood cell count at 12,500 mm3 b) Excessive salivation c) +3 pitting edema d) Platelets 95,000 mm3 a) 108 of 640 87) A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage . The nurse should identify that which of the following medications is contraindicated ? a)Methylergonovine. b) Misoprostol c) Dinoprostone d) Oxytocin 88) A nurse is caring for client was GERD . Which of the followingassessment findings the nurse expect to find? a) Shortness of breath b) Rebound tenderness c) Atypical chest pain d) Vomiting blood 89) A nurse is caring for a newborn who is under phototherapy lights . Which of the following is an appropriate nursing action? a) Ensure eye shield is covering the eyes. Apply lotion to expose skin. Offer glucose water between feedings. Discontinue breast-feeding during treatment. 90) This is assessing clients as had a long arm cast. Which of the following findings of the dress moderate and when assessing for acute compartment syndrome? a) Shortness of breath b) Petechiae c) Change in mental status d) Edema d) c) b) a) 109 of 640 91) I Just came from client is receiving IV moderate (Conscious) sedation with midazolam . The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse? a) Placed the client in a prone proposition. b) Implement Positive pressure ventilation. c) Perform nasopharyngeal suctioning. d) administer flumazenil 92) A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are using the clients name and discussingdetails of his diagnosis. Which of following actions should the nurse take first? a) Report the AP’s behavior to the supervisor. b) Completed instant report regarding the Aps conversation. c) Provide the AP with written documentation regarding client confidentiality d) Tell the AP to discontinue their conversation 93) A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include African American males almost twice as likely as caucasian males to experience which of the following? a) testicular Cancer b) Obesity c) Stroke d) Melanoma 94) A nurse is caring for a client who sprained his left ankle 12hrs ago . Which of the following prescription is given by the provider should the nurse clarify? a) Over the fact that extremities and two pillows. b) Apply heat to affect extremity for 45 minutes on the 45 is off. a) 110 of 640 wrap the affected extremity with a compression dressing. Assess the affected extremity for sensation movement impulse every four hours 95) A nurse is providing dietary teachings for client who has hepatic encephalopathy . Which the following food selections indicates that client understands teaching? a) A sandwich and milkshake b) Rice with black beans Cottage cheese and tuna lettuce Three egg omelette with low-sodium ham 96) A nurse is planning care for client sealed radiation implant andis to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? a) Remove dirty linens from the room after double bagging. b) Wear a dosimeter film badge while in the client’s room Limit each of the clients is yours to one hour per day. Ensure family members remain at least 3 feet from the client. 97) A nurses for Caring for four clients. Which of the following clientshould the nurse care for first? a) A client to receive a chemotherapy treatment or first national b) A client who has an appendectomy to these don’t has diminished all sounds c) A client is hypothyroidism and his stuporous d) A client who is a burn requiring a sterile dressing change 98) The nurses planning care for newly admitted adolescent who has bacterial meningitis . Which the following instructions is appropriate for the nurse to include in the plan of care? a) Initiate droplet precautions for the client b) Assisted client to supine position d) c) d) c) d) c) a) 111 of 640 c) Performing Glasgow coma scale every 24 hrs d) Recommend prophylactic acyclovir there for the clients family. 99) Nurse is giving discharge instructions to client has new ileostomy . The nurse should recognize that the teaching has been effective when the client states. a) I want sure that my medications are enteric coated b) My stoma will drain liquid fluid continuously c) I will change my pump system every two weeks d) My stoma size will stay the same even after healed 100) A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client’s history is a contraindication to use in combination oral contraceptives? a) thyroid disease b) Allergy to penicillin c) impaired liver function d) abnormal blood glucose 101) The nurses providing teaching to a client who has mild persistent asthma has been prescribed montelukast. Which of the following statements to the nursing put in teaching? a) This medication can be used to help you when have an acute asthma attack b) This medication should be taken before exercise and physical activity c) This medication can be taken for 10 days and then gradually discontinued d) This medication helps decrease swelling and mucus production a) 112 of 640 102) I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess first? a) A client who is receiving warfarin and has and INR of 3.3 b) A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL c) A client who had a NG tube inserted 6 hr ago and has abdominal distention d) A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the throat 103) A nurse is assessing a client who has pericarditis . Which ofthe following findings is priority a) Paradoxical pulse pg. 389 under complications b) dependent edema c) Pericardial friction rub d) Substernal chest pain 104) A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces contaminated with blood. Which of the following agents said the nurse include in the teaching? a) Hydrogen peroxide b) Chlorhexidine c) Isopropyl alcohol d) Chlorine bleach 105) *A nurse is preparing to feed a newly admitted patient with dysphagia . Which of the following actions in response take? a) instruct the client to lift her chin when swallowing b) discourage the client from coughing during feedings c) Sit at or below the clients eye level during feedings. d) Talk with the client during her feeding. a) 113 of 640 106) A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client. “If you don't eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a) Assault b) Battery c) Malpractice d) Negligence 107) A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following? a) Re-Evaluate priorities halfway through the shift b) Delegate changing sterile dressing for licensed practical nurse c) Groups activities for the Same client d) Works on several tasks simultaneously 108) A nurse is monitoring the client during an IV urographyprocedure . Which of the following client reports is the priority finding? a) Feeling flushed and warm b) Abdominal fullness c) Swollen lips d) Metallic taste in mouth 109) A nurse is planning to delegate client assignments to the assistive personnel. which of the following task is appropriate for the nurse to delegate? a) Just the flow rate of the clients oxygen tank b) Collecting urine sample c) Measuring the clients pain level d) Monitoring blood glucose levels a) 114 of 640 110) A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure ? a) Systolic presssure subtracted by diastolic pressure (132 - 40) = 92 111) A nurse if caring for a group of clients in a medical surgical unit.Which of the following situations requires completion of an incident report? a) A client who is absent gag reflex following a bronchoscopy b) A client whose IV pump has malfunctioned c) A client who requires insertion of NG tube due to a bowel obstruction d) A client who is absent bell sounds following a gastrectomy 112) A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin . Which of the following should nurse monitor? a) Fasting blood glucose b) Carbohydrate intake c) Hematocrit d) Weight 113) The nurses providing discharge instructions about engorgement for client has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction by the nurse? a) I can wear support bra b) I will play cold compression my breasts c) I will manually express breastmilk d) I can take a mild analgesic 114) A nurses caring for client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the a) 115 of 640 c) following client findings indicates medication toxicity ? a) Blood glucose of 150 mg/dL b) Urine output of 20 mL per hour c) Systolic blood pressure at 140 mm Hg d) BUN 20 mg/dL 115) The nurse is completing an assessment for newborn who is 2 hrs old . Which of the following findings are indicative of cold stress ? a)Respiratory rate of 60 per minute b) Jitteriness of the hands Diaphoretic Bounding peripheral pulses in all extremities 116. A nurse is planning care for four clients. Which of the followingclients is the highest priority? a. A client who is dry, black eschar on the heel b. A client who is wearing an arm cast and reports numb fingers c. The client was reddened skin area with blanching around the coccyx d. The client who has frequent incontinence 117. A nurse is caring for a male adolescent client who has heartfailure . Based on the client’s chart finds. Which of the following actions should the nurse plan to take? a. Withholds spiranolactone b. Administer ferrous sulfate c. Administer furosemide d. Withhold digoxin (0.8-2.0) 118. The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical manifestations are associated with this finding? d) a) 116 of 640 a. Confusion (hypoglycemia) b. Thirst c. Diaphoresis (hypoglycemia) d. Shakiness (hypoglycemia) 119. A nurse is assessing for allergies before administering Propofolto a client placed on the mechanical ventilator. Which of the following allergies is a contraindication to the medication? a. Eggs b. Milk c. Shrimp d. Peanuts 120. A nurse is assessing a client diagnosed with schizophrenia . Thenurse asks the client to interpret the following statement, “When the cat’s away, the mice will play”. The client response was, “The mice come out when the cat is not around”. The nurse should document this finding which of the following in the client’s chart? a. Echolalia b. Associative looseness c. Neologisms d. Concrete thinking 121. A nurse caring for a client who is receiving total parental nutrition . Which of the following assessment findings requiredimmediate intervention by the nurse? a. prealbumin level of 20 mg/dL b. Weight increase of two kg/day c. Temperature of 37.6°C d. Blood glucose level of 120 mg/dL a) 117 of 640 122. A nurse in the telemetry unit is receiving the laboratory findings for adult male client who’s been treated for myocardial function . The following is an expected finding for the client? a. Troponin 1 (TNI) 8 ng/ml b. Brain natriuretic peptide (BNP) 10 ng/L c. Alanine aminotransferase (ALT 45 unit/L d. High density lipoprotein (HDL) 75 mg/dl 123. A nurse is reviewing the results of an ABG performed on a clientwith chronic emphysema . Which of the following results suggests the need for further treatment? a. paO2 level of 89 mm Hg b. PaCO2 level of 55 mm Hg c. HCO2 level of 25 mEq/L d. pH level of 7.37 124. A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching? a. "Carbohydrates should be at least 45% of your caloric intake." b. "Protein should be at least 55% of your calorie intake." c. "Carbohydrates should be at least 30% of your caloric intake." d. "Protein should be at least 60% of your caloric intake." 125. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the troughlevel to be drawn at which of the following times? a. 2100 b. 0900 a) 118 of 640 c. 1300 d. 1800 126. A nurse is planning an education session for a client who has type 1 diabetes mellitus . Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? a. diaphoresis b. polyuria c. abdominal pain d. thirst 127. A nurse in an urgent-care clinic is collecting admission historyfrom a client who is 16 weeks of gestation and has bacterial vaginosis . The nurse should recognize that which of the following clinical findings are associated with this infection? a. Frequency and dysuria b. Profuse milky white discharge c. Hematuria d. Low grade fever 128. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding? a. beef broth b. oatmeal c. apple juice d. toast 129. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first? a. A client who reports tingling in the fingers following a thyroidectorny a) 119 of 640 b. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr c. A client who is in a long leg cast and reports cool feet bilaterally d. A client who has a productive cough and an oral temperature of 36° C (96.80 F) 130. A nurse is caring for a client who has lactose intolerance and haseliminated dairy products from his diet. The nurse should instruct the client to increase consumption of which of the following foods? a. spinach b. peanut butter c. ground beef d. carrots 131. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin . The client is gravida 2, para 2, andher blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate? a. You only need to receive Rh immune globulin if you have apositive blood type." b. You should receive Rh immune globulin within 72 hours of delivery." c. "Both you and your baby should receive Rh immune globulin at your -week appointment." d. "immune globulin is not necessary since this is your second pregnancy." 132. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, a) 120 of 640 I never should have let him take the car. Its all my fault!" Which of the following responses by the nurse is appropriate? a. You had no way of knowing this would happen." b. Most parents blame themselves when losing a child." c. Tell me why you feel this is your fault." d. You appear to be feeling overwhelmed" 133. A nurse is educating a client about caloric intake and weight reduction. Which of the following client statements indicates an understanding of the teaching? a. “If I eat 500 fewer calories per day, I should lose 1 pound per week.” b. “ If I eat 500 fewer calories per day, I should lose 1 pound per week." c. "If I eat 450 fewer calories per day, I should lose 2 pounds per week." d. "If I eat 250 fewer calories per day, I should lose 2 pounds per week." e. "If I eat 300 fewer calories per day, I should lose 1 pound per week.” 134. A nurses is teaching post-operative care with the parents of a toddler following a cleft palate repair. Which of the followingshould be included in the teaching? a. Provide an orthodontic pacifier for comfort. b. Offer fluids by using a straw. c. Cleanse suture line with a cotton tip swab. d. Remove elbow splints periodically to perform range of motion. 135. A nurse is caring for four clients. Which of the following tasks canthe nurse delegate to an assistive personnel? a. Perform chest compressions during cardiac resuscitation. a) 121 of 640 b. Perform a dressing change for a new amputee. c. Assess effectiveness of antiemetic medication. d. Provide discharge instructions 136. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox ? a. Bloody diarrhea b. Ptosis of the eyelids c. Descending paralysis d. Rash in the mouth 137. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate bythe nurse? a. Aspirate the irrigation solution from the bladder. b. Insert the tip of the irrigation syringe into the catheter opening. c. Apply sterile gloves. 1296 in med surgical book d. open the flow clamp to the irrigating fluid infusion tubing. 138. A nurse is caring for a client who has been taking haloperidol forseveral years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication? a. Lipsmacking b. Agranulocytosis c. Clang association d. Alopecia a) 122 of 640 139. A nurse is planning care for a client who has Alzheimersdisease and demonstrates confusion and wandering behavior . Which of the following should the nurse include in the plan of care? a. Place the client in seclusion when she is confused. b. Request a prescription for PRN restraints when the client is wandering. c. Dim the lighting in the clients room. d. Leave one side rail up on the clients bed. 140. A nurse is reviewing the laboratory data of a client who has diabetes mellitus . Which of the following laboratory tests isan indicator of long-term disease management ? a. Postorandial blood glucose b. Glycosylated hemoglobin - Ha1c c. Glucose tolerance test d. Fasting blood glucose 141. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel? a. Initiate a dietary consult for a toddler. b. Administer a glycerin suppository to a preschool-age child. c. Evaluate gastric residual following intermittent feeding of an adolescent. d. Transport a school-age child to x-ray. 142. A nurse is caring for a client who has been taking propranolol .Which of the following findings indicates a need to withhold the medication? a) 123 of 640 a. sodium 130 mEq/L b. Blood pressure 156/90 mm Hg c. Potassium 5.2 mEq/L d. Pulse 54/min 143. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse? a. Apologize to the others for your behavior." b. I am disappointed that you continue to act out when you are angry." c. Come outside with me for a walk." d. If you dont calm down, you will have to go into seclusion." 144. A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia. Which of the following precautions should the nurse take while caring for this client a. Wear an N95 respirator while caring for the client. b. Use a dedicated stethoscope for the client. c. Insert an indwelling urinary catheter to monitor urinary output. d. Monitor the client’s vital signs every 8 hr. 145. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia? a. serum sodium 138 mEq/L b. Urine specific gravity 1.001 c. serum calcium 10 mg/dL d. Urine pH 6 a) 124 of 640 146. A nurse is caring for a group of clients in a long-term care facility . Which of the following situations should the nurse recognize as a safety hazard ? a. A client’s wrist restraints tied to the bed rails b. A clients bedside table placed across the foot of the bed c. A meal tray left at the bedside from breakfast d. A call light extension cord pinned to the bedspread 147. A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response? a. I’d like to know more about what’s bothering you." b. "Why are you feeling this way" c. "You did the right thing by bringing him here." d. "I’m sure your father doesn’t blame you." 148. A nurse is planning care for a client following gastric bypass surgery . The nurse should include which of the following dietaryinstructions when preparing the client for discharge? a. start each meal with a protein source. b. Consume at least 25 g of fiber daily. c. Check your blood glucose level before each meal. d. Limit your meals to three times per day. 149. 149 A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findingsrequires interventio n by the nurse? a. Tidaling with spontaneous respirations b. Drainage collection chamber is 1/3 full c. 1 cm of water present in the water seal chamber a) 125 of 640 d. Suction chamber pressure of -20 cm H20 150. A provider has written a do not resuscitate order for a client who is comatose and does not have advance directives. A member of the clients family says to the nurse, “I wonder when the doctor will tell us what’s going on" Which of the following actions should the nurse take first a. Request that the provider provide more information to the family. b. Refer the family to a support group for grief counseling. c. Offer to answer questions that family members have. d. Ask the family what the provider has discussed with them. 151. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is a. scaly and red b. asymmetric, with variegated coloring c. firm and rubbery d. brown with a wart-like texture 152. A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process? a. Decreased sense of taste b. Decreased blood pressure c. Increased gastric secretions d. Increased accommodation to near vision a) 126 of 640 153. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the followingshould the nurse include in the plan of care? a. Administer disulfiram. b. Provide frequent orientation to time and place. c. Engage the client in group therapy. d. Perform gastric lavage. 154. A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve . (Selectable areas or Hot Spots" can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.) a. Top left site 155. A nurse manager is planning an audit to measure the quality of care on the unit. Which of the following is the most appropriate source for the nurse to consult? a. Nursing manager colleagues b. Evidence-based practice data c. Hospital administrators d. Protocols in other hospitals a) 127 of 640 156. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect? ( Select all thatapply) a. Facial flushing b. Syncope c. Diaphoresis d. Vertigo e. Bradycardia 157. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. feelings of dread b. rapid speech c. purposeless activity d. heightened perceptual field 158. A nurse is delegating tasks to an assistive personnel. Which of the following instructions demonstrates appropriate communication of the task? a. "Take a blood glucose fingerstick on the client in room 102 before breakfast and then place the glucometer into the docking station." after lunch and report a systoli c level less than 90." c. "Assist the client in room 110 to ambulate once around the unit and stop if she gets short of breath." d. "Turn the client in room 126 to prevent pressure areas on his hip bones." b. "Obtain a blood pressure reading from the client in room 116 a) 128 of 640 c. b. 159. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following? a. Nicotine withdrawal b. Heroin intoxication c. Alcohol withdrawal d. Amphetamine intoxication 160. A nurse is assessing an older adult client who had a stroke. Which of the following findings should the nurse recognize as an indication of dysphagia? a. Abnormal movements of the mouth Inability to stand without assistance Paralysis of the right arm Loss of appetite 161. *A nurse is providing preoperative teaching to a client who willusePCA morphine sulfate following surgery. Which of the following information should the nurse include? a. The client should notify the nurse when administering a dose of the medication. b. The client can administer a dose of medication every 6 to 8 min. c. The client should be cautious to avoid overmedication (OD). d. Family members can administer a dose the client. 162. A nurse is assisting the provider with a paracentesis for a client who has ascites. Following collection of the specimen, which ofthe following actions should the nurse take next a. Document the procedure. d. a) 129 of 640 c. b. b. Measure the drainage. c. Record the color of the drainage. d. Label the specimen. 163. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take? a. Notify security to monitor the facility exits. b. Place the client in seclusion. c. Inform the client of the risks involved if she leaves. d. Call the provider for a discharge prescription. 164. A nurse is preparing to administer a measles, mumps, rubella (MMR ) immunization to a child. Which of the following is a contraindication for administration? a. Recent blood transfusion Allergy to penicillin Minor acute illness Low-grade fever 165. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client . Which of the following isthe safest site for the nurse to use? a. Ventrogluteal Dorsogluteal Vastus lateralis Rectus femoris 166. A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should thenurse include as a risk factor for developing a UTI? d. c. b. d. a) 130 of 640 a. Wearing underwear with a cotton crotch b. Wiping from front to back c. Using perfumed toilet paper d. Urinating immediately after intercourse 167. A nurse is providing discharge instructions for a client who has a new prescription for furosemide . Which of the following client statements indicates a need for further teaching? a. "I will take my morning pills with food or milk." b. "I will weigh myself every day." c. "I will notify the nurse if I have muscle cramps." d. "I will limit my intake of fish." 168. A nurse is caring for a client who has a prescription for atorvastatin . Which of the following client conditions is acontraindication to this medication? a. hepatits C peptic ulcer disease bronchitis chrohn’s disease 169. A nurse is planning care for an adolescent who has chronic renal failure . Which of the following actions should the nurseinclude in the plan of care? a. Encourage a diet high in calcium. b. Provide a diet high in potassium. c. Ensure increased fluid intake. d. Restrict protein intake to the RDA. d. c. b. a) 131 of 640 170. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first? a. Take vital signs. b. Assess lochia. c. Massage the fundus. d. Give oxytocin IV bolus. 171. A nurse is caring for a client who is receiving intermittent enteral tube feedings . Which of the following interventions should the nurse perform a. Give 100 mL of water with every feeding. b. Obtain gastric residuals every 24 hr. c. Position the head of bed at 30 degrees during feeding. d. Mix the clients medications with the tube feedings. 172. A nurse is caring for a 7 month-old infant who is being treated for severe dehydration . Which of the following assessment findings indicates treatment has been effective? a. Skin turgor displays tenting b. Flat anterior fontanel c. Cool, mottled skin d. hyperpnea 173. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiation therapy. Which of thefollowing should the nurse include in the teaching? a. Remove dye markings after each radiation treatment. b. Apply a warm compress to the irradiated site. c. Wear clothing over the area of radiation treatment. a) 132 of 640 d. Use a washcloth to bathe the treatment area. 174. A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide a. Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is effective." b. "Take your iron medication with fluids other than coffee or tea." c. "It is important to take your iron medication on a full stomach." d. "If you miss a dose one day, take two doses the next day." 175. 175 A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess a. A client who had a hip arthroplasty reports pain and erythema in his calf A client who has anorexia and peripheral edema A client who has Addison's disease with a blood glucose level of 75 mg/dL d. A client who had a barium enema 2 days ago and reports constipation 176. A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which of the following medications should the nurse administer? a. Albuterol sulfate b. Hydromorphone c. Diphenhydramine c. b. a) 133 of 640 d. Amitriptyline 177. A client who does not speak English arrives at the emergency department accompanied by a child. Which of the following actions should the nurse take? a. Ask the assistive personnel to assist the client in signing consent for treatment b. Ask the child to interpret for the client. c. Ascertain what language the client speaks and get an interpreter. d. Try to find an adult relative to help the client communicate. 178. A nurse is caring for a client who has severe preeclampsia and isreceiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity . Which of the following actions should the nurse take? a. Position the client supine. b. Prepare an IV bolus of dextrose 5% in water c. Administer calcium gluconate IV. d. Administer methylergonovine IM. 179. A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant primigravida. The first day of the clients last period was October. What is the expected delivery date? (Provide the date using four numerals, the first two for the month and the second two for the day. For example, January 2 0102) a. 0711 (July 7, 2011) Formula: +1 year, -3 months, +7 days a) 134 of 640 180. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is scheduled for chemotherapy and has a hemoglobin of 9 b. A client who is 24 hr postoperative following a transurethral resection of the prostate (TURP) and has small blood clots in the urinary catheter c. A client who is receiving a blood transfusion and reports low-back pain d. A client who has a new colostomy with a reddish-pink stoma VERSION 7 RN COMPREHENSIVE ONLINE PRACTICE 2019 A 1. A nurse is performing tracheostomy care for a client who is a) 135 of 640 postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway? Withdraw the catheter if the client begins coughing. Apply suction for 10 seconds. Advance the catheter 2 cm (0.8 in) after resistance is met. Use medical asepsis when performing the procedure. 2. A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? Teach the client reportable adverse effects from the medication. Check the insulin dose with another licensed nurse Administer the insulin at a 90° angle. Clean the insertion site. 3. A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider? Urine output 120 mL in 4 hr Systolic blood pressure 12 mm Hg lower than the preoperative level Audible stridor Normal sinus rhythm with an occasional premature ventricular contraction 4. A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.6 5. A charge nurse is planning an educational session for staff a) 136 of 640 nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? Choosing to donate organs can delay the timing of the child's funeral. The family can have the child an open casket without fearing that the organ donation might disfigure the childs body The family should understand that an autopsy is mandatory prior to organ donation. The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death. 6. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff 's acceptance of this change, which of the following actions should the nurse manager take first? Provide information about scheduling issues to the staff Ask staff members to participate in a trial of the new scheduling system. Encourage staff to offer alternate scheduling solutions.
 Develop goals to implement the new scheduling system. 7. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? Bradycardia Low back pain Hypertension a) 137 of 640 Distended jugular veins 8. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? Increased intraocular pressure Floating dark spots Decreased central vision Double vision 9. A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury? Report of persistent constipation Hgb 14 g/dL Albumin 4.2 g/dL Recent weight loss 10. A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? "This type of nutrition is more effective than eating by mouth." “You will receive fingersticks for blood glucose testing. "TPN is a way to provide vitamins and minerals without increased calories." "Taking TPN can increase the risk of developing a latex allergy." 11. A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which a) 138 of 640 of the following findings as an indication the client is experiencing fuid volume de deficit? Shortness of breath Visual disturbances Decreased BUN levels •Orthostatic hypotension 12. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? Continue observing the fetal heart rate Assist the client to a knee-chest position.
 Prepare the client for continuous internal monitoring. Prepare for an emergency cesarean birth. 13. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? Initiate the referral at the time of discharge. Have the client contact a physical therapist when feeling ready to begin therapy. Verify that insurance will pay for outpatient physical therapy. •Involve the client in selection of a physical therapy provider. 14. A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a a) 139 of 640 manifestation of vaso-occlusive crisis? Diminished reflexes Hematuria Hyperglycemia Hearing loss 15. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? "I will make sure my 4-year-old child wears a helmet when using a skateboard." "I should have my child avoid sun exposure between 10 am and 2 pm." 
"I can give my 2-year-old child a whole hotdog on a bun." 
"When my infant is in the carrier, I will place it on a raised, at surface whenever possible." 16. A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first? A client who has a temperature of 38.2° C (100.8° F) and requests a cup of ice chips A client who is postoperative and reports a pain level of 5 on a scale from0 to 10 A client who has voided and is ready for a bladder scan
 A client who is confused and has been attempting to get out of bed 17. A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which a) 140 of 640 of the following assessment findings should the nurse identify as the priority? Lethargy Confusio nPolyuria 
Fine hand tremors 18. 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 Contact the triage officer. Implement the client tracking system. 
Ask the communications officer to release a press statement. Notify the incident commander. 19. A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care? Notify the provider if a thrill is palpated at the fistula. Auscultate the affected extremity for a bruit Discourage range-of-motion exercises in the affected extremity. Perform venipuncture in the affected extremity. 20. A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? "There's a protocol for reviewing your medical record, and I can initiate the process." a) 141 of 640 "The medical record has a lot of medical terminology, and it might be di cult for you to understand." "You should really talk to your provider if you have any questions about your treatment." "Some parts of your medical record are restricted, but I can show you theparts that you are allowed to see." 21. A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? Weight loss Urinary retention Hypertension Hypoglycemia 22. A nurse is preparing to administer heparin 5,000 units subcutaneously. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.5 23. A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect? Lethargy Diaphoresis Bradycardia Cough 24. A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? a) 142 of 640 "You will need to draft a health care proxy so a designee can make this decision for you." "I will make sure that no one performs any lifesaving measures if your heart stops." "Your provider determines if you should have lifesaving measures if your heart stops." "I will provide you with information about medical treatment to include in your living will." 25. A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? Give an antiemetic 30 min after medication administration. Monitor blood glucose levels. Monitor for tumor lysis syndrome. Maintain hydration with liberal fluid intake 26. A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? Uric acid crystalsProtein WBCs Nitrites 27. A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. Dampen the skin before applying the skin barrier and ostomy pouch. Place the skin barrier over the stoma and hold it for 30 seconds a) 143 of 640 Cut the skin barrier opening 0.6 cm (0.25 in) larger than the stoma. 28. A nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? Flush the clients gastrostomy tube with 30 ml of water before administering the medication. Crush the client's medications and mix them in with the tube feedingformula prior to administration. Change the client's feeding bag every 72 hr.
 Administer multiple prescribed medications at the same time. 29. A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? The client needs assistance when transferring from the bed to a wheelchair. The client will have a visit by a home health nurse tomorrow.
 The client's partner will bring clothes for the client to change into prior to discharge. The client often needs encouragement to engage in personal hygiene activities. 30. A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching? Liver Oranges Chicken a) 144 of 640 Red wine 31. 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? Collection of a stool specimen Preparation of a client's postoperative bed Preparation of a teaching plan about pneumonia Insertion of a nasogastric tube 32. A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? Contact Droplet 
Airborne
 Protective environment 33. A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take? Instill chilled lavage solution into the client's NG tube. Attach the client's NG tube to low intermittent suction.Use 0.9% sodium chloride for irrigation of the NG tube. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time. 34. A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? Install a raised toilet seat at home. Maintain the hip at an angle greater than 90°. a) 145 of 640 Minimize the use of a walker.
 Place a pillow under the knees when lying down. 35. A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? Amylase Troponin T 
Low-density lipoprotein (LDL) Homocysteine 36. A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner should the nurse identify as the priority? "Will my husband be able to continue as the executor of his parents'estate?" "One of my husband's coworkers visited last week to tell me my husband might lose his job." "Do you think it is necessary to postpone our daughter's wedding until myhusband is feeling better?" "My husband doesn't know that I've already moved out of the house and led for a divorce." 37. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? Assist the client with contacting individuals from the client's supportsystem. Give the client information about available community resources forshelter. Suggest the client obtain mental health counseling. Determine the client's perception of the personal impact of the crisis. a) 146 of 640 38. An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? Uses a draw sheet to move the client to the left side of the bed Raises the total height of the bed to waist level Places a pillow under the client's right arm Lowers the side rails on the left side of the bed 39. A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? A client who is alert and has a 2.5 cm (1 in) laceration on the forehead A client who has significant head trauma and agonal respirations. A client who has an open fracture of the right forearm
 A client who is unconscious and has a rapid, thready radial pulse 40. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement? Airborne Droplet Contact Protective environment 41. A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? 1 medium raw carrot 1/2 cup cooked spinach a) 147 of 640 
1/2 cup cooked butternut squash 1 cup sliced cantaloupe 42. A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? Ask for help with a two-person assist transfer. Assess the client for functional limitations Request a mechanical lift device. Medicate the client for pain. 43. A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child? "You should leave your glasses o throughout the testing." "You should stand 15 feet away from the chart."
 "You should get three symbols on a line correct to pass the line." "You should keep both eyes open during the testing." 44. A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruption placentae. Which of the following findings should the nurse expect? Persistent uterine contractions Bright red vaginal bleeding Hyperactive deep-tendon re exes Fundal height of 40 cm 45. A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect? Butter y rash over the cheeks and nose Report of pain in the joints of the lower extremities a) 148 of 640 Blanching of the fingers and toes Scaly patches over the knees and elbows 46. A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take? Inject 20 units of air into the NPH insulin vial . Shake the NPH insulin vial vigorously to mix the insulin.
 Use a new needle to draw up the insulin from the second vial. Draw the longer-acting insulin into the syringe first. 47. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? Encourage friends and family to visit the child. Withhold administering the varicella vaccine to the child. Collect a daily urine specimen from the child to check for proteinuria. Provide a low-protein diet for the child. 48. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique? Open the top outer flap of the package toward the body. Clean the penis with the nondominant hand. 
Don sterile gloves after opening the lubricant packet. Set the catheter tray on the overbed table at waist height. 49. A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which of the following findings indicates effective a) 149 of 640 breastfeeding? The newborn nurses every 4 hr during the day and sleeps through the night. The newborn has six to eight wet diapers per day. The newborn's current weight is 3.18 kg (7 lb). The newborn has sticky, greenish stools. 50. A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition? A client who is pregnant and has cytomegalovirus (CMV)An adolescent client who has foodborne botulism A child who has erythema infectiosum
 A young adult client who has herpes simplex virus type 1 (HSV-1) 51. A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? Provide an opportunity for the client to express their feelings. Move the client to a quiet place away from others. State expectations that set limits on the client's behavior. Administer a PRN dose of haloperidol to calm the client. 52. A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? Spinal manipulation a) 150 of 640 Acupuncture Therapeutic touch Guided imagery 53. 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 hospitalizations for diabetic ketoacidosis A client who has alcohol use disorder and has decided to start attendingAlcoholics Anonymous meetings A client who was admitted for dehydration and is receiving a continuous IV infusion A client who has a history of two prior miscarriages and has ruptured membranes at 38 weeks of gestation 54. A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms? Displacement Regression Suppression Sublimation 55. A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? Decreased blood pressure Increased cardiac output Increased oral temperature Decreased lung expansion a) 151 of 640 56. 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. Assist the client in changing positions. Administer a PRN analgesic medication. Explain the importance of early ambulation. 57. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? "I should report a change in the color of my stools." "I can take acetaminophen to treat a headache."
 "I will take a calcium supplement while taking this medication." "I will return in a month to have my blood tested." 58. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? "Place your baby's car seat at a 30-degree angle." "Your baby's car seat should be rear-facing until he is 6 months old." "Swaddle your baby in a light blanket before placing him in the car seat." "Secure the retainer clip at the level of your baby's armpits." 59. A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? Tell the client to self-report to the state health department.Require that the client speak with a public health nurse. Explain to the client why this information will be shared. Refer the client to a social worker for counseling. a) 152 of 640 60. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? Provide the infant with 1 cup of cereal. Give the infant 240 mL (8 oz) of juice per day. Introduce new foods one at a time over 5 to 7 days. Give whole milk first, then small amounts of solid food. 61. A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? Constipation Nausea Wheezing Muscle rigidity 62. A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? Intermittent cramping Moderate lochia rubra Boggy uterus
 Perineal edema 63. A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make? "Your mother might still know you are here." "Why do you feel that way?" "It seems like you feel your visits are a waste of time." a) 153 of 640 "Are you sure you would not want to see your mother again?" a) 154 of 640 64. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? Maintain the client on bed rest. Restrict the client to 1 L of fluid per day.
 Place cool compresses on the edematous area. Elevate the a effected leg. 65. A nurse in an acute 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? Give the client a choice of foods and beverages. Supervise the client during and after eating.
 Encourage casual conversation about food during meal times. Provide opportunities for the client to choose their own meal times. 66. A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching? "I should avoid eating smoked meat, cheeses, and ripe avocados while taking this type of medication." "I should watch for common reactions like dry mouth and constipation." "I will be at increased risk for high blood pressure while taking this medication." "I will take my daily dose of this medication every morning before breakfast." 67. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse a) 155 of 640 requires the nurse manager to intervene? Informs the provider about a client's suicide plan Notifes the health department of a client's diagnosis of chlamydia Reports suspected child maltreatment to social services Tells the hospital chaplain a client's diagnosis 68. A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect? "I have not had any food cravings." "The spotting I was having has stopped." "I don't feel depressed anymore." "I have not vomited as much recently." 69. A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? Investigate environmental factors that might be contributing to client injury during these hours. Review the performance evaluations of nurses who work during thesehours.
 Implement a plan to transition from team nursing to primary care nursing during these hours. Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours. 70. A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? Measure the client's vital signs. a) 156 of 640 Reposition the client.
 Encourage the client to use an incentive spirometer. Administer pain medication. 71. A nurse is assessing a client who is 2 hr postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider? Pain level Neurologic status Laboratory results Urinary output 72. A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information? An RN who is monitoring a client who started receiving a bloodtransfusion 5 min ago An assistive personnel (AP) who just began performing a bed bath
 A licensed practical nurse (LPN) who is reinforcing discharge instructions with a client An assistive personnel (AP) who is assisting a client to return to bed 73. A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take? Keep the client resting in bed. Ask the client to restate directions. 
Clear objects from the client's walking area. Evaluate the client's ability to swallow. a) 157 of 640 74. A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? "I should administer the ear drops as soon as I remove them from therefrigerator." "I should pull the top of the ear upward and back while instilling the medication." "I should massage behind the ear after I instill the drops." "I should have my child lie on the a effected side for a few minutes after I put the drops in the ear." 75. A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? Wheezes Tachycardia Restlessness Substernal pain 76. A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actions should the nurse take? Ask the caller for verification of their identity. Give the caller limited information about the client.
 Transfer the phone call to the client's room. 
Inform the caller that they should obtain permission from the client's provider. 77. A nurse is assessing a client who has skeletal traction for a a) 158 of 640 femur fracture. Which of the following findings should the nurse identify as the priority? Muscle spasms of the affected extremity A pain rating of 6 on a scale from 0 to 10Upper chest petechiae Ecchymosis over the fractured area 78. A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? Apologize to the client for the nurses' actions. Advise the nurses that they are being insubordinate. Tell the nurses to stop the discussion.
 Document the incident in the client's medical record. 79. A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? Lack of remorse Sensitivity to rejection Extreme mood swings Self-mutilating behavior 80. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? Refer the nurse to the procedure manual. Use a diagram to explain the procedure to the nurse. a) 159 of 640 Demonstrate the procedure to the nurse.
 Ask the nurse about their knowledge of the procedure. 81. A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority? The client reports leg itching under the cast around the mid-upper thigh area. The client reports increased pain when the leg is lowered below the levelof the heart. The client's cast became wet during a sponge bath. 
The client's heel is reddened and tender. 82. A nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following manifestations should the nurse monitor? Increased bowel sounds Dry, sticky mucous membranes Decreased deep tendon reflexes Numbness and tingling of the extremities 83. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? Administer oxygen. Initiate an infusion of oxytocin. Massage the uterus to expel clots. Obtain a CBC. 84. A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? a) 160 of 640 Ensure that the staff nurse changes the dressing. Notify the nurse manager.
 Complete an incident report.
 Gather more information about the staff nurse's actions. 85. A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? "Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer sooner." "Let's go on that family vacation we've got planned. We will deal with this when we return." "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." "This isn't possible. Just last week the doctor said that the cancer was responding well to treatment." 86. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider? Temperature 39.4° C (102.9° F)Headache Constipation Dry mouth 87. A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? •Use hydrogen peroxide to clean kitchen surfaces. Seal non washable items in a plastic bag for 2 weeks. Wear a surgical mask when in public. a) 161 of 640 
Limit family visits to 30 min periods. 88. A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills? Compare the nurse's time management skills to the skills of coworkers. Review client satisfaction reports about the nurse's performance.
 Ask another staff nurse to evaluate the nurse's time management skills. Maintain regular notes about the nurse's time management skills. 89. A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A a) 162 of 640 90. A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? Abdominal striae Masklike face Nystagmus - Ptosis 91. A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3, PaO2 56 mm Hg, a) 163 of 640 PaCO2 54 mm Hg, HCO3 - 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values? Uncompensated metabolic acidosis Uncompensated respiratory acidosis Compensated respiratory acidosis Compensated metabolic acidosis 92. A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? Bleeding Potassium deficiency Infection Hyperbilirubinemia 93. A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? Include chicken broth in the toddler's diet. Feed the toddler the BRAT diet. 
Initiate oral rehydration therapy for the toddler. Offer the toddler flavored gelatin. 94. A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply.) Nystagmus Facial flushing a) 164 of 640 Diplopia
 Nasal congestion Headache 95. A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make? "When the lesions no longer itch." "Three days after the lesions appeared." "When crusts have formed on every lesion." "When the lesions disappear." 96. 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 the nurse make? "Estrogen levels decrease during pregnancy, causing the stool to become hardened." "Decreased water absorption in the intestine during pregnancy causes constipation." "The intestine absorbs iron less efficiently during pregnancy, leading to constipation." "The enlarged uterus compresses the intestines and causes constipation." 97. A nurse is initiating discharge planning for a client who had a stroke and is experiencing right- sided weakness. Which of the following actions should the nurse take first? Ask a social worker to identify the client's insurance eligibility forrehabilitation services. Request a referral for the client to receive physical therapy.
 Arrange for the delivery of prescribed medications to the client's home. Provide the client with a list of community resources. a) 165 of 640 98. 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 information should the nurse include in the teaching? "You should flush the catheter with 0.9% sodium chloride solution daily when not using it regularly." • "You should keep the catheter clamped when not in use."
 "You should swim twice weekly to prevent tissue from adhering to the cu ." "You should change your dressing every 10 days." 99. A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? (Click on the audio button to listen to the clip.) Clang association Echolalia Neologisms Word salad 100. A nurse is caring for a child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into child's mouth. Place the child in a side-lying position.
 Administer rescue breaths until the seizure subsides. Obtain an ECG during the seizure. 101. A nurse is preparing to administer 2 units of fresh frozen a) 166 of 640 plasma to a client. Which of the following actions should the nurse plan to take? Allow the plasma to warm for 30 min before transfusion. Confirm the client's identification by checking the room number. Enter the plasma product number into the client's medical record.Administer each unit of plasma over 4 hr. 102. A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? Mark the edges of stairs for contrast. Cover exposed extension cords with throw rugs. 
Use 40-watt bulbs in lighting fixtures.
 Instruct the client to obtain vison testing once every other year. 103. A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? (Select all that apply.) "A speech pathologist will be performing a swallowing study for you." "You should rest before eating a meal."
 "You should restrict foods that are high in vitamin D." "Reduce your intake of dietary fiber."
 "Thicken your beverages before drinking." 104. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? Dry the newborn. Assign the first Apgar score to the newborn. Place an identification bracelet on the newborn. a) 167 of 640 Obtain the newborn's weight. 105. A home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? "I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature." "I will clean my toothbrush in my dishwasher once each month."
 "I will take my temperature once each week and let my doctor know if itis high." "I will walk for short distances throughout the day." 106. A nurse is assessing a client who has delirium. Which of the following g manifestations should the nurse expect? Projective blame Excessive clingingRapid Speech Social Awkwardness 107. A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? Decreased activity Hemoptysis 275 mL/24 hr Fever Weight loss 2.3 kg (5 lb) 108. A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? a) 168 of 640 Ketonuria Fecal impaction Latex allergy Tachycardia 109. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? "I can resume my daily aspirin therapy." "I will contact my provider if my eye feels itchy." "I will bend at my knees when picking an object up off the floor." "It's okay for me to pick up my grandchild who weighs 20 pounds." 110. A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? Identify health-related issues within the community. Develop measurable health goals for community residents. Create safety education classes for the program. Enlist volunteers from the rural community to promote the program. 111. A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? Carotid bruit Tracheal deviation Pulsus paradoxus Heart murmur 112. A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the a) 169 of 640 following findings should the nurse identify as a contraindication for the client to receive clozapine? BP 150/87 mm Hg WBC count 2,800/mm3 Auditory hallucinations Nausea 113. A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care? Avoid venipunctures when possible. Restrict visitors to family members. Limit oral fluid intake to between meals. Prohibit fresh flowers in the client's room. 114. When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? Coloring with crayons in a coloring book Deep breathing and "going limp as a rag doll" Blowing bubbles with liquid soap to "blow the hurt away" Taking a warm bath and playing with a bath toy 115. A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? The client's partner tells the nurse that the client understands the procedure. The nurse locates the provider's prescription for the surgical procedure. a) 170 of 640 The nurse witnesses the provider's explanation of the procedure. The client is able to accurately describe the upcoming procedure 116. A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 1-Remove the inner cannula. 2-Remove the soiled dressing. 3-Clean the stoma with 0.9% sodium chloride irrigation. 4- Change the tracheostomy collar. 117. A nurse is caring for four clients. Which of the following clients should the nurse assign to an assistive personnel (AP) to assist with meals? A client who has Alzheimer's disease and is demonstrating aphasia A client who has asthma and an increased respiratory rate A client who had a stroke and is to start oral intake A client who had diabetic ketoacidosis and is difficult to rouse 118. 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 indicates an understanding of the teaching? "We will let our child watch a favorite video before bed." "We should read a story together every night before bedtime." "We can let our child fall asleep in our room, and then move to her to herown bed." "We should change the bedtime to be an hour later." 119. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion a) 171 of 640 at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? Administer the TPN solution at the same rate using manual drip tubing. Offer the client oral fluids in place of the TPN solution. Infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr 120. A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? Fever unresponsive to antipyretics Pain in weight-bearing joints Decreased heart rate Peeling of the soles of the feet 121. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? Contractions will be felt primarily in the upper abdomen. The cervix transitions to an anterior position. Contraction intensity decreases with ambulation. The cervix progressively thickens. 122. 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? While performing a breast examination, the newly licensed nurse discusses techniques of breast self-examination with the client. a) 172 of 640 The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. The newly licensed nurse uses a penlight to assess for changes in thecontour of the body. The newly licensed nurse uses the dorsal surface of the hand to assessskin temperature. 123. 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. Depress the infant's tongue. Turn the infant's head to one side. Tap on the bridge of the infant's nose. 124. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering? Naloxone Flumazenil Acetylcystein eAtropine 125. 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? Check the client's temperature every 2 hr.Initiate fall precautions for the client. Monitor the client's urine for discoloration. Limit the client's fluid intake to 1 L per day. a) 173 of 640 126. A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care? Encourage the parents to bring toys from home. Use a visual analog scale to rate the toddler's pain. Inform the toddler about the procedure 1 week before hospitalization. Stress to the parents the need for maintaining the hospital's daily routine. 127. A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? Document the client's refusal of the medication. Administer the medication that the provider prescribed. Request consent from the client's family to administer the medication. Administer an oral dose of the medication. 128. A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? Muscle damage Partial-thickness skin loss Visible subcutaneous tissue Tendon exposure 129. A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? "Set your hot water heater temperature at or below 120 degrees Fahrenheit." "Cover your baby with a light blanket while sleeping." "Make sure the slats on the baby's crib are no more than 3 inches apart." a) 174 of 640 "Place your baby's car seat rear-facing until the age of 1 year old." 130. A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? Encourage the client's problem-solving abilities. Discuss the client's previous experience with loss. Promote the client's self-esteem. Establish the termination date of therapy. 131. A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? Popcorn Diced steamed carrots Whole celery sticks Marshmallows 132. 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. A nurse follows a client's advance directives and discontinues enteralfeedings. A nurse discards unused, expired bags of IV fluids. A client refuses an IV bolus of pain medication. 133. A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Obtain the client's blood pressure before the nurse administers medication. Initiate a referral with a dietitian for the client. Inform the client about the adverse effects of the medication. a) 175 of 640 Recommend a salt substitute to the client. 134. A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies." Which of the following actions should the nurse take? (Select all that apply.) Refer the client to a community-based social worker. Initiate a consult with a home health care provider. Provide the client with information about the American Red Cross.Postpone the discharge until someone can stay with the client. Give the client information about local support groups 135. A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? Document the actual time of medication administration. Notify the risk manager. Complete an incident report. Inform the nurse manager of the issue 136. A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend? Apply an over-the-counter cream if the wound becomes infected. Clean the wound twice a day with povidone-iodine. Apply heat to the wound for 10 min, four times per day. Double-bag soiled dressings in plastic bags for disposal. 137. A nurse is caring for a client who vomits on a reusable BP cu. Which of the following actions should the nurse take? a) 176 of 640 Place the BP cu in a labeled bag to send it for decontamination. Immediately rinse the BP cu in hot running water. Dispose of the contaminated BP cu in the bag lining the trash can. Clean the BP cu with a chlorine bleach solution. 138. A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information? Increase intake of fluids and fiber to prevent constipation. Complete a serum pregnancy test before taking the medication. This medication coats stomach ulcers so that they can heal. Take a magnesium-containing antacid along with this medication. 139. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? Slightly blue hands and feet Respiratory rate 40/min Axillary temperature 36.2° C (97.2° F)Apical pulse 136/min 140. A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? Remove the client's restraints while sleeping. Document the client's status every 60 min. Check for a new prescription every 6 hr. Provide a staff member to stay with the client continuously 141. A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? "If you suspect you are pregnant, stop taking this medication." a) 177 of 640 "You cannot become physically dependent on this medication." "Sedation is a common adverse effect of this medication." "If you forget a dose, you can double your next dose." 142. A nurse is preparing to perform an intermittent urinary catheterization for a client who has urinary retention. Which of the following images indicates the catheter the nurse should use? a) 178 of 640 143. A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? Allow the newborn to breastfeed temporarily. Relieve pressure by expressing milk daily. Place ice packs on the breasts for 15 min several times per day. Sleep with a loose-fitting bra to prevent nipple stimulation. 144. A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Instills 100 mL of air into the NG tube after checking for residual Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr Adds 20 mL of blue dye to each feeding to help detect aspiration Keeps the head of the bed elevated to 45° for 1 hr after feedings 145. A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect? Hypersensitivity to criticismFears of abandonment Grandiose delusions Reclusive behavior 146. A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? Offer a referral to the client for social services. Develop a safety plan with the client. a) 179 of 640 Encourage the client to reach out to family and friends. Provide the client with a list of support groups. 147. A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? Hypotension Headaches Bruising Oliguria 148. A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? "You don't need advance directives now because you are competent andcan make decisions for yourself." "You must wait for a period of 6 months after your diagnosis before initiating advance directives." "You will have to speak to an expert who works in the social service department." "You should complete advance directives in the event you cannot expressyour own wishes." 149. A community health nurse is assisting with the development of a disaster management plan. What nursing responsibility should be included in the disaster response stage? perform a rapid needs assessment 150. A nurse has 4 patients. What should the nurse delegate to the AP for meals? a) 180 of 640 alzheimers w/ aphasia VERSION 8 ATI RN COMPREHENSIVE EXIT EXAM diet for chronic renal failure low protein & potassium DM pt teaching change shoes, wash feet w/soap & water pulse pressure subtract systolic value from diastolic value lantus never mix, long lasting, no peak rhogam given @ 28 weeks & 72hours post delivery when mom is negative & baby positive indication of baby dehydration improving smooth fontanel pt w/orthostatic hypotension a) 181 of 640 put near nursing station cleaning a wound clean to dirty use bulb syringe peripheral arterial disease cramp in leg while walking intermittent claudication seizure precautions supine position 20 weeks gestation, having urinary frequencyu/a & c/s report to new nurse @ shift change pt @ xray s/s of hemolytic blood transfusion flank pain ER rape victim priorityacess anxiety nutrition carbs 45%, protein 10-15% latex allergy tape up cords first ingredient on a food label most content a) 182 of 640 thoracentesis, & painful w/breathing put pt on UNAFFECTED side for 1 hour or longer pt w/IV sedation check LOC if not responsive help older brother get used to baby get a gift for big brother early decelerations head compressions methergine contraindication HTN delegate to AP I & O HF monitoring weights location for peripheral line radial prioritizing care for multiple pt's low flank pain ativan for seizures med for diabetes insipidus desmopressin radiation tatoo a) 183 of 640 use mild soap & water uric acid stones eat low fat yogurt antigout med decreases uric acid level allopurinol non-pharm relation technique for pain managementin labor hypnosis psychotic disorder assessment finding flat affect newborn withdrawal from heroin (opioids) hypertonicity mitral valve location 5th intercostal amniocentesis go pee before procedure total gastrectomy lack b 12 takes 30-60 meal to eat a meal stoma color pink or red is normal MAOI's diet no pepperoni, no tyramine, COTTAGE CHEESE OKJgive iron w/? a) 184 of 640 OJ statins contraindication Grapefruit juice haldol lip smacking mag sulfate decreased urine output decreased respirations decreased pulmonary edema antidote for mag sulfate calcium gluconate clozaril interventions monitor WBC valproic acid liver function thyroid med effectiveness weight loss diuretics don't skip doses DIG adverse effects N/V & HA prednisone a) 185 of 640 take with milk hemo/peritoneal dialysis pt teaching medical asepsis cranial nerve 11 shoulder peripheral catheter insertion advance catheter when you see flash back of blood return dispose of insulin needles @ home in coffee container confirmation of ng placement x ray swallowing difficulty referralspeech therapy acrabose skip a meal, skip dose, give w/1st bite of food sprains & strains RICE pt DNR-CC & family asking questions related to. therapeutic communication: THERAPEUTIC RESPONSE What did the dr tell you? delegating to AP about skeletal traction: NEEDS MORE TEACHINGAP places weight on bed a) 186 of 640 daughter feeling guilty about admitting parent into long-term facility: THERAPEU TIC RESPONSE rephrase what daughter is feeling how good nurse plans her day rechecks her priorities half way through her shift good nurse sets these when she works GOALS pt gets bad dx, & asks you not to tell her spouse:YOUR RESPONSE you have a right to privacy delegate to AP CPR baby in contact precautions in a private room, what would you do to save hospital $? bring formula prn how does a nurse properly manage her time mid-shift?reevaluates goals which psych pt would you see first? hallucinations dementia pt @ ER, w/marks on coccyx & wrist, suspected abuse. what do you do? ask pt. INTERVIEW HIM psych pt yelling in front of group. very agitated, what do you do? isolate pt a) 187 of 640 charge nurse scheduling resolution between nurses nurse listens to both sides respite care gives family a break pt in seclusion documentation what happened prior to seclusion that caused forseclusion parkinson's : pt teaching nutrition- thicken liquids pt receiving radiation, what should you wear? lead apron pt suffering from hyperthermia seizure precautions pt refuses last minute for a procedure he already consented for okay to stop procedure s/s of smallpox rash on tongue xerostoma humidifier vagina procedure, cervical cancer place catheter Lyme disease report it a) 188 of 640 lice (pediculodis capitis) can survive on surfaces for up to 48 hours RSV keep stethescope in room (droplet) 16 weeks gestation can get AFP test done bacterial meningitis droplet precautions when can kid return to school for chicken pox when lesions are crusted over kicks a ball: developmental stage 24 months baby w/cleft lip untie arms & perform ROM wrong ostomy care changing everyday may lead to skin irritation after male circumcision apply petroleum jelly w/every diaper change breastfeeding w/hep c don't breast feed if you have cracked nipples contraindication w/oral contraceptives HTN a) 189 of 640 combination contraceptives contraindications pt w/migraines when percussing RUQ, what should we feel dullness dementia pt offer finger foods black males @ great risk forCVA med for alcohol withdrawal disulfiran (antabuse) better nutririon canola oil healthy eating 45 % carbs to prevent neuro tube defects folate prevnting delays of healing protein & o2 pt raped & @ ERassess anxiety pt reports abuse assess pt, check for injuries a) 190 of 640 anorexia 60% refeeding-pre-albumin of 10 telemetry is used for check for dysrythmia do not give mmr to child bearing pt b4 pregnancy test pt w/hx of blood transfusion diet for hf dry spices to flavor food TURP: closed intrermittment irrigation let it drain Cranial nerve XI (hot spot) shoulder Proper lifting technique (picture) bending at knees 24 month old walk up steps Food label greatest weight listed first IVtechnique advance catheter Refeeding syndrome a) 191 of 640 60% Low fat diet canola oil instead of vegetable oil Prior to amniocentesis empty bladder Radiation implant limit visitors to 30 minutes Levothyroxine take on empty stomach, in am; increases tsh Metformin contraindication kidney disease, severe infection, shock, hypoxic conditions Mastectomy lay of affected side to promote drainage, support arm on pillow, HOB 30 Circumcision use petroleum jelly with every diaper change Check for NG tube placement in the jejunum X-ray Colostomy care cut the bag Seizure precautions saline lock IV Ethical medical error veracity a) 192 of 640 Early decelerations head compressions Magnesium sulfate interventions (select all) calcium gluconate, stop infusion, UO less than 30, RR less than 12, decreased reflexes Thoracentesis causes pneumothorax expected finding not friction rub; tracheal deviation AP's talking in cafeteria tell them to stop talking Safety for parkinson's clear area Warfarin vitamin k for toxicity; INR 2-3; PT 11-12.5 Contraindication of MMRblood transfusion Diabetic foot care (select all) change shoes frequently, wash feet with soap and water Sprains avoid warm compress Expected finding of smallpox rash in mouth 16 weeks pregnant alpha protein a) 193 of 640 Psych med lip smacking Where to start IV first (picture) hand PRBC need further teachingstart IV on other arm Delegate to AP CPR compressions Delegate to LPNsterile dressing Postural drainage give albuterol, trendelenberg; 1 hour before meals or 2 hours after Dumping syndrome high protein and fat; avoid milk, sweets, and sugar; small, frequent meals DASH diet increase fruit, vegetables, and low fat dairy; k, mg, ca Baby with reflux small, frequent meals, thicken formula with rice cereal, HOB 30 Cleft palate repair periodic restraints Nephrotic syndrome vitamin K a) 194 of 640 Pernicious anemia schilling's test Peritoneal dialysis report cloudy; monitor glucose; warm solution before Gastric surgery eat 3 meals Gastrectomy small, frequent meals; vitamin B12, D, iron, and folate Statin grapefruit Preventing uric acid stones yogurt RSV have own stethoscope in room Change of shift report orthostatic hypotension by nurses station Confused patient raise 1 side rail Hypoglycemia cool and clammy skin Hyperglycemi athirst Glycosylated blood test a) 195 of 640 HbA1C Priority for patient in seclusion document Buddhist patient vegetarian Positive TB hard raised bump Heart murmur sound blowing or swishing Dehydration oliguria NST PAD pain/cramping when walking, calf muscle atrophy, shiny cool extremities; elevate legs Cast with white extremity compartment syndrome Alcohol withdrawal expected finding n&v, tachycardia, diaphoresis, tremors, seizures Varicella scabs okay Hyperthermia not blanket or ice a) 196 of 640 Purpose of ice decrease inflammation Sexual assault assess anxiety THA avoid flexion greater than 90 Beta blocker teaching don't stop abruptly; avoid in asthma; take with food Combination contraceptives increase BP Myelosuppressio n flu shot Glucocorticoid increase dose in DM; take with meals; avoid NSAIDs; Addison's crisis if stopped abruptly Extreme focus mild anxiety Good diet 30% carbs Family concern what has the doctor told you Adolescent 1300 mg of calciumLyme a) 197 of 640 disease a) 198 of 640 report to health department Organize workload goals for the day Intervene pacing around wife Renal failure decrease protein, K, Na, increase carbs, strict I&O Preeclampsia proteinuria Urine frequency in pregnancy urine sensitivity test Lice can live for 48 hours on surfaces Chest tube complications bubbling in water seal Elderly abuse ask privately Informed consent signed willingly Sibling bonding offer gift each time sibling gets one TURP complication a) 199 of 640 hematuria African american over Caucasian heart disease Sickle cell priorityhydration Sickle cell complicationSOB Respite care give caretaker break Acarbuse take with first bite of each meal Hallucination I understand you are scared Fire extinguisher PASS Advanced directive don't need a lawyer Breastfeeding and hepatitis c as long as you don't have cracked nipples ICP keep HOBmidline Long term use of proton pump a) 200 of 640 inhibitors osteoporosis Diabetes insipidus polyuria Difficulty voidingwarm water ACE inhibitors cough What do you hear when you palpate abdomen resonance Negotiation strategy understand both sides Dying patient wants to be alone depression or dysfunctional Wife progressing quicklycan you tell me more Pregnant non-pharmacological pain management aromatherapy, breathing techniques, imagery, music, use of focal points, subdued lighting Hypnosis purpose alter perception of pain Complication of conscious sedation with RR 6 stop infusion or give something a) 201 of 640 Major depression, OCDgive fluoxetine What causes constipation iron Patient can't sleep don't drink caffeine before bed Collecting urine culture on baby straight cath Electrolytes Na - 136-145 K - 3.5-5 Ca - 9-10.5 Mg - 1.3-2.1 P - 3-4.5 Cl - 98-106 Hypervolemia bounding, JVD, edema, confusion, increase everything Anorexia prealbumin 10 Dehydration improving baby flat fontanelle Unsaturated fat coconut oil Priority abdominal pain and went away a) 202 of 640 Opioid agonist naloxone (Narcan) COPD increase calories and protein Needle disposal at home coffee container on top shelf Give RhoGAM in second pregnancyprotect future pregnancy Swallow problem refer to speech therapist Nutrition for heart failure Decrease Na, increase fluids, increase fiber; increase K with diuretic Adverse affects of dogoxin Bleeding gums, bloody urine and stools, arrhythmias, petichiae NG nutrition Increase K Methotrexate adverse affect High blood pressure I.M. site for children VASTUS LATERALIS or antelolateral thigh is the site for IM injections in children < 2 yrs. of age Peak Levels show the highest concentration a) 203 of 640 Time for drawing Peak levels: Oral Intake 1 to 2 hour after administration Time for drawing Peak levels: I.M.1 hour after administration Time for drawing Peak levels: I.V.30 minutes after administration Trough Levels show the lowest concentration or residual level, usually obtained within 15 minutes before next dose. Do not administer until confirmed. Can meds be administered through blood tubing? NO. Never administer meds through tubing being used for blood administration How long should fluids be infused? Fluids should be infused within 24 hours, discard unused potion, to prevent infection Complications associated with IV infusion infiltration, extravasation, phlebitis, thrombophlebitis, hematoma, venous spasm Preventing Infiltration use smallest catheter for prescribed therapy, stabilize port-access, assessblood return Treatment of Infiltration stop, remove, cold compress, elevate extremity, insert new cath in opposite extremity Preventing Extravasation know vesicant potential before giving medication a) 204 of 640 Treatment of Extravasation stop, discontinue, aspirate med if possible, cold compress, document Preventing Phlebitis & Thrombophlebitis rotate sites every 72 to 96 hrs, secure catheter, aseptic technique forPICC lines, limit activity with extremity Treatment of Phlebitis & Thrombophlebitis stop, remove, heat compress, insert new cath in opposite extremity Preventing Hematoma avoid veins not easily seen or palpated, obtain hemostasis after insertion Treatment of Hematoma remove, apply pressure, monitor for signs of phlebitis and treat Preventing Venous Spasm allow time for vein diameter to return after tourniquet removed, infusefluids at room temp Treatment of Venous Spasm temporarily slow infusion rate, warm compress TPN hypertonic solution, contains dextrose, proteins, electrolytes, minerals, trace elements, and insulin prescribed, administered via central venous device like PICC line, subclavian, or internal jugular vein Care for TPN verify with another nurse, use infusion pump, monitor daily weights, I & O, fluid balance, serum glucose q4 to 6 hrs, infection, change dressing q48 to 72 hrs, change tubing and fluid q24 hours, if TPN is unavailable, administer dextrose 10% in water to prevent hypoglycemia Complications of central venous catheters a) 205 of 640 pneumothorax during insertion, air embolism, lumen occlusion, bloodstream infection Pneumothorax during insertion use ultrasound to locate veins, avoid subclavian insertion when possible, treat with O2, assist with chest tube insertion Air Embolism have client lie flat when changing administration set or needleless connectors, ask client to perform Valsava maneuver, treat by placing client in left lateral trendelenberg, and O2 Lumen Occlusion flush promptly with NS between, before, and after each med, treat with10 cc syringe with pulsing motion Bloodstream Infection maintain sterile technique, treat by changing entire infusion system,notify MD, obtain cultures, and administer antibiotics Antidote for Acetaminophen Acetylcysteine, Mucomyst Antidote for Benzodiazepine Flumazenil, romazicon Antidote for Curare edrophonium, tensilon Antidote for Cyanide Poisoning methylene blue Antidote for Digitalis digoxin immune FAB, Digibind a) 206 of 640 Antidote for ethylene poisioning fomepizole, antizol Antidote for Heparin and enoxaparin or Lovenox Protamine Sulfate Antidote for Iron Deferoxamine, desferal Antidote for Magnesium Sulfate calcium gluconate 10%, kalcinate Antidote for Narcotics naloxone, narcan Antidote for Warfarin phytonadione, vitamin K aminophylline 10 to 20 mcg/ml carbamazepin e 5 to 12 mcg/ml digoxin 0.8 to 2.0 mcg/ml gentamicin 0.5 to 0.8 mcg/ml lidocaine 1.5 to 5.0 mcg/ml a) 207 of 640 lithium 0.4 to 1.4 mcg/ml magnesium sulfate 4 to 8 mcg/ml phenobarbital 10 to 30 mcg/ml phenytoin 10 to 20 mcg/ml quinidine 2 to 5 mcg/ml salicylate 100 to 250 mcg/ml theophylline 10 to 20 mcg/ml tobramycin 5 to 10 mcg/ml acetaminophen toxicity > 250 aminophylline toxicity > 20 a) 208 of 640 amitriptyline toxicity > 500 digoxin toxicity > 2.4 gentamicin toxicity > 12 lidocaine toxicity > 5 lithium toxicity > 2.0 magnesium sulfate toxicty > 9 methotrexate toxicity > 10 over 24 hours phenobarbital toxicity > 40 phenytoin toxicity > 30 quinidine toxicity > 10 salicylate toxicity > 300 a) 209 of 640 theophylline toxicity > 20 tobramycin toxicity > 12 PRIL ace inhibitors, captopril, enalapril VIR antivirals, acyclovir, valacylovir AZOLE anti fungals, fluconazole, variconazole STATIN antilipidemics, atorvastatin, simvastatin SARTAN angiotensin 2 receptor blockers, ARBS, valsartan, losartan OLOL beta blockers, metoprolol, nadolol DIPINE calcium channel blockers, amlodipine, nifedipine AFIL erectile dysfunction meds, sidenafil, tadalafil DINE histamine 2 receptor blockers, ranitidine, famotidine PRAZOLE a) 210 of 640 proton pump inhibitors, pantoprazole CAINE anesthetics PAM, LAM benzodiazepine ASONE, SOLONE corticosteroid CILLIN penecillin IDE oral hypoglycemi c ASE thromolytic AZINE anti emetic PHYLLINE bronchodilator ARIN anticoagulant TIDINE anti ulcer ZINE anti histamine a) 211 of 640 CYCLINE antibiotic MYCIN aminoglycoside FLOXACIN antibiotic TYLINE tryciclic antidepressant PRAM, INESSRI anti hypertensives assess weight, VS, hydration, ortho BP, renal function, coagulation, educate to take same time each day, avoid hot tubs and saunas, do not discontinue abruptly ACE inhibitors (angiotensin converting enzyme) block the conversion of angiotensin 1 to angiotensin 2 Angiotensin 2 Receptor Blockers selectively block the binding of angiotensin 2 to angiotensin 1 receptors found in tissues ACE Inhibitors captopril or capoten, enalapril or vasotec, enalaripat or vasotec IV,fosinopril or monopril, lisinopril or prinivil ARBs losartan or cozaar, valsartan or diovan, irbesartan or avapro a) 212 of 640 ACE inhibitors and ARBs for HTN, heart failure, MI, and diabetic nephropathy, monitor potassium,use with caution if diuretic therapy is in use ACE inhibitors and ARBs side effects persistent non productive cough with ACE inhibitors, angio edema, hypotension, contra for 2nd and 3rd trimester in pregnancy ACE inhibitors and ARBs nursing interventions captopril should be taken 1 hr before meals, monitor BP, monitor for angio edema and promptly administer epinephrine 0.5 ml of 1:1000 solution sub q Calcium Channel Blockers slows movement of calcium into smooth muscle cells, resulting in arterial dilation and decreased BP, examples are nifedipine/adalat/procardia, verapamil/calan, dilitiazem/cardizem, amlodipine/norvasc Calcium Channel Blockers Use for angina, HTN, veripamil and diltiazem may be used for A Fib, A flutter,or SVT Calcium Channel Blockers Precautions use cautiously in clients taking digoxin and beta blockers, contra for client who have heart failure, heart block, or bradycardia, avoid grapefruit juice (toxic) Calcium Channel Blockers side effects constipation, reflex tachycardia, peripheral edema, toxicity Calcium Channel Blockers nursing interventions do not crush or chew sustained release tablets, administer IV injection over 2 to 3 mins, slowly taper dose if discontinuing, monitor HR and BP a) 213 of 640 Alpha Adrenergic Blockers (symphatholytics) selectively inhibit alpha, adrenergic receptors, resulting in peripheralarterial and venous dilation that lowers BP, esamples are Alpha Adrenergic Blockers (symphatholytics) Use for primary HTN, cardura may be used intreatment of BPH Alpha Adrenergic Blockers (symphatholytics) Precautions increased risk of hypotension and syncope if given with other anti hypertensives, beta blockers, or diuretics, NSAIDs may decrease effect of prazosin Alpha Adrenergic Blockers (symphatholytics) side effects dizziness, fainting Alpha Adrenergic Blockers (symphatholytics) nursing interventions monitor HR and BP, take meds at bed time to minimize effects of hypotension, advise to notify prescriber immediately about adverse reactions, consult prescriber before taking any OTC meds. Lorazepam antidote flumazenil Fluid overload dyspnea s/s, back up of fluid in pulm system Rheumatoid arthritis pain freq rest during the day case mgr arranges for transportation to health care appts w/mental health Total hip install raised toilet seat at home a) 214 of 640 verapamil and grapefruit causes hypotension, g. increases blood levels of v. by inhibiting metabolism vaso occlusive crisis in sickle cell start ivfluids 1st to promote hydration and circulation Do not increase this if pt has COPD exaserbation O2 hemianopsia hemi=half, an=without, opsia=seeing *use scanning tequnique when ambulating narrow QRS complex, irregular 170 bpm,no p waves a fib N/V will cause what lab value to elevate? urine specific gravity-dehydration enoxaparin aka lovenox blowing bubbles to make the "hurt go away" is an example of what?nonpharm visualization for pain mgmt w/kids hypoglycemia irritability hyperglycemia polyuria a) 215 of 640 One or more surgical drains after? masectomy, exercise after 24 hrs TB meds or longer 6 mo If client is disorientated and combative during the night, what should Rn do? move client closer to Rn station Wash clients hand with soap/water prior to? CBG Changing this is final step in trachcare trach ties Diazepam (benzo) should be given for? status epileptcus HA is adverse effect of? fluoxetine, hypotension too Use ventrogluteal site with these patients for IM obese Clonidine side affectdry mouth Clozapine sideaffect wt gain Unstable vs are immediate threat to life? t/f true! TPN pt's need this monitored frequently blood glucose, 24 hr TPN at first then 8-12 hrs per day once stable a) 216 of 640 ECT can cause short term memory loss Nurse should use with transfusion 0.9% sodium chloride to prevent clotting, **not D5W Expected finding in cardiac tamponade pulsus paradoxus-drop in bp during inspiration Nonmaleficence duty to do no harm autonomy informed consent pattern paced breathing during this phase oflabor transition position client who is at risk for pressure ulcer at this level 30 degree lateral position in bed Pt with femur fracture highest prioroty upper chest petechiae-risk for fat embolism syndrome Tremors can indicate hyperthyroidism Cloudiness with blurred visioncataracts this med will help reduce icp mannitol-osmotic a) 217 of 640 lung expansion with age decreased precautions with hsv contact Occupational therapy for difficulty performing personal hygeine Have pt lie on this side during gastric levage for NG tube left-prevents aspiration Celiac diet gluten free-chicken and wild rice to decrese icp put in quiet env quick notes during h-t assessment Diaphram should be removed how long after intercourse? 6 hrs or more intervention to prevent heat loss with infant pad scale with paper Pt admitted with dka, first priority? vs If INR is 1.8 and ptt is 98hold heparin infusion 6-8 wet diapers a day indicates? a) 218 of 640 effective breastfeeding Brat diets are contraindicated with diarrhea Ask this if pt refuses to ambulate after surgery pain Review chest x-ray report prior to initiating infusion in picc LPN can insertNG pt with this needs private room with negativeair pressure pulm tb if pt is unconsious and needs er help proceed without consent opioid side effect u. retention Use 1:100 chlorine solution to clean kitchen surfaces with this illness hep A make referral for social services for pt with this terminal illness serum magnesium of 2.5 initiate continuous cardiac monitoring Cold therapy for these patients Rheumatoid arthritis to relieve inflammed joints a) 219 of 640 fluoxetine SSRI antidepressant-watch for tremors since this can cause serotonin syndrome w/in 2-72 stage II pressure ulcer partial thickness skin loss stage III pressure ulcer visible sq tissue stage IV muscle damage, tendon exposure Cyclophosphamide treats cancer, drink 1-1.5x h2o to prevent hemmoragic cystitis and prevent dehydration Valporic acid treats seizures-can cause hepatic toxicity digoxin toxicity signnausea estradiol (estrace) side effect HA Report findings for pt post ruptured appendix 48 hr ago rigid, board like abdomen absent bowel sounds elevated temp elevated wbc (could be indication of peritonitis) Chlorpromazine a) 220 of 640 antipsychotic to decrease hallucinations Theophylline toxicity bronchodilator-can cause anorexia Check this pulse with an infant during cpr brachial Client is in active labor and receiving oxytocin. FHR shows variability w/accelerations. What is correct response? Document and continue to monitor. This is a reassuring pattern indicating intact fetal CNS and healthy placental/fetal exchange of oxygen. Indication of oxygen toxicity Bradypnea-hypoxic drive is removed Advance Directives 2 components of an advance directive are the living will, and a durable power of attorney. Legal documents that allow people to choose what kind of medical care they wish to have if they cannot make those decisions themselves. Nsg responsibilities are-providing info regaurding advance dir,documenting status of advance dir, ensuring they are current, and reflect pt. status. Recognizing they take prioritiy for the pt. Ensuring that all healthcare team members are aware. living will legal document that expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. Ex. cpr, mechanical ventilation, and feeding by artificial means. durable power of attorney enables patient (called the "principal" in thepower of attorney document) to appoint an "agent," such as a trusted relative or friend, to handle healthcare decisions on behalf of patient. a) 221 of 640 advocacy supporting pts. by ensuring that they are properly informed, that their rights are respected, and that they are receiving the proper level of care.Nurses must act as advocates even when they disagree with pts. wishes. Nurses are the pts. voice when healthcare system is not acting in pt. bestinterest. Assigning the process of transferring authority, accountability, responsibility of pt,care to another health care member. delegating The process of transferring authority and responsibility to another team member to complete a task while retaining accountability. supervising Process of directing monitoring and evaluating performance of tasks by another member of the health care team. case management a methodology for moving a patient through the healthcare system while streamlining costs and maintaining quality, Explore resources available to assist with the pt. in achieving or maintaining independence. airway 1st Identify airway concern( obstruction,stridor) Establish a patent airway recognize that 3-5 mins without o2 is irreversible brain damage 2ndary to cerebral anoxia. Breathing 2nd Access effectiveness of pt. breathing(apnea,depressed, respiratory rate, Intervene as appropriate(reposition, administer narcan). circulation 3rd a) 222 of 640 Identify circulation concern (hypotension ,dysrhythmia, inadequate cardiac output, compartment syndrome) identify ways to minimize orreverse circulatory alteration). disability 4th Access for current evolving disability (neurological deficits stroke evolution) Implement actions to slow down disability. Pt. Rights Nurses role Be informed about all aspects of care and take an active role in decision making process. Accept refuse or request a modification to a plan of care. Receive care that is delivered by a competent individual. Prioritize systemic before local. (life before limb) prioritize interventions for a pt. in shock over interventions for a pt. witha localized limb injury. Prioritize acute before chronic Care of pts. with new injuries/illness( confusion, chest pain) over acute exacerbation of a previous illness, over the care over a pt. with a long-term chronic illness. prioritize actual problems before future potential problems. prioritize administration of medication to a pt. experiencing acute pain over a pt. ambulating and at risk for thrombophlebitis. Hypoglycemia risk factors for Newborns, Blood glucose <40 in term newborn, <25 in preterm newborn POST TERM, IUGR, ASPHYXIA, COLD STRESS, Maternal diabetes, Gestational hypertension, Tocolytic therapy, Prematurity, LGA, SGA, Perinatal hypoxia, Infection, Hypothermia Prioritizing care in clients with hyperthyroidism Alternate periods of activity with rest a) 223 of 640 provide calm environment access mental status increased calories and protein monitor intake and output, wt pt. eye protection for pt. with exophthalmos reporta degree of 1 or more to MD prepare for thyroidectomy if meds become unresponsive. Pt. education r/t hyperthyroidism medications, methimazole (tapazole)and (PTU) propylthiouracil. These inhibit the production of thyroid hormone. report fever, sore throat, or bruising to md report any jaundice or dark urine follow md instructions about daily intake of iodine. dysphagia Latex allergies must use latex free equipment, gloves and supplies. Risk Factors of Diabetes being African American, Hispanic, or Asian obesity and fat distribution, inactivity, family history, race, age, pre-diabetes, Overweight, family hx,ethnicity, HTN, gestational diabetes, age, viruses, lifestyle, disease of pancreas. Dilantin (phenytoin) Anticonvulsant Seizures, therapeutic levels are determined by blood test. Meds should be taken at the same everyday. Some antieplitic cause overgrowth of the gums, routine oral hygiene. NO ORAL CONTRACEPTIVES OR COUMADIN. a) 224 of 640 Seclusion/ restraints *In emergency situation where there is immediate danger to the pt. or others, the nurse may place the pt. in restraints, nurse must maintain prescription as soon as possible usually within 1 hour. Nsg*assess skin integrity, offer food and fluid, provide hygiene and elimination, vss, rom q2hr. quick release knots to bed frame. Postpartum hemorrhage/ postpartum disorders appropriate assessment. Assess fundus for height firmness and position. If boggy massage fundus to increase muscle contraction. Assess lochia for color, quantity, and clots. Assess for signs of bleeding from lacerations, episiotomy site, or hematomas. Assess for bladder distention, may need to insert urinary catheter toassess kidney function. Pitocin, methergine, IV fluids. X1 (spinal accessory) Cranial nerve 11 Motor turning the head, shrugging shoulders. Head and neck. cultural/spiritual nursing care, use of a interpreter Facility approved interpreter, don't designate the family, or a non designated employee. Inform the interpreter the type of questions that will be answered. Allow time for family and interpreter to be introduced. Direct the questions toward family/pt. not interpreter. Following the interview ask the interpreter if they have any thoughtsabout pt. verbal or non verbal. Dietary guidelines for celiac disease children-s/s diarrhea, steatorrhea, anemia abdominal distention, impaired growth, lack of appetite and fatigue. Adults- diarrhea, abdominal pain, bloating, anemia, steatorrhea,and osteomalacia. Dietary* Foods that are gluten free-milk, cheese, rice, corn, eggs, potatoes, fruit, veg, fresh poultry, meats, fish, dried beans. * Gravy mixessauces,cold cuts, and soups, have gluten. a) 225 of 640 Parkinson client safety Encourage exercise (yoga), assistive devices, rom, teach pt. to stop when walking to slow down and reduce speed. pace activities by providing rest periods. assist with adls. Nephrotic Syndrome dietary modifications D/T protein loss, you will need adequate amount of protein and low sodium. Protein-0.7 to 1.0g/kg/day. Soy based proteins, Low sodium 1000-2000g per day. Carbohydrates, trans fat and cholesterol is limited, and total fat should be less than 30% per day, provide multi vitamin supplements. prevention of uric acid stones Increase fluid consumption 1500-3000 ml at least preferably h20, at nightbecause that's when urine is most concentrated. Foods high in oxlate such as spinach,rhubarb, beets, nuts, chocolate, tea, wheat bran, and strawberries., Avoid mega doses of vitamin c, and limit foods high in purine lean meats, organ meats, whole grains and legumes. Pt. teaching about self blood glucose monitoring Check the accuracy of the strips with the solution use the correct code number in the meter to match strip. store strips in closed container adequate amount of blood proper hand hygiene fresh lancets avoid sharing keep record ofblood sugars the calories and exercise taken in. food and otherevents may alter blood glucose metabolism such as activity or illness. Pt. care following a mastectomy Assessment findings for increased intracranial pressure. a) 226 of 640 Severe HA,deteriorating loc, restlessness, irritiability, dilated pinpoint pupils, asymmetric pupils, slow to react or non reactive, alteration with breathing patterns, cheyne stokes respirations, hyperventilation, apnea, deteriation in motor function, abnormal posturing, decerebrate, decorticate, or flaccidity, cushing reflex, htn, widening pulse pressure, and bradycardia, csf leakage, halo sign, seizures,. Deep Vein thrombosis Interventions Encourage pt. to rest Facilitate bed rest and elevation of extremity donot massage extremity thigh high compression stockings monitor APTT,and platelet count. Delegation the 5 rights right task right circumstance right person right communication right evaluation/supervison providing cost effective care using all levels of personnel to fullest when making assignments. providing necessary equipment and charging thept. Returning uncontaminated or unused equipment to appropriate dept. forcredit. Using equipment properly to prevent wastage providing training to staff unfamiliar with equipment, Returning equipment to proper dept. as soon as its no longer needed.Heart failure nutrition recommendations a) 227 of 640 Reduce sodium intake to 2000 mg/day or less monitor fluid intake restrict to 1.5 liters fluid a day. Psychotic disorders assessment findings Hallucinations, deluisons, alterations in speech, bizarre behavior arepositive signs of schizophrenia. Negative signs-affect or flat facial expression, alogia-poverty of thought of speech, Anergia-lack of energy, anhedonia- lack of pleasure or joy, avolition-lack of motivation in activities and hygiene 00 Adolescent nutritional needs 2000 cal for female and 4000 cal for male. They need a adequate diet in folate, vit a&e, iron, zinc, mag, cal and fiber. Newborn withdrawl from opioids medications opiate withdrawl, can last 2 to 3 weeks rapid mood changes, hypersensitivity to noise and external stimuli, dehydration, and poor weight gain. Alcohol withdrawl nabdominal cramping, vomiting, tremors, restlessness, inability to sleep, increased heart rate, hallucinations, illusions, anxiety, increased blood pressure, respiratory rate, temp, and tonic clonic seizures. May occur 2-3 days after cessation of alcohol, and may last for 2-3 days, *THIS IS A MEDICAL EMERGENCY. severe disorientation, severe htn, psychotic symptoms, cardiac dysthymias, delirium. Meds- valium, Ativan,carbamazepine (tegretrol) seizures, clonidine (catapres) Librium (chlordiazepoxide) Contraindications to oral contraceptives Hx of blood clots, stroke, cardiac problems, breast or estrogen related cancers, pregnancy or smoking if over 35, are advised not to take oral contraceptives. a) 228 of 640 Oral contraceptives decreases its effectiveness when taking meds that effect liver enzymes, such as ATB's, and anticonvulsants. Antibiotics affecting bacterial cell wallPenicillin, cillians. amoxicillin etc. Magnesium signs of toxicity Access to medical records Clients have a right to read their on records. Nurses may not photocopy any part of mar. Communication should only take place in a private setting. Shred any printed written pt. info after pt. care or use. Discharge teaching regarding circumsion A tub bath should not be given unti healed Notify md of redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying, will heal completely in 2 weeks.Give Tylenol for first 24 to 48 hours. Assess for bleeding every 15 min for the first hour, then every hour for at least 12 hour, then the 1st voiding. Stroke priority assess findings Expressive and receptive aphasia, agnosia, (unable to recognize objects), alexia (difficulty to reading), a graphic (writing difficulty), hemiplegia,(paralysis), or hemiparesis (weakness), slow behavior, depression, anger, visual changes(hemianopsia). Findings of recent cocaine use Rush of euphoria, pleasure, increased energy. Stimulant withdrawl (cocaine) a) 229 of 640 Occurs within1 hour to several days, depression,fatigue,craving,excess sleeping, insomnia, dramatic unpleasant dreams, psychomotor retardation, possible suicide ideation. Withdrawl stimulant (tobacco) Abstinence irritability craving nervousness restlessness anxiety insomniaincreased appetite difficulty concentrating anger depressed mood, COPD managing nutritionHigh calorie foods for energy Encourage rest periods. Drink plenty of fluids to liquidfy mucous, and promote hydration. IV Therapy documenting complications. Require notification of MD, and documentation, all IV infusions should be restarted with new tubing and catheters. Inflitration Infiltration- pallor and local swelling at site, slowed rate of infusion, treatment-stop and remove catheter, elevate extremity, encourage active ROM, apply warm or cold compress. Restart proximal to site or another extremity. Phlebitis Edema, throbbing, or burning at site. Increased skin temp, erythema redline up the arm, with a palpable band at the vein, slowed rate infusion. Treatment- discontinue IV and remove catheter, elevate extremity, warm compresses 3x daily, restart proximal to site, culture the site and catheterif drainage is present. Use surgical aseptic technique. Rotate sites q 72 hours. Ecchymosis Don't apply alcohol apply pressure after IV catheter removal. Use warm compress and elevate after bleeding has subsided. Prevention- minimize a) 230 of 640 tourniquet time, remove tourniquet before starting IV infusion, maintain pressure after removal of catheter. Fluid overload Distended neck veins, increased BP, tachycardia, sob, crackles in lungs, edema. Treatment- stop infusion, raise hob, assess vs & O2 saturation, adjust the rate as prescribed, and administer diuretics as prescribed. Prevention- monitor I&O. Respiration assessing them Observing the rate, depth and rhythm of chest wall movements. Post arthroplasty Use elevated seat, or raised toilet seat. Use straight chairs with arms Use abduction pillow, or pillow if prescribed, b/w the pt. legs while in bed, and with turning, if restless or in a altered mental state. Externally rotate pt. toes. Do not do, cross legs, avoid low chairs, avoid flex ion of hips at 90 degrees,do not internally rotate the toes. Preventing foot drop Cane Keep cane on stronger side of body Support body weight on both legs, move cane forward 6-10 inches, thenmove weaker leg forward, next advance the stronger leg past the cane. Crutch walking Do not alter after crutches after fitting Support body weight at the hand grips, with elbows flexed at 30 degrees, position the crutches on the unaffected side when sitting or rising from a chair. a) 231 of 640 Insertion of a urinary catheter Usually 8-10 French for kids, 12-14 for women, and 16-18 for men. Use silicon or Teflon if pt. has latex allergies. Explain procedure, a closed intermittent irrigation. if pt. reports fullness in bladder area, check for kinks in tubing or sediment, may need irrigated, make sure bag is below bladder. Ototoxic medications Multiple antibiotics, gentamicin, amikacin, metronidazole(flagyl), lasix,NSAIDs, chemotherapeutic agents. Nursing care of a pt. who is pregnant and has gonorrhea Urethral discharge, yellowish green vaginal discharge, reddened vulva and vaginal walls. Ceftriaxone (rocephin) and azithromycin (Zithromax) pro for gonorrhea, take entire prescription, repeat culture, and educateon safe sex practices. Esophageal prescription for a pt. with esophageal varices No selective beta blockers, propranolol (inderal), are prescribed to decrease heart rate, and reduce hepatic pressure. Vasoconstrictors IV terlipressin and somatostatin increase portal inflow. And vasopressin (desmopressin) and ortreotide ( sandostatin) are avoided d/t multiple adverse reactions. Interventions for prolapse cord Call for assistance ASAP, notify MD, use a sterile gloved hand, insert 2 fingers in vagina, and apply finger pressure on on either side of the cord, to fetal presenting part to elevate it off cord, reposition knee chest position, or trendelenburg, or side lying with a rolled towel under the pt. right or left hip, to relieve pressure on cord. Apply a warm saline soaked sterile towel to cord to prevent from drying. Provide cont electronic monitoring of FHR for variable decels. O2 at 8-10 liters, IV access, preparefor c-section, educate and inform pt. on interventions. Interventions for dementia a) 232 of 640 Provide clocks and memory aids, photographs, memorabilia, seasonal decorations, familiar objects, orient if necessary. Daily routine, allow for safe pacing and wandering. Assign room closets to nurses station, well lit environment. Restraints as a last resort, COver or remove mirrors to reduce anxiety and frustration. Encourage pt. to talk about good times, break instructions and activities into short timeframes. Dumping syndrome S/S Fullness, faintness, diaphoresis, tachycardia, palpitations, hypotension, nausea, abdominal distinction, cramping, diarrhea, weakness, and syncope. Psychotic disorders long term adverse reactions New onset of diabetes, or loss of glucose control in pets. With diabetes, weight gain, increased cholesterol with HTN, orthostatic hypotension, anticholinergic effects such as urinary hesitancy or retention, and dry mouth. agitation, dizziness, sedation, and sleep disruption, mild eps such as tremor. Seizure precautions Suction equipment at bedside, Valium or Ativan. Treating xerostomia following radiation Avoid spicy, salty, acidic foods, hot foods may not be tolerated. Gently wash over irradiated skin with mild soap and water, pat dry. Dips of h20, and candies to prevent dry mouth. Post procedure following a throcentesis Apply dressing and assess for bleeding, or drainage, monitor vs, and resp hourly. Auscultation lungs for reduced breath sounds, encourage deep breathing to assist with lung expansion. CHESTXRAY post procedure. Interventions for icp Hob 30 degrees, avoid extreme flexion, midline neutral position, keep body aligned. Decrease stimuli. a) 233 of 640 Do not delegate What you can EAT E-evaluate A-assess T-teach Addison's & Cushings Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? EleVate Veins, DAngle Arteries APGAR Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Airborne precautions MTV or My chicken hez tb measles, chickenpox (varicella) Herpeszoster/shingles TB Airborne precautions protective equip private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB Droplet precautions spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precaution a) 234 of 640 MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies,Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bagwithout touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves Skin infection VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impendingdoom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) a) 235 of 640 After lumbar puncture and oil based myelogram pt is flat SUPINE (preventheadache and leaking of CSF) Pt with heat stroke flat with legs elevated during Continuous Bladder Irrigation (CBI) catheter is taped to the thigh. leg must bekept straight. After Myringotomy position on the side of AFFECTED ear, allows drainage. After Cateract surgery pt sleep on UNAFFECTED side with a night shield for 1-4 weeks after Thyroidectomy low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida Prone so that sac does not rupture Buck's Traction (skin) elevate foot of bed for counter traction After total hip replacement don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed cord Knee to chest or Trendelenburg oxygen 8 to 10 L a) 236 of 640 Cleft Lip position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHOand fiber diet. small, frequent meals. AKA (above knee amputation) elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina area of detachment should be in the dependent position administration of enema pt should be left side lying (Sim's) with knee flexed. After supratentorial surgery (incision behind hairline on forhead) elevate HOB 30-40 degrees After infratentorial surgery (incision at the nape of neck) position pt flat and lateral on either side. During internal radiation on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! a) 237 of 640 Shock bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) turn pt from side to side BEFORE checking for kinks in tubing Lumbar Puncture After the procedure, the pt should be supine for 4-12 hours as prescribed. Myesthenia Gravis worsens with exercise and improves with rest Myesthenia Gravis a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) must have lab results for prothrombin time Myxedema/ hypothyroidism slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism accelerated physicaland mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm increased temp, pulse and HTN a) 238 of 640 Post-Thyroidectomy semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia increased temp, rapid/weak pulse, increase respiration, hypotension,anxiety. Urine specific gravity >1.030 Hypervolemia bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's Diabetes insipidus (decreased ADH) excessive urine output and thirst, dehydration, weakness, administerPitressin SIADH (increased ADH) change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics hypokalemia muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes a) 239 of 640 Hyponatremia nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypernatremia increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypocalcemia CATS Convulsions, Arrythmias, Tetany, spasms and stridor Hypercalcemia muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! Hypo Mg Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) Hyper Mg depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY Addison's Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Cushings Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addesonian crisis N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma a) 240 of 640 hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) Tetrology of Fallot DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Autonomic Dysreflexia (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) FHR patterns for OBThink VEAL CHOP! V-variable decels; C- cord compression causedE-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill what to check with pregnancy Never check the monitor or machine as a first action. Always assess thepatient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart sounds Posterior --heard at sides Anterior---midline by unbilicus andside Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Ventilatory alarms HOLD High alarm--Obstruction due to secretions, kink, pt cough etc a) 241 of 640 Low alarm--Disconnection, leak, etc ICP and Shock ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp Cor pumonae Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) Heroin withdrawal neonate irritable, poor sucking brachial pulse pulse area on an infant lead poisoning test at 12 months of age Before starting IV antibioticsobtain cultures! pt with leukemia may have epistaxis due to low platelets when a pt comes in and is in active labor first action of nurse is to listen to fetal heart tones/rate for phobias use systematic desensitization NCLEX answer tips choose assessment first! (assess, collect, auscultate, monitor, palpate)only choose intervention in an emergency or stress situation. If the a) 242 of 640 answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. ARDS and DIC are always secondary to another disease or trauma In an emergency patients with a greater chance to live are treated first Cardinal sign of ARDShypoxemia Edema is located in the interstitial space, not the cardiovascular space (outside of thecirculatory system) the best indicator of dehydration? weight---and skin turgor heat/cold hot for chronic pain; cold for accute pain (sprain etc) When pt is in distress... medication administration is rarely a good choice pneumonia fever and chills are usually present. For the elderly confusion is often present. before IV antibiotics? check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. COPD and O2 a) 243 of 640 with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt'sstimulation to breathe. Prednisone toxicity Cushings (buffalo hump, moon face, high blood sugar, HTN) Neutropenic pts no fresh fruits or flowers Chest tubes are placed in the pleural space Preload/Afterload Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. CABG Great Saphenous vein in leg is taken and turned inside out (because ofvalves inside) . Used for bypass surgery of the heart. Unstable Angina not relieved by nitro PVC's can turn into V fib. 1 tsp 5 mL 1 oz 30 mL a) 244 of 640 1 cup 8 oz 1 quart 2 pints 1 pint 2 cups 1 g (gram) 1000 mg 1 kg 2.2 lbs I lb 16 oz centigrade to Fahrenheit conversion F= C+40 multiply5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 Angiotenson II In the lungs...potent vasodialator, aldosterone attracts sodium. Iron toxicity reversal deferoxamine S3 sound normal in CHF. Not normal in MI After endoscopy check gag reflex a) 245 of 640 TPN given in subclavian line pain with diverticulitis located in LLQ appendicitis pain located in RLQ Trousseau and Chvostek's signs observed in Hypocalcemia never give K+ inIV push DKA is rare in DM II (there is enough insulin to prevent fat breakdown) Glaucoma patients lose peripheral vision. Autonomic dysreflexia patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) Spinal shock occurs immediately after injury multiple sclerosis myelin sheath destruction. disruptions in nerve impulse conduction a) 246 of 640 Myasthenia gravis decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. Gullian -Barre syndrome ascending paralysis. watch for respiratory problems. TIA transient ischemic attack....mini stroke, no dead tissue. CVA cerebriovascular accident. brain tissue dies. Hodgkin's disease cancer of the lymph. very curable in early stages burns rule of Nines head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% birth weight doubles by 6 months triples by 1 year if HR is <100 (children) Hold Dig early sign of cystic fibrosis a) 247 of 640 meconium in ileus at birth Meningitis--check for Kernig's/ brudinski's signs wilm's tumor encapsulated above kidneys...causes flank pain hemophilia is x linked passed from mother to son when phenylaline increases brain problems occur buck's traction knee immobility; dont adjust weights russell traction femur or lower leg dunlap traction skeletal or skin bryant's traction children <3 y <35 lbs with femur fx eclampsia is a seizure perform amniocentesis before 20 weeks to check for cardiac and pulmonary abnormalities Rh mothers receive Rhogam to protect next baby a) 248 of 640 anterior fontanelle closes by...posterior by.. 18 months, 6-8 weeks caput succedaneum diffuse edema of the fetal scalp that crossesthe suture lines. reabsorbes within 1 to 3 days pathological jaundice occurs: physiological jaundice occurs: before 24 hours (lasts 7 days) after 24 hours placenta previa s/s placental abrution s/s there is no pain, but there is bleeding there is pain, but no bleeding (board like abd) bethamethasone (celestone) surfactant. premature babies milieu therapy taking care of pt and environmental therapy cognitive therapy counseling five interventions for psych patients safety setting limits establish trusting relationship meds least restrictive methods/environment SSRI's a) 249 of 640 take about 3 weeks to work patients with hallucinations patients with delusions redirect them distract them Thorazine and Haldolcan cause EPS Alzheimer's 60% of all dementias, chronic, progressive degenerative cognitive disorder. draw up regular and NHP? Air into NHP, air into Regular. Draw regular, then NHP Cranial nerves S=sensory M=motor B=bothOh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) MarryTo (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) BigVagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More Hypernatremia a) 250 of 640 S (Skin flushed) a) 251 of 640 A (agitation) L (low grade fever )T (thirst) Developmental 2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup Hepatitis A Ends in a vowel, comes from the bowel Hepatitis b B= blood and body fluids (hep c is the same) Apgar measures HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate Glasgow coma scale eyes, verbal, motor Max- 15 pts, below 8=coma Addison's disease: Cushing's syndrome: "add" hormone have extra "cushion" of hormone Dumping syndrome increase fat and protein, small frequent meals, lie down after meal todecrease peristalsis. Wait 1 hr after meals to drink a) 252 of 640 Disseminated herpes zoster localized herpes zoster Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered! Isoniazid causes peripheral neuritis Weighted NI (naso intestinal tubes) Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT tofacilitate movement through pyloris Cushings ulcersr/t brain injury Cushing's triad r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure) Thyroid storm HOT (hyperthermia) Myxedema coma COLD (hypothermia) Glaucoma No atropine Non Dairy calcium Rhubarb sardines collard greens a) 253 of 640 Koplick's spots prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth INH can cause peripheral neuritis Take vitamin B6 to prevent. Hepatotoxic pancreatitis pts put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids Murphy's sign Pain with palplation of gall bladder (seen with cholecystitis) Cullen's sign ecchymosis in umbilical area, seen with pancreatitis Turner's sign Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis McBurney's point Pain in RLQ with appendicitis LLQ Diverticulitis RLQ appendicitis watch for peritonitis Guthrie test Tests for PKU. Baby should have eaten protein first shilling test Test for pernicious anemia a) 254 of 640 Peritoneal dialysis Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok Hyper reflexes absent reflexes upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue Latex allergies assess for allergies to bananas, apricots, cherries, grapes, kiwis, passionfruit, avocados, chestnuts, tomatoes and peaches Tensilon used in myesthenia gravis to confirm diagnosis ALS (amyotrophic lateral sclerosis) degeneration of motor neurons in bothupper and lower motor neuron systems Transesophageal fistula esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis) MMR is given SQ not IM codes for pt care Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival a) 255 of 640 Contraindication for Hep B vaccine anaphylactic reaction to baker's yeast what to ask before flu shot allergy to eggs what to ask before MMR allergy to eggs or neomycin when on nitroprusside monitor: cyanide. normal value should be 1. William's position semi Fowler's with knees flexed to reduce low back pain S/S of hip fx External rotation, shortening adduction Fat embolism blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids. complications of mechanical ventilation pneumothorax, ulcers Paget's disease tinnitus, bone pain, elnargement of bone, thick bones with allopurinol no vitamin C or warfarin! IVP requires a) 256 of 640 bowel prep so bladder can be visualized acid ash diet cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread alk ash diet milk, veggies,rhubarb, salmon orange tag in psych is emergent psych thyroid med side effects insomnia. body metabolism increases Tidal volume is7-10 ml/kg COPD patients and O2 2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less Kidney glucose threshold 180 Stranger anxiety is greatest at what age? 7-9 months..separation anxiety peaks in toddlerhood when drawing an ABG put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2 Munchausen syndrome vs munchausen by proxy Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child a) 257 of 640 multiple sclerosis motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia hungtington's 50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure WBC left shift pt with pyelo. neutrophils kick in to fight infections pancreatic enzymes are taken with each meal! infants IM site Vastus lateralis Toddler 18 months+ IM siteVentrogluteal IM site for children deltoid and gluteus maximus Thoracentesis: position pt on side or over bed table. no more than 1000cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing Cardiac cath NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr Cerebral angio prep well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids. a) 258 of 640 lumbar puncture fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache. ECG no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure. Myelogram NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site Liver biopsy administer Vitamin K, NPO morning of exam 6 hrs. Givesedative. Teach pt to expect to be asked to hold breath for 5-10 sec.supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. noheavy lifting 1 wk Paracentesis semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia laparoscopy CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup PTB low grade afternoon fever a) 259 of 640 pneumonia rusty sputum; when percuss-will hear dull sounds asthma wheezing on expiration emphysema barrel chest kawasaki syndrome strawberry tongue pernicious anemia red beefy tongue downs syndrome protruding tongue cholera rice watery stool malaria stepladder like fever--with chills typhoid rose spots on the abdomen diptheria pseudo membrane formation measles koplick's spots sle (systemic lupus) butterfly rash a) 260 of 640 pyloric stenosis olive like mass Addison's bronze likeskin pigmentation Cushing's moon face, buffalo hump hyperthyroidism/ grave's disease exophthalmos myasthenia gravis descending musle weakness gullian-barre syndrome ascending muscle weakness angina crushing, stabbing chest pain relieved by nitro MI crushing stabbing chest pain unrelieved by nitro cystic fibrosissalty skin DM polyuria, polydipsia,polyphagia DKA kussmal's breathing (deep rapid) a) 261 of 640 Bladder CA painless hematuria BPH reduced size and force of urine retinal detachment floaters and flashes of light. curtain vision glaucoma painful vision loss. tunnel vision. halo retino blastoma cat's eye reflex increased ICP hypertension, bradypnea,, bradycarday (cushing's triad) shock Hypotension, tachypnea, tachycardia Lymes disease bullseye rash intraosseous infusion often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist. sickle cell crisis two interventions to prioritize: fluids and pain relief. glomuloneprhitis the most importantassessment is blood pressure a) 262 of 640 children 5 and up should have an explanation of what will happen a week before surgery Kawasaki disease (inflammation of blood vessles, hence the strawberry tongue) causescoronary artery aneurysms. ventriculoperitoneal shunt watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees 3-4 cups of milk a day for a child? NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA MMR and varicella immunizaions after 15 months! cryptorchidism undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence CSF meningitis HIGH protein LOW glucoseHead injury or skull fx no nasotracheal suctioning otitis media feed upright to avoid otitis media! positioning for pneumonia lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick a) 263 of 640 lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!) for neutropenic pts no fresh flowers, fresh fruits or veggies and no milk antiplatelet drug hypersensitivity bronchospasm bowel obstruction more important to maintain fluid balance than toestablish a normal bowel pattern (they cant take in oral fluids) Basophils reliease histamine during an allergic response Iatragenic means it was caused by treatment, procedure or medication Tamoxifen watch for visual changes--indicates toxicity post spelectomy pneumovax 23 is administered to prevent pneumococcal sepsis Alkalosis/ Acidosis and K+ ALKalosis=al K= low sis. Acidosis (K+ high) No phenylalanine to a kid with PKU. No meat, dairy or aspartame never give potassium to a pt who has low urine output! a) 264 of 640 nephrotic syndrome characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay the first sign of ARDS increased respirations!followed by dyspnea and tachypnea normal PCWC (pulmonary capillary wedge pressure)is 8-13 readings 18-20 are considered high first sign of PE sudden chest pain followed by dyspnea and tachypnea Digitalis increases ventricular irritability --- could convert a rhythm to v-fib following cardioversion Cold stress and the newborn biggest concern resp. distress Parathyroid relies on vitamin D to work Glucagon increases the effects of?anticoagulants Sucking stab wound cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a closed pneumo or tension pneumo! chest tube pulled out? occlusive dressing PE Needs O2! a) 265 of 640 DKA acetone and keytones increase! once treated expect postassium to drop!have K+ ready Hirschprung's diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools Intussusception Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements laboring mom's water breaks? first thing--worry about prolapsed cord! Toddlers need to express independence! Addison's causes sever hypotension! pancreatitis first pain relief, second cough and deep breathe CF chief concern? Respiratory problems a nurse makes a mistake? take it to him/her first then take up the chain a) 266 of 640 nitrazine paper turns blue with alkaline amniotic fluid. turns pink with other fluids up stairs with crutches? down stairs with crutches? good leg first followed by crutches(good girls go to heaven) crutches with the injured leg followed by the good leg. dumping syndrome? use low fowler's to avoid. limit fluids TB drugs are hepatotoxic! clozapine, Clozaril antipsychotic anticholinergic clozapine s/e weight gain, hypotension, hyperglycemia, agranulocytosis dehydration -hypovolemia - elevated urine specific gravity flumazenil, Romaziconbenzo overdose umbilical cord compression reposition side to side or knee-chest short cord a) 267 of 640 discontinue pictocin a) 268 of 640 TB A positive Mantoux test indicates pt developed an immune response to TB. Acid-fast bacilli smear and culture:(+suggests an active infection) the diagnosis is CONFIRM by a positive culture for M TB A chest x-ray may be ordered to detect active lesions in the lungs QuantiFERON-TB Gold: DIAGNOSTIC for infection, whether it is active orlatent Battery performing procedure without consent Assault Threatening to give pt. medication putting another person in fear of a harmful or an offensive contact. Imprisonment Telling the client you cannot leave the hospital Defamation is a false communication or careless disregard for the truth that causesdamage to someone's reputation. in writing(Libel) or Verbally(Slander) Sprain or Strain RICE Rest Ice Compress Elevate quad cane place of unaffected side of body place it 6-12 in in front of the body before walking steps a) 269 of 640 forward with affected leg first bring the unaffected leg as well, bringing the foot past the cane hand roll in each hand maintains functional position Fluoxetine (Prozac) report tremors, agitation, confusion, anxiety, hallucinations=serotonin syndrome (risk in the first 2-72 hrs after given first time); client will stop the meds; weight gain/diabetes/ hyperglicemia asthma kid should participate in sports, inhaler prior to sports, stay inside when cold, use peak flow meter every day same time, annual influenta vaccine important increased ICP in bacterial meningitis sign memory loss bacterial meningitis Kernig sign, nuchal rigidity, are clinical manifestations fetal heart rate end of first trimester place the scope midline just above the symphysis pubis and apply firm pressure thrombocytopenia dont blow your nose=bleeding delirium fluctuating level of consciousness; more agitated in the evening; acute memory deficit pt on seizure precautions have suction next to bed available, keep siderails up a) 270 of 640 outcome audit good to check if infection rates have declined; this audit determine results from a specific intervention impaired vision client color tape stairs-good for safety Ethambutol (Myambutol)-for tb loss of color discrimination-discontinue Nitro patch effective 20 to 60 min after applied; chest, back, abdomen, anterior tight-best locations; keep patch on 12 to 14 hrs a day, not more so tolerance is prevented Celebrex (OA) contraindicated in pt's allergic to sulfa meds-because it cotains sulfa Dexamethasone for RA AE: hyperglycemia, glicosuria, adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte imbalance, cataracts, pud intermittent enteral tube feeding diarrhea after each feeding intervention: reduce rate of feeding or switch to continuous feeding intermittent enteral tube feeding room temperature formula, not cold-if not-cramps, nausea, vomiting; elevate bed to at least 30 degreeswhile feeding breast CA signs report: dumpling of the tissue=tissue is retracted, silver striae-expected, new nipple inversion-report, if pt had it ever since menarche-ok, visible symmetrical venous pattern-ok, not symmetrical-not ok a) 271 of 640 after CVA-possible problems swallowing and risk for aspiration chin to chest will help Digoxin levels report 3.0-toxic full liquid diet peanut butter, ice cream, grape juice vancomyocyn hearring loss stage II pressure ulcer partial thickness skin loss stage III vissible subq fatfullthickness skin loss stage IV exposed muscle modified 3 point crutch gait-going upstairs order stand and bear weighton the unaffected leg transfer body weight to the crutches advance the unaffected leg between the crutches shift leg from the crutches to the unaffected leg alling crutches on the stairs enema position sims-on the side with knees flexed wrapping culf to loose on the arm false high BP a) 272 of 640 culf too wide false low BP reading Thorazine dry mouth, photosensitivity Heparin givein the belly after partial mastectomy expect drainage tubes, they can start ROM within 25 hrs, no pick up things delegate to UAP feeding a alzheimer pt with aphasia borderline personality disorder would cut himself/harm self/self mutilation antisocial lack of remorse following total knee arthroplasty CPM receive-stop during meal times signs for increased ICPirritability dehydration increased urine specific gravity hypotonic dehydration will have low sodium, so normal sodium will show that pt is responding well to oral rehydration solution a) 273 of 640 thoracentesis avoid deep breathing during procedure-will avoid puncture of the pelura boggy uterus PP massage to prevent bleeding preeclampsia report decreased urine output, edema of hands and face;don decrease fluids-drink 2-3 L a day failure to thrive check for mom and baby bonding; develop a structure routine with baby; feed as needed NG tube verify placement if new-xray if not new, just to verify before new feeding-aspirate contents of the tube and verify PH (1-4) Crohn's disease pt with enteroenteric fistula low fiber diet, increased K, increased protein, increased calories eye drops administration keep eyes closed for 1 min after Estradiol (Climara)report headache Digoxin (Lanoxin) toxicity s/snausea, diarrhea infant pulse check brachial artery stoma care barrier-hold it for 30 secs before putting the bag on a) 274 of 640 Babinski stroke outer area of foot moving upwardsickle cell anemia crisisfluids first, pain after incidence report dont mention in a chart Autism kid lack of responsiveness, less interest in others, impaired social interactions, repetitive movements ?, Oppositional defiant disorder disobedience Theophylline (Theochron) toxicity anorexia, tachycardia, albuminuria, hypotension PAD (peripheral arterial disease) lubricate skin of feet with lotion, don't use heating pads, trim toenails straight, dont elevate feet above level of heart AIDS no exposure to soil=no gardening; dont use pepper; dont eat food that has been sitting out for more than 1 hr; wash toothbrush in dishwasher weekly vacuum assisted birth complications for mom perineal, vaginal and cervical lacerations good coping exercising, doing a hobby a) 275 of 640 crisis interventions help client find out the cause of his reaction Cyclophosphomide (Cytoxan) for a toddler for neuroblastoma increase fluids to prevent hemorrhagic cystitis, give early in the day Coumadin first 5 days-blood work q day, don't take acetaminophen RACE assess pt first evisceration stay with pt and call for help, cover with sterile, put pt supine with bend knees, assess vitals newborn ascultate pulse listen apical pulse for 1 min episiotomy sitz bath 24 hrs after (will increase circulation), sit on hard surface, ice packs (reduce edema and discomfort) Cushings moon face, hypertension, weight gain Arthroplasty postop primary thing-prevent bleeding newborn prevent conduction heat loss put a paper in between baby and metal table Post partum client risk of DVT-unilateral leg pain, calf tenderness, leg swelling a) 276 of 640 intravenous pylogram laxative right before procedure, clear liquids or nothing after midnight, check for allergies for seafood, milk, eggs, chocolate; encourage fluids after to remove dye immobile client use trochanter rolls, lots of fluids, no massage sterile field/ aseptic technique maintain things within line of vision, 1 in border is contaminated, nothing bellow waist, dont tie dr's gown in the BACK-thats contaminated, dont turn your back on the field, tight hands together above waist Infertility after trying one year, refer to support group Respiratory acidosis uncompensated low ph, high CO2, normal bicarb Respiratory acidosis compensated low ph, high CO2, increased bicarb Pitocin post partum bleeding prevention; heavy lochia and boggy fundus Nubain/Nalbuphine pain relief during labor Brethine (Terbutaline) and Mag Sulfate either one are given to decrease preterm labor contractions-its a muscle relaxant Suctioning-pt with tracheostomy following a laryngectomy pass catheter no more than three times, cough is normal-expected, surgical Not medical asepsis used, resistance-> withdraw catheter 1-2 cm a) 277 of 640 Amitryptaline (Elavil) for depression-TCA anticholinergic, watch for dry mouth and constipation; take it with orright after food, urine could turn blue-green, MAOI avoid tyramine foods like: avocado, smoked meats, cheeses, crutches going up the stairs advance unaffected leg to the stairs, place the put weight on good leg and cruthes, weight on unaffectedleg and the crutches, advance affected leg and crutches forward upthe stairs nausea alternative method adjustable band with bead Cefazolin infusion piggy bag with 0.9 NaCl-if NaCl is already running thrombocytopenia low platelets; risk for bleeding; avoid venipunctures neutropenia wbc low; no fresh flower or fruits; limit time with family members when visiting peritonitis rigid board like abdomen, absent bowel sounds,wbc 20,000; fever; REPORT RDS maintain normal body temp-main priority neuborn-REPORT and immediate attention grunting, tachypnea, nasal flaring early decells continue to observ a) 278 of 640 estrogen replacement therapy helps prevent osteoporosis; also exercise does Evisceration and dehiscence require emergency treatment. ■ Call for help. ■ Stay with the client. ■ Cover the wound and any protruding organs with sterile towels or dressings soaked with sterile normal saline solution. Do not attempt to reinsert the organs. ■ Position the client supine with the hips and knees bent. ■ Observe for signs of shock. ■ Maintain a calm environment. ■ Keep the client NPO in preparation for returning to surgery. Ulcers ◯Stage I - Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. ◯Stage II - Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. ◯Stage III - Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. ◯Stage IV - Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). a) 279 of 640 ◯Unstageable - No determination of stage because eschar or slough obscures the wound. Intussusception (peds) red currant jelly stools, bloody mucus stools, telescoping intestine, resulting sausage shaped abdominal mass. hypertrophic pyloric stenosis (peds) Projectile vomiting, Dry mucus membranes, Constant hunger Hirschsprung disease (peds) surgery to remove the affected segment ofthe intestine, low-fiber, high-protein, high-calorie diet. Meckel's diverticulum bed rest to prevent bleeding postoperative following cleft lip and palaterepair prone position to facilitate drainage cleft lip and palate bottle with a one-way valve, wide-based nipple bottle Meckel's diverticulum Abdominal pain, Mucus, bloody stools risk for newborn hypoglicemia mother has diabetes mellitus RDS newborn ■ Tachypnea (respiratory rate greater than 60/min) ■ Nasal flaring ■ Expiratory grunting ■ Retractions ■ Labored breathing with prolonged expiration ■ Fine crackles on auscultation ■ Cyanosis a) 280 of 640 ■ Unresponsiveness, flaccidity, and apnea with decreased breath sounds(manifestations of worsened RDS) phototherapy for high billirubin ■ Maintain an eye mask over the newborn's eyes for protection ofcorneas and retinas. ■ Keep the newborn undressed with the exception of a male newborn. A surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning. ■ Avoid applying lotions or ointments to the skin because they absorb heat and can cause burns. ■Remove the newborn from phototherapy every 4 hr, and unmask the newborn's eyes, checking for inflammation or injury. ■ Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. ■ Check the lamp energy with a photometer per facility protocol. ■ Turn off the phototherapy lights before drawing blood for testing. epiglottitis Difficulty swallowing, high fever, Drooling, stridor croup Dry, barking cough Authoritative Makes decisions for the group. ☐ Motivates by coercion. ☐ Communication occurs down the chain of command. ☐ Work output by staff is usually high - good for crisis situations andbureaucratic settings. ☐ a) 281 of 640 Effective for employees with little or no formal education. Democratic ☐ Includes the group when decisions are made. ☐ Motivates by supporting staff achievements. ☐ Communication occurs up and down the chain of command. ☐ Work output by staff is usually of good quality - good when cooperation and collaboration are necessary Laissez-faire ☐ Makes very few decisions, and does little planning. ☐ Motivation is largely the responsibility of individual staff members. ☐ Communication occurs up and down the chain of command and betweengroup members. ☐ Work output is low unless an informal leader evolves from the group. ☐ Effective with professional employees. Quality Improvement ◯ Outcome, or clinical, indicators reflect desired client outcomes related to the standard under review. ◯ Structure indicators reflect the setting in which care is being provided and the available human and material resources. ◯ a) 282 of 640 Process indicators reflect how client care is provided and are established by policies and procedures (clinical practice guidelines). ◯ Benchmarks are goals that are set to determine at what level the outcome indicators should be met QI eg While process indicators provide important information about how a procedure is being carried out, an outcome indicator measures whether that procedure is effective in meeting the desired benchmark. For example: the use of incentive spirometers in postoperative clients may be determined to be 92% (process indicator) but the rate of postoperative pneumonia may be determined to be 8% (outcome indicator). If the benchmark is set at 5%, the benchmark for that outcome indicator is not being met and the structure and process variables need to be analyzed to identify potential areas for improvement Cane, left leg is affected hold cane on strong side, keep two points support all the time on the ground, place cane 6 to 10 in in front before advancing, advance weak leg first followed by good leg, advance strong lef past the cane Cardiac tamponade muffled heart sounds, pulsus paradoxus, Pneumothorax tracheal deviation Pericarditis pericardial friction rub MAOI's SE-metallic taste a) 283 of 640 Fluoxetine/Prozac-SSRI SEROTONIN SYNDROMEheadachehypotension, urinary frequency, Sodium (Na) 136-145 mEq/L Calcium 9.0-10 mg/dL Chloride 98-106 mEq/L Bicarb HCO 21-28 mEq/L Potassium 3.5-5.0 mg/L Phosphorus PO4 3.0-4.5 mg/dL Magnesium 1.3- 2.1 mEq/L Stomach pH1.5-2.5 Ammonia 15-110 mg/dL a) 284 of 640 Bilirubin • Total 0-1.0 a) 285 of 640 • Unconjugated (indirect) 0.2 -0.8mg/dL • Conjugated (direct) 0.1 1.0 mg/dL Cholesterol • Total <200mg/dL • LDL ("bad") <100 • HDL ("good) >40 • Triglycerides <150mg/dL Liver enzymes • ALT/SGPT 8-20 units/L • AST/SGOT 5-40 units/L • ALP 42-128 units/L • Total protein 6-8 gm/dL Pancreatic enzymes • Amylase 56-90 IU/L • Lipase 0-110 units/L • Prothrombin time 0.8-1.2 Glucose • Preprandial (fasting) 70-110 mg/dL • Postprandial 70-140 mg/dL • HbA1c (glycosylated hemoglobin) <6% RBC • Females 4.2-5.4 million/uL • Males 4.7-6.1 million /uL WBC 5000 -10,000 a) 286 of 640 MCV 80-90mm3 MCH 27 -31 pg/cell TIBC 250-460 mcg/dL Iron • Females 60-160 mcg/dL • Males 80-180 mcg/dL Platelets 150,000-450,000 Hemoglobin (Hgb) • Females 12-16 g/dL • Males 14-18 g/dL Hematocrit (Hct) • Females 37-47% • Males 42-52% Prothrombin Time (PT) (Coumadin) 11-14 seconds: therapeutic range 1.5-2x normal or control value Partial thromboplastin Time (aPTT) (Heparin) 16-40 range; therapeutic range 1.5-2x normal or control value INR 0.9 - 1.2 but 2 to 3 on Coumadin therapy (therapeutic) D-dimer a) 287 of 640 • 0.43 - 2.33 mcg/mL • 0 to 250 ng/mL Fibrinogen levels 170 - 340mg/dL Fibrin degradation products < then 10 mcg/mL Arterial Blood Gases (ABG)pH 7.35 -7.45 Pa02 80-100 mm Hg PaC02 35-45 mm Hg HCO3 21 - 28 mEq/L Sa O2 95-100% Cl 98-106 Urine specific gravity1.015-1.030 Urine pH average 6.0; range 4.6-8.0 Urinalysis Negative for glucose, RBC, WBC, Albumin, bacteria: <1000 colonies/ml Glomerular filtration rate (GFR)90-120 ml/min BUN 10-20 mg/dL Creatinine males 0.6 - 1.2 mg/dL; female 0.5-1.1 a) 288 of 640 Creatinine phosphokinase MB (CK-MB) normal 30-170 units/L *increase 4-6 hrs after MI and remains elevated 24-72hrs troponin normal <0.2 ng/dL *gold standard for MI Describe the following ECG findings in 1st degree AV block: rhythm rate QRS durationP wave P wave rate P-R interval Describe the following ECG findings in 2nd degree block - Mobitz Type 1 (Wenckebach): rhythm rate QRS duration a) 289 of 640 P:QRS ratio P wave rate a) 290 of 640 P-R interval What type of heart block is associated with a QRS drop? 2nd degree heart block Describe the following ECG findings in 2nd degree block - Mobitz Type 2: rhythm rate QRS duration P:QRS ratio P wave rate P-R interval What causes a 2nd degree block - Mobitz Type 2? Describe the following ECG findings in 3rd degree block (complete AV block): rhythm rate QRS a) 291 of 640 durationP wave a) 292 of 640 P wave rate P-R interval List the 3 basic mechanisms for tachyarrhythmias. Which is most common? increased automaticity of pacemaker spontaneous depolarizations re-entrant circuit (most common) List 3 causes of sinus tachycardia. Describe the following ECG findings in sinus tachycardia: rhythm rate QRS duration P wave P-R interval rate is less than 150 beats per minute What phase of the ventricular action potential corresponds to the STsegment? phase 2 During which 2 phases of the ventricular action potential do spontaneous depolarizations occur? a) 293 of 640 phase 3 phase 4 Reduced function of what channels leads to a prolonged plateau period, leading to a prolonged QT interval? potassium channels A "twisting" polymorphic ventricular tachycardia that is observed in situations where the QT interval has been prolonged torsades de pointes What fatal disorder is associated with torsades de points? ventricular fibrillation Describe the mechanism of re-entrant circuit tachyarrhythmia. List 3 examples of re-entrant arrhythmias. Atria tachycardia atrial flutter atrial fibrillation supraventricular re-entrant tachycardia as in Wolff-Parkinson-White syndrome ventricular tachycardia A 17-year-old boy is referred to a cardiologist by a primary care physician for evaluation of recurrent spells of dizziness. During the episodes, he feels intense anxiety with palpitations and breathlessness. a) 294 of 640 He is asymptomatic in between episodes; There is no h/o chest pain or syncope. Physical examination: No abnormalities detected Lab: EKG: Short PR interval; wide QRS with a slurred upstroke. Blood: Normal; Chest X ray: NormalWolff-Parkinson-White syndrome List 3 ECG findings in Wolff-Parkinson-White syndrome.short PR interval wide QRS delta wave What is the name of the wide QRS wave with a slurred upstroke seen in Wolff-Parkinson-White syndrome? delta wave - widened QRS signifies pre-excitation What disorder is caused by an accessory atrioventricular connection leading to re-entrant supraventricular tachycardia? Wolff-Parkinson-White syndrome Compare Wolff-Parkinson-White syndrome to long QT syndrome. A 46-year-old woman arrived in the ER complaining of sudden onset of palpitations, lightheadedness, and shortness of breath. These symptomsbegan approximately 2 hours previously. PE: BP 95/70 mm Hg Heart Rate - averages 170 beats/min, regular Rest of her physical examination is unremarkable a) 295 of 640 EKG: abnormal P waves; P-R intervals are within normal limits; normal QRS complexes supraventricular tachycardia How can one use an ECG to differentiate between supraventricular and ventricular tachycardia? If the QRS complex is narrow (<3 small boxes) -SVT. If the QRS complex is wide (>3 small boxes) - VT. Describe the following ECG findings in supraventricular tachycardia:rhythm rate QRS duration P wave P-R interval List 4 types of supraventricular tachycardias. atrial tachycardia atrial flutter atrial fibrillation AV node reentrant tachycardia atrioventricular reentrant tachycardia Describe the following ECG findings in atrial flutter: a) 296 of 640 rhythm rate QRS durationP wave P wave rate P-R interval A 44-year-old male complains of occasional palpitations, shortness ofbreath, dizziness and chest discomfort. Physical examination: Pulse: Irregularly irregularJVP: absent "a" waves Heart sounds: variable intensity S1 with occasional S3 Lab: EKG: Variable ventricular rate (90-190); Irregular RR intervals. Blood: CK-MB normal Chest X ray: Normalatrial fibrillation Atrial tachycardia (SVT) atrial rate150-250/min Atrial flutter (SVT) atrial a) 297 of 640 rate250-350/min Atrial fibrillation (SVT) atrial rate > 350/min and multifocal a) 298 of 640 Describe the following ECG findings in atrial fibrillation: rhythm rate QRS duration P wave P-R interval Describe the following ECG findings in ventricular tachycardia: rhythm rate QRS durationP wave Describe the following ECG findings in ventricular fibrillation: rhythm rate QRS durationP a) 299 of 640 wave a) 300 of 640 List 3 possible diagnoses if QRS < 120 ms. sinus arrhythmia supraventricular rhythm junctional tachycardia List 3 possible diagnoses if QRS > 120 ms. ventricular tachycardia supraventricular rhythm with additional bundle branch block additional accessory AV pathway A patient asks you about his risk of cardiovascular disease. He is 50-years old and has diabetes, is overweight and smokes cigarettes. You advise him that: He can modify his risk for cardiovascular disease by losing weight and not smoking Which of the following is true of the coronary arteries? The coronary arteries begin just above the aortic valve The circumflex artery is a branch of the: Left coronary artery In the event of a coronary artery blockage, the muscle of the heart can receive blood from the: Anastomoses that provide collateral circulation The right atrium receives blood from the systemic circulation and the: Coronary veins a) 301 of 640 The valve between the right atrium and the right ventricle is the: Tricuspid valve Relaxation of the heart is referred to as: Diastole Stroke volume depends on preload, afterload, and: Myocardial contractility The Starling law states that: Myocardial fibers contract more forcefully when they are stretched The most important factor in determining stroke volume in a healthy heart is: Preload An increase in peripheral vascular resistance: Decreases stroke volume To increase cardiac output, you can: Increase both heart rate and stroke volume The ventricles of the heart are innervated mainly by: Sympathetic nerve fibers Parasympathetic control of the heart is provided by the: Vagus nerve The resting membrane potential is determined primarily by the differencebetween the intracellular potassium ion level and the Extracellular potassium ion level Depolarization takes place when: Sodium ions rush into the cell a) 302 of 640 The sodium-potassium pump functions to move: Potassium ions into the cell and sodium ions out of the cell Phase I of the action potential represents the period of: Early rapid repolarization During the period between action potentials: There is excessive sodium in the cell The AV junction is formed by the AV node and the: Bundle of His The dominant pacemaker of the heart under normal conditions is the: SA node You are treating a patient who has a damaged SA node that is no longerpacing the heart. You would expect the patient's heart to: Beat more slowly Which of the following cardiac pacemakers has an intrinsic rate of 40 to 60 beats per minute? AV junction Acetylcholine affects the heart by: Decreasing heart rate The activation of myocardial tissue more than one time by the sameimpulse is called: Reentry You are treating a 75-year-old woman who has a history of diabetes and atherosclerosis. Her chief complaint is persistent heartburn. You suspect: This may be a cardiovascular problem Jugular vein distention in cardiac patients should be evaluated with the patient positioned: With the head elevated 45 degrees a) 303 of 640 While assessing a patient you identify a carotid bruit. This leads you to believe that the patient: Has atherosclerosis An ECG can help to determine: Whether there is ischemic cardiac muscle Which of the following is a bipolar lead?Lead II In lead II ECG placement, the positive lead is located on the: Left leg Leads II and III are: Inferior leads Lead I looks at the heart from what view? Lateral A lead used for routinely monitoring dysrhythmias is: Lead II A paramedic places 10 leads: 4 on the limbs and 6 on the chest. Theparamedic is preparing for viewing a: 12-lead ECG In a 12-lead ECG, leads V1 and V2 are: Septal leads When preparing for a 12-lead ECG, locate the 4th intercostal space, justto the right of the sternum and place lead: V1 a) 304 of 640 Standard ECG paper is divided into 1-mm blocks and moves past the stylus of the ECG at 25 mm per second. Each small block represents: 0.04 second Each small square of graph paper represents mV .0.1 The first upward deflection on an ECG tracing is the: P wave The PR interval represents the time it takes an electrical impulse to: Be conducted through the atria and the AV node The duration of the QRS complex should be second. 0.08 to 0.10 While analyzing an ECG you cannot identify a Q wave. This means: The Q wave may not be visible in the lead you are viewing The ST segment reflects the: Early repolarization of the ventricles Deep and symmetrically inverted T waves may be indicative of: Cardiac ischemia The part of the ECG tracing that is most important for detecting life-threatening arrhythmias is the: QRS complex The triplicate method of determining heart rate is: Accurate when the heart rate is normal and greater than 50 beats perminute a) 305 of 640 When analyzing an ECG tracing, you notice that the rhythm is highly irregular. The best method to calculate the rate is the Six-second count method While evaluating a 22-year-old female runner who called 911 because she fell and twisted her ankle, you apply an ECG monitor. Her heart rate is 46, P waves are normal and upright, the PR interval is 0.16 second, and the QRS complex looks normal. There is a QRS complex following each P wave.The patient's ECG tracing reflects: Sinus bradycardia While evaluating a 22-year-old female runner who called 911 because she fell and twisted her ankle, you apply an ECG monitor. Her heart rate is 46, P waves are normal and upright, the PR interval is 0.16 second, and the QRS complex looks normal. There is a QRS complex following each P wave.Treatment for this patient's heart rate should include: No treatment at this time An undesirable side effect of atropine is: Increased myocardial oxygen demand Isoproterenol raises the heart rate by functioning as a:Beta agonist ECG analysis reveals that each P wave in the tracing has a different shape. The heart rate is 80 beats per minute. This is called: Wandering pacemaker Which of the following may cause sinus bradycardia? Intrinsic sinus node disease Atropine works by inhibiting:Parasympathetic response a) 306 of 640 An ECG strip shows a regular rhythm with a QRS complex of 0.08, a rate of 145, a PR interval of 0.12, and one upright P wave before each QRS complex. You suspect that this rhythm is: Sinus tachycardia You are called to evaluate a 64-year-old woman who complains of palpitations, weakness, and dizziness. Her heart rate is 160 beats per minute, her blood pressure is 118/ 80 and her respiratory rate is 28. The ECG tracing shows narrow QRS complexes and no identifiable P waves. This rhythm is most likely: SVT You are called to evaluate a 64-year-old woman who complains of palpitations, weakness, and dizziness. Her heart rate is 160 beats per minute, her blood pressure is 118/ 80 and her respiratory rate is 28. The ECG tracing shows narrow QRS complexes and no identifiable P waves. The first recommended treatment for this patient is: Valsalva maneuver Which of the followinYou are called to evaluate a 64-year-old woman who complains of palpitations, weakness, and dizziness. Her heart rate is 160 beats per minute, her blood pressure is 118/ 80 and her respiratory rate is 28. The ECG tracing shows narrow QRS complexes and no identifiable P waves. Which of the following drugs is a class I (recommended) drug for this patient? Adenosine You are called to evaluate a 64-year-old woman who complains of palpitations, weakness, and dizziness. Her heart rate is 160 beats per minute, her blood pressure is 118/ 80 and her respiratory rate is 28. The ECG tracing shows narrow QRS complexes and no identifiable P waves. The patient begins to develop chest pain, and her blood pressure drops to 100/60. The treatment of choice for this patient is now: Synchronous cardioversion a) 307 of 640 first synchronous cardioversion for patients in PSVT should be at: 50 J You see an irregular rhythm on the monitor with a rate of 66 to 80, a normal PR interval, and a P wave for every QRS. The rate speeds up andslows down with the patient's respiratory rate. You suspect that this rhythm is: Sinus dysrhythmia Vagal maneuvers for SVT include: Facial immersion in ice water Atrial flutter is almost always caused by: Rapid reentry You are treating a 70-year-old male patient with atrial fibrillation. The patient's ventricular heart rate is 180 beats per minute, the blood pressure is 90/60, and the patient complains of chest pain. The hallmarkof atrial fibrillation is: An irregularly irregular rhythm You are treating a 70-year-old male patient with atrial fibrillation. The patient's ventricular heart rate is 180 beats per minute, the blood pressure is 90/60, and the patient complains of chest pain. You have determined that your atrial fibrillation patient is unstable and requires electrical therapy. You will perform countershock with joules Synchronized; 100 You are treating a 70-year-old male patient with atrial fibrillation. The patient's ventricular heart rate is 180 beats per minute, the blood pressure is 90/60, and the patient complains of chest pain. If this patient's atrial fibrillation has been present for more than 48 hours, conversion of this patient's rhythm may lead to: Release of emboli a) 308 of 640 Junctional escape rhythms: Occur when the SA node fails to fire An ECG strip shows a rhythm with a rate of 45, a QRS of 0.08, and a P wave that appears after the QRS. You suspect that this dysrhythmia ismost likely: Junctional The intrinsic rate for a ventricular pacemaker is beats per minute. 20 to 40 Your patient has a regular bradycardic rhythm with a rate of 40, no P waves, and a QRS greater than 0.12. This is: Ventricular escape rhythm Absolute bradycardia means that: The heart rate is less than 60 beats per minute Which of the following may be a lethal treatment for a patient with a ventricular escape rhythm? Lidocaine You are treating a patient who is complaining that his heart is "skippingbeats." On ECG evaluation, you see frequent PVCs that are occurring ingroups. The patient's blood pressure is 100 systolic. Treatment for this patient: Should include oxygen and lidocaine The treatment of choice for a symptomatic ventricular escape rhythm is: Pacing Which of the following is true of ventricular tachycardia? Ventricular tachycardia is triggered by a PVC a) 309 of 640 Patients with pulseless ventricular tachycardia should be treated as though they have: Ventricular fibrillation Synchronized cardioversion is acceptable for patients with ventricular tachycardia: In all cases The most common arrhythmia in sudden cardiac arrest is: Ventricular fibrillation Defibrillation of patients in asystole: Is not recommended Which of the following is an absolute indication for unsynchronized cardioversion? Ventricular fibrillation Demand pacemakers fire: When the patient's rate drops below a preset number You are treating a 65-year-old man who is complaining of chest pain and difficulty breathing. On ECG examination, you note that his ventricular heart rate is 56, and there are more P waves than QRS complexes. The PR interval is constant when a QRS follows a P wave. The QRS complexes are normal and narrow.You suspect this patient has what type of heart block? Second-degree type II You are treating a 65-year-old man who is complaining of chest pain and difficulty breathing. On ECG examination, you note that his ventricular heart rate is 56, and there are more P waves than QRS complexes. The PR interval is constant when a QRS follows a P wave. The QRS complexes are normal and narrow. This type of heart block is typically considered to be a: Serious arrhythmia regardless of signs and symptoms You are treating a 65-year-old man who is complaining of chest pain and difficulty breathing. On ECG examination, you note that his ventricular heart rate is 56, and there are more P waves than QRS complexes. The PR a) 310 of 640 interval is constant when a QRS follows a P wave. The QRS complexes are normal and narrow. The definitive treatment for this patient is: Transvenous pacemaker insertion You are treating a 65-year-old man who is complaining of chest pain and difficulty breathing. On ECG examination, you note that his ventricular heart rate is 56, and there are more P waves than QRS complexes. The PR interval is constant when a QRS follows a P wave. The QRS complexes are normal and narrow. Prehospital care for this patient consists of: Transcutaneous pacing You are treating a 65-year-old man who is complaining of chest pain and difficulty breathing. On ECG examination, you note that his ventricular heart rate is 56, and there are more P waves than QRS complexes. The PR interval is constant when a QRS follows a P wave. The QRS complexes are normal and narrow. This type of block occurs when the impulse is not conducted through the: AV node You are treating a 65-year-old man who is complaining of chest pain and difficulty breathing. On ECG examination, you note that his ventricular heart rate is 56, and there are more P waves than QRS complexes. The PR interval is constant when a QRS follows a P wave. The QRS complexes are normal and narrow. This type of block is usually associated with: Septal MI Third-degree heart block tends to have: Regular but independent atrial and ventricular rhythms Which of the following is a class I intervention for all symptomaticbradycardias? Transcutaneous pacing How does atropine affect the ventricular rate of third-degree heart block? Has no effect on the rate Identification of bundle branch blocks is: a) 311 of 640 Helpful in identifying patients at risk for third-degree heart block Which of the following is typically found on an ECG with a bundle-branch block? A notched QRS complex (rabbit ears) In a left bundle-branch block: A Q wave is seen instead of an R wave in MCL1 You are evaluating an ECG tracing that shows wide QRS complexes that were produced by supraventricular activity. On MCL1 you see a QS pattern. You suspect: Left bundle-branch block A right axis shift of the ECG is noted when the QRS deflection is: Negative in lead I, negative or positive in lead II, and positive in lead III Emergency care for a bundle-branch block is: Aimed at the cause of the block if it is identifiable On ECG, pulseless electrical activity looks like: Any electrical activity other than ventricular fibrillation or ventricular tachycardia Which of the following is a correctable cause of PEA? Tension pneumothorax You are treating a patient who is in PEA following home dialysis. Which of the following drugs may be indicated? Sodium bicarbonate Wolff-Parkinson-White syndrome is a:Preexcitation syndrome Wolff-Parkinson-White syndrome is of little clinical importance unless the patient: Is tachycardic a) 312 of 640 The three characteristics of Wolff-Parkinson-White syndrome are a short PR interval, QRS widening, and a(n): Delta wave Atherosclerosis is a disease characterized by: Progressive narrowing of the lumen of medium and large arteries Prinzmetal angina occurs when: Coronary arteries spasm The first medication a paramedic should administer to a patient with angina is: Oxygen Most myocardial infarctions are caused by: Acute thrombotic occlusion The majority of acute myocardial infarctions involve the: Left ventricle An inferior-wall MI is usually caused by occlusion of the artery. Right coronary Ischemia caused by unstable angina: Responds well to treatment with antiplatelet agents If the left ventricle loses 25% of its muscle mass due to myocardial infarction: The heart can still pump effectively The most common cause of death following myocardial infarction is: Fatal dysrhythmia Chest pain associated with MI: a) 313 of 640 Is constant You are transporting a patient to a cardiac center after a suspected myocardial infarction. The patient's vital signs are stable. ECG shows sinus rhythm with elevated ST segments. The ST segment is elevated because the damaged muscle is: Constantly depolarized You are transporting a patient to a cardiac center after a suspected myocardial infarction. The patient's vital signs are stable. ECG shows sinus rhythm with elevated ST segments. When you analyze the ECG, ST segment elevation is determined when the ST segment is elevated: By more than 1.0 mV in at least two leads You are transporting a patient to a cardiac center after a suspected myocardial infarction. The patient's vital signs are stable. ECG shows sinus rhythm with elevated ST segments. The patient's ST segment elevation is seen in leads II, III, and aVF, leading you to suspect: Inferior-wall MI You are transporting a patient to a cardiac center after a suspected myocardial infarction. The patient's vital signs are stable. ECG shows sinusrhythm with elevated ST segments. Fibrinolytic therapy for this patient will be most effective if: Administered within 12 hours after the onset of symptoms You are transporting a patient to a cardiac center after a suspected myocardial infarction. The patient's vital signs are stable. ECG shows sinusrhythm with elevated ST segments. Fibrinolytic therapy is contraindicatedfor this patient if he: Had laser eye surgery 3 weeks ago A patient in left ventricular failure is expected to have: Activation of the renin-angiotensin-aldosterone system a) 314 of 640 The position of comfort for a patient with left ventricular failure is usually: Sitting with legs dependent Treatment for a patient with left ventricular failure includes medications to: Reduce afterload Right ventricular failure most often results from: Left ventricular failure Which of the following is most indicative of right ventricular infarct? Peripheral edema Cardiogenic shock is defined by shock symptoms after: Hypovolemia and dysrhythmias have been corrected A drug that may improve the symptoms of cardiogenic shock patients in the field is: Dopamine Signs of cardiac tamponade include: Muffled heart tones If a patient with cardiac tamponade becomes hypotensive in the field,you should: Administer a fluid bolus Aneurysms are most commonly the result of: Atherosclerotic disease Which of the following is true of abdominal aortic aneurysm (AAA)? AAA may be asymptomatic as long as it is stable While assessing a patient, you note a pulsatile mass in the abdomen. Suddenly this mass is no longer palpable, and the patient's blood pressure begins to drop. You suspect that the: Patient's aneurysm hasruptured a) 315 of 640 Dissections of the aorta are typically found: In the ascending aorta Patients usually describe the pain of an aortic dissection as: Ripping or tearing You are called to the local airport to evaluate a 40-year-old obese woman who is complaining of pain in her left lower leg. She has just completed a 12-hour flight, and the pain developed as she got off the plane. Her leg is warm, swollen, and painful. You suspect: Deep-vein thrombosis A compensatory mechanism of the heart in the presence of chronic hypertension is to: Enlarge the muscle mass of the heart The organ(s) most at risk in a hypertensive crisis include the: Kidneys You are treating a patient with blood pressure of 200 over 140. The patient initially complained of headache and nausea. During your 3-hour transport, the patient began to seize and is now unresponsive to any stimulus. You suspect the patient has: Hypertensive encephalopathy You are treating a patient with blood pressure of 200 over 140. The patient initially complained of headache and nausea. During your 3-hour transport, the patient began to seize and is now unresponsive to any stimulus. ment for this condition includes: Labetalol Most new AEDs: Use waveforms that are more effective at lower energy settings a) 316 of 640 If the paddle positions are switched (if the apex paddle is applied to the sternum and the sternum paddle to the apex) during defibrillation: Defibrillation will occur as usual The initial pediatric defibrillation should occur at: 2 J/kg Second and subsequent defibrillations for pediatric patientsshould occur at: .4 J/kg To help reduce impedance to electrical current: Apply 25 pounds of pressure with the paddles against the chest wall If you see the outline of a small box implanted under skin in the left upper abdomen, you would suspect the patient has a(n): Implantable cardioverter-defibrillator After delivering five shocks, an implantable cardioverter-defibrillator will: Not deliver more shocks until a slower rate is restored for 30 seconds Synchronous cardioversion delivers energy: 10 ms after the peak of the R wave Pacemakers are usually set to a rate of beats per minute beginning with amps. 70 to 80; 50 A blood pressure reading in an adult of 180/110 is considered: Stage 3 hypertension When performing CPR on an adult, you would compress the chest to a depth of inches. 1 1/2 to 2 a) 317 of 640 The sound heard when the AV valves close during ventricular systole is: S1 The right coronary artery and the left anterior descending artery supplymost of the blood to the: Right atrium and ventricle The circumflex branch of the left coronary artery mainly supplies blood to the: Left atrium The left anterior descending coronary artery mainly supplies blood to the: Septum Preload is defined as: Ventricular end-diastolic volume The group of nerves that innervates the atria and ventricles is known as the: Cardiac plexus The major neurotransmitter for the parasympathetic system is: Acetylcholine Norepinephrine's major effect is: Vasoconstriction Parasympathetic stimulation of the heart causes: A decreased heart rate seconds is/are measured in each large box on ECG graph paper? 0.20 Each square on ECG paper is mm in height and width. 1 An elevated ST segment suggests: a) 318 of 640 Injury A depressed ST segment suggests: Ischemia T wave inversion suggests: Ischemia Which of the following home medicines would indicate that your patienthas a strong risk factor for heart disease? Metformin After you administer nitroglycerine 0.4 mg SL to a patient with chest pain who has ST-segment elevation in leads II, III and AVF, his blood pressure drops to 78/50 mmHg. You anticipated this side effect in this patient because his ECG changes indicate damage to the: Inferior wall which increases the dependence on preload Normal Sinus Rhythm Heart Rate: 60-100 bpm Regularity: Regular PRI: .12-.20 seconds QRS: <.12 seconds Normal Sinus BradycardiaHeart Rate: <60 bpm Regularity: Regular PRI: .12-.20 seconds QRS: <.12 seconds Normal Sinus TachycardiaHeart Rate: >100 bpm Regularity: Regular PRI: .12-.20 seconds QRS: <.12 seconds a) 319 of 640 Normal Sinus Arrhythmia Heart Rate: 60-100 bpm; can be <60 Regularity: Irregular PRI: .12-.20 seconds QRS: <.12 seconds Premature Atrial Contraction (PAC) Heart Rate: Depends on underlying rhythm Regularity: Interrupts the regularity of underlying rhythm P-Wave: can be flattened, notched, or unusual. May be hidden within the T wave PRI: measures between .12-.20 seconds and can be prolonged; can be different from other complexes QRS: <.12 seconds Atrial Tachycardia (SVT) Regularity: R-R intervals are constant; Regular Rate: artial/ventricular rates are equal; heart rate is between 150-250bpm. P-Wave: One P Wave in front of every QRS; may be flattened or notched; because of the rapid rate, the P waves can be hidden within the T waves PRI: .12-.20 seconds and constant QRS: <.12 seconds Atrial Flutter Rhythm: Regular atrial rhythm; irregular ventricular rate Rate: 250-350 bpm P-Wave: well defined P waves; "sawtooth" appearance PRI: Usually impossible to determine the PR in this arrhythmia. QRS: <.12 seconds Atrial Fibrillation (Uncontrolled) Regularity: Irregular; no pattern to it's irregularity Rate: Majority of time is >350 bpm P Waves: No P Waves Present a) 320 of 640 PRI: Since no P Waves, no PRI can be determined QRS: Should be <.12 seconds Atrial Fibrillation (controlled) Regularity: Irregular; no pattern to it's irregularity Rate: <100 bpm P-Wave: Not present PRI: Since no P wave is present, PRI is not determined QRS: <.12 seconds Junctional Rhythms -Occurs when the AV node takes over as the primary pacemaker in the heart rather than the SA node. AV node takes over when is moves fasterthan SA node. Rate: 40-60 bpm; Accelerated Junctional: 60-100 bpm; Junctional Tachycardia: 100 bpm or greater P Wave: If before QRS, P wave will be inverted. P Wave can also behidden within the QRS complex. P Wave is usually <.12 seconds QRS: <.12 seconds What are the four Supra-Ventricular Tachycardias (SVT)? Sinus Tachycardia (100-160 bpm) Atrial Tachycardia (150-250 bpm) Atrial Flutter (150-250 bpm) Junctional Tachycardia (100-180 bpm) First Degree Heart Block Regularity: depend on the rhythm Rate: Depend on underlying rhythm P Waves: Upright and Uniform; each P Wave will be followed by aQRS complex PRI: constant across entire strip, but always > .20 seconds. QRS: < .12 seconds Second Degree Heart Block (Wenckebach) a) 321 of 640 Regularity: R-R Wave is irregular; R-R interval gets progressively shorter as PRI gets progressively longer Rate: Ventricular rate is slightly slower than normal; atrial rate is normal P-Waves: upright and uniform; some p waves are not followed by the QRS complex PRI: gets progressively longer until one p wave is not followed by a QRS complex; after the blocked beat, cycle starts over QRS: < .12 seconds Second Degree Heart Block (Morbitz) Regularity: if conduction ratio is consistent, R-R interval will be constantand rhythm, regular. If conduction ratio varies, the R-R will be irregular Rate: atrial rate is usually normal; ventricular rate will be in bradycardiaP Waves: upright and uniform; always be more P waves than QRS PRI: constant; might be longer than normal QRS: <.12 seconds Premature Ventricular Contraction (PVC) Regularity: Regular or Irregular Rate: Determined by underlying rhythm; but frequently do not produce apulse P-Waves: Ectopic is not preceded by a PWavePRI: None QRS: Wide and Bizarre; measuring at least .12 seconds; T wave is often in opposite direction from QRS. Ventricular Tachycardia Regularity: Usually regular Rate: Ventricular Rate: 150-250 bpm; if rate is <150 bpm, it's a slow VT; if exceeds 250 bpm, Ventricular Flutter P Waves: None of QRS will be preceded by P WavesPRI: no PRI QRS: wide and bizarre measuring at least .12 seconds; hard to tell between QRS and T wave Ventricular Fibrillation a) 322 of 640 Regularity: chaotic Rate: cannot be determined P Waves: no P waves present PRI: no PRI QRS: no discernible QRS complexes Asystole No electrical activity; only a straight line 3rd Degree Heart BlockRegularity: Regular Rate: 40-60 bpm if junctional; 20-40 bpm if focus is ventricular. P Wave: upright and uniform; more p waves than QRS complexes PRI: no relationship between p waves and QRS complexes QRS: < .12 seconds if junctional; > .12 seconds if ventricular Bundle Branch Block (Left)Wide QRS (>.12 seconds) Left Bundle Branch ("M") Can deteriorate to a 3rd Degree HB Bundle Branch Block (Right)Wide QRS (>.12 seconds) Right Bundle Branch Block ("V") Can deteriorate to a 3rd Degree HB Lead Placement Left: Smoke (Black) over Fire (Red) Right: Snow (White) over Grass (Green) Center: Chocolate (place a little off center for possible CPR) Sinus Tachycardia Etiology/Clinical Signs Etiology: a) 323 of 640 -Physiologic demand for oxygen -Sympathomimetric Drugs a) 324 of 640 -Fever -Pain Clinical Signs: -increased HR; increased oxygen demand Sinus Tachycardia Treatment -May resolve with treatment of underlying cause -Digoxin, Beta Blockers (-olol), Verapamil -Vagal Maneuver Sinus Bradycardia Etiology/Clinical SignsEtiology: -response to myocardial ischemia -vagal stimulation -electrolyte imbalance -drugs -increased intracranial pressure -highly trained athlete Clinical Signs: -decreased CO if body can't compensate; improved CO due to diastolic filling time Sinus Bradycardia Treatment -Atropine -Avoid Valsalva -Hold Rate Slowing Drugs (Digoxin, Beta Blockers) Sinus Bradycardia: Example: Your pt is pale, c/o dizziness and fatigue; pulse 56, BP 86/60. How would you follow protocol according to ACLS? 1. Airway 2. Oxygen 3. ECG, BP, Oximetry 4. IV Access a) 325 of 640 5. If s/s of perfusion, altered mental status, CP, hypotension, signs of shock: a. prepare for transcutaneous placing b. atropine 0.5mg IV while waiting for pacer (may repeat for total of 3mg IV) c. epi or dopamine drip while waiting pacer Atrial Flutter Etiology/ Clinical SignsEtiology: -occurs w/ heart disease -CAD -Valve Disorders Clinical Signs: -may cause thrombus -"saw tooth" -250-400 bpm Atrial Flutter Treatment -Give anticoagulants (faster the HR, more risk for thrombus) -treat underlying cause -digoxin (slows rate by enhancing AV block) -Quinidine (supresses atrial ectopic block) -Amiodarone -Calcium Channel Blockers (Cardizem)/Beta Blockers (-olol) -consider cardioversion Atrial Fibrillation Etiology/Causes Etiology: -Advanced Age -Valve Disorders -cardiomyopathy Causes: -chocolate (theobromine-stimulant) -sleep apnea a) 326 of 640 -athletes -tall athletes -aging heart -men more than women Atrial Fibrillation Treatment 1. Amiodarone 2. Calcium Channel Blockers, Beta Blockers, digoxin 3. Synchronized cardioversion if unstable 4. radio frequency catheter ablation 5. anti-coagulation therapy 6. Cardizem Amiodarone May cause liver, lung damage, and worsening of arrhythmias. Pt to report SOB, wheezing, jaundice, palpitations, lightheadedness Rhythms for cardioversion 1. A-Fib 2. A-Flutter 3. SVT Electrical Cardioversion Tx of choice if pt has a hemodynamically unstable tachydysrhythmia; unstable ventricular tachycardia w/ a pulse; prevention of life-threatening dysrhythmias; cardioversion can be planned or emergent; proper cardioversion will correct pt dysrhythmia w/ minimal discomfort and maximum safety Post Cardioversion Care Same as when a pt is in AFib a) 327 of 640 If elective, digoxin is usually withheld for 48hrs prior to cardioversion to prevent dysrhythmias after procedure airway patency should be maintained and the patient state of consciousness should be evaluated Paroxysmal SVT Treatment 1. treat underlying cause 2. adenosine, beta blockers, digoxin, quinidine, MS 3. Carotid/Vagal Maeuver 4. Synchronized cardioversion if unstable Premature Ventricular Contraction Etiology 1. Hypoxia 2. Digoxin Toxicity 3. Mechanical Stimulation 4. Electrolyte Imbalance (potassium) 5. MI Premature Ventricular Contraction Clinical Signs 1. Depends on frequency 2. short diastolic filling time, decreased cardiac output 3. sensation of palpitations, skipped beats 4. Bigeminy (pvc every other beat) 5. Trigeminy (pvc every 3rd beat) Premature Ventricular Contraction Treatment 1. treat impaired hemodynamics 2. antiarrythmics 3. oxygen 4. monitor for PVC on T-Wave a) 328 of 640 Ventricular Arrythmias Etiology Same as PVC but also cardiomyopathy, myocardial irritability Ventricular Arrythmias Treatment 1. VT w/ a pulse: cardiovert 2. monitor more closely 3. prepare cardioversion (oxygen, lidocaine, treat cause) 4. VT w/o a pulse: defibrillate (call code) Torsades De Pointes Treatment IV Magnesium Ventricular Fib (Etiology, Clinical Signs) 1. Same as VT, PVC 2. Surgical Manipulation of heart 3. Failed cardioversion 1. Same as cardiac arrest 2. EKG is disorganized rhythm Ventricular Fib Treatment 1. IMMEDIATE DEFIBRILLATION X3 2. CPR 3. SURVIVAL IS <10% FOR EVERY MINUTE THE PT REMAINS IN V-FIB SCREAM (acronym) for VFib and VTach 1. Shock Q2min 2. CPR after shock (compressions followed by resp 30:2) for 2min 3. Rhythm check after 2 min of CPR and shock again if indicated 4. Epinephrine or vasopressin 5. Antiarrythmic medications: Amiodarone/Lidocaine 6. Magnesium Sulfate a) 329 of 640 Cardiac Arrest Ventricular Asystole due to VFibEtiology: trauma, overdose, MI Clinical Signs: asystole or VFib, no definable waves, absence of VS Ventricular Asystole TEA: trans-cutaneous pacemaker, epinephrine, atropine 1st Degree Heart Block Causes May be normal variant; inferior wall MI; drugs: verapamil or digoxin 1st Degree Heart Block Treatment Monitor; Observe for symptoms 2nd Degree Heart Block Causes organic heart disease, MI, Dig Toxicity, Beta and Calcium Blockers 2nd Degree Heart Block Treatment Monitor HR, Atropine, Temp Pacemaker, Avoid meds that decrease conductivity 3rd Degree Heart Block Causes Organic Heart Disease, MI, Drugs, Electrolyte Imbalance, Excess Vagal Tone 3rd Degree Heart Block Signs & Symptoms Extreme Dizziness, Hypotension, Syncope, Decrease CO, Altered Mental Status 3rd Degree Heart Block Treatment Pacemaker (temporary or permanent) a) 330 of 640 Loop diuretics: furosemide, ethacrynic acid, bumetande, torsemide excessive diuresis, monitor for dehydration, output less than 30ml/hr, hypotension, ototoxcity (irreversible w/ ethacrynic acid), hypokalemia,avoid in pregnancy, digoxin can increase toxicity, monitor BP, lithium, NSAIDs decrease effect thiazide diuretics: hydrochlorothiazide, chlorothiazide, methyclothiazide, thiazide-type diuretics, indapamide, chlorthalidone, metolazonemoderate diuretic assess for dehydration, report less that 30ml/hr, decrease in K, increase in glucose, avoid in pregnancy and lactation, no risk of hearing loss- alternate day can increase electrolyte imbalance K-sparing diuretics: spironolactone, triamterene, amiloride, may take 12-48hr to work- less strong hyperkalemia, endocrine effects (impotence and irregular menstrual), no w/ kidney failure osmotic diuretics: mannitol acute phase kidney injury, cerebral edema, prevent kidney failure in shock, monitor for heart failure, kidney failure, lithium excretion is increased ACE inhibitors: captopril (1hr before meal), enalapril, enalaprilat (only one for IV), fosinopril, lisinopril, ramipril, moexipril (1hr before meal): vasodilate, excrete water and sodium used in: heart failure, HTN, MI, nephropathy. stop diuretic 2-3days before ACE, dry cough, hyperkalmeia, rash and alter taste-report, angiodema, neutropenia, can increase lithium levels, avoid use of NSAIDs ARBs: losartan, valsartan, irbesartan, candesartan, olmesartan: dilate and excrete uses: HTN, prevent mortality following MI, stroke, angiodema, fetal injury, given PO aldosterone antagonists: eplerenone, spironolactone: used w/ HTN, Heart failure hyperkalemia, hyponatremia, flulike manifestations-report, dizziness, can cause lithium toxicity a) 331 of 640 Direct renin inhibitors: aliskiren, HTN angiodema, hyperkalemia, diarrhea- dose related, decreases levels of furosemide, atorvastatin can increase levels, monitor for hypotension,avoid high fat meals calcium channel blockers: nifedipine,verapamil, diltiazem, amlodipine, felodipine, nicardipine works on arteries, veins not affected meds used for angina nefedipine, amlodipine, nicardipine, verapamil, diltiazem meds used for HTN nifedipine,verapamil, diltiazem, amlodipine, felodipine, nicardipine meds used for cardiac dysrhythmias verapamil, diltiazem Nifedipein increased HR- can give beta blocker to fix, observe for swelling (can give diuretic), acute toxicity- monitor VS, admin. norepi, calcium, isoproterenol, lidocaine, iv fluids, gastric lavarge- slowling HR w/ beta blockers, no grapefruit juice verapamil, diltiazem OH and peripheral edema, constipation, cardiac suppression, dysrhtymias, acute toxicity , increase digoxin, don't use w/ beta blockers, avoid grapefruit juice alpha adrenergic blockers: prazosin, doxazosin mesylate, terazosin: HTN, BPH start with low dose, first dose given at night, change positions slowly, use carefully w/ antihypertensives. take med w/ food. a) 332 of 640 centrally acting alpha agonists: clonidine, guanfacine HCL, methyldopa: migraine, ADHD, HTN, withdrawal, severe cancer pain drowsiness, dry mouth, rebound hypertension so taper. don't use patch w/ sclerodermaand lupus, use cautiously w/ stroke, MI, DM, depression, renal failure. careful w/ prazosin and TCAs, Beta Blockers: metoprolol, atenolol, metoprolol succinate, esmolol, propranolol, nadolol, carvedilol, labetalol: HTN, agnina, migraine, glaucoma metoprolol and propranolol bradycardia, cautiously in diabetes, decreased cardiac output- monitor and notify, AV clock- baseline ECG,OH, rebound myocardium excitation: taper off meds: monitor clients taking beta blocker concurrently propranolol avoid w/ asthma, diabetes- monitor blood glucose b/c it masks signs of hypoglycemia hypertensive crisis: nitroprusside, nitroglycerin, nicardipine, clevidipine, enalaprilat, esmolol HCl excessive hypotension, cyanide poisoning- increased for liver issues, reduce by giving less than 5mcg/kg/min or thiosulfate, avoid prolonged use, protect from light, discard after 24 hr cardiac glycosides: digoxin: treatment of heart failure and dysrhythmias dysrhythmias, consume high K foods, .5-2 serum levels of digoxin, avoid use of quinidine, verapamil, thiazide, ACE can increase digoxin levels, antacids decrease adrenergic agonists: epinephrine, dopamine, dobutamine, isoproterenol, terbutaline Epinephrine: alpha 1, beta 1 and 2 vacoconstrict, increase HR, heart contraction, rate of conduction, bronchodilation helps w/ slows absorption of local anesthetics, manages a) 333 of 640 superficial bleeding, decreased congestion of nasal mucosa, increased BP, treatment of AV block and cardiac arrest, asthma dopamine: shock and heart failure low dose: renal blood dilation moderate: beta 1: renal dilation, increase HR, myocardial contractility, increased rate of conduction high: all above and vasoconstriction dobutamine: beta 1 increased HR, myocardial contraction,rate of conduction: used w/ heart failure epinephrine complications: hypertension, dysrhythmias, dopamine adverse dysrhythmias, necrosis dobutamine adverse increased HR Interactions of adrenergic agonists MAOIs with epi, TCAs with epi, general anesthetics w/ epi, alpha and beta adrengergic blockers and diuretics block dopamine organic nitrates: nitroglycerin, nitro-time (capsules), nitrostat (subling tablet), nitorlingual (spray), nitro-bid (topical), nitro-dur (transderm), nitro-bid Iv, isosorbide dinitrate, isosorbide mononitrate- treat angina use aspirin or acetaminophen to relive pain, OH, reflex tachy, tolerance, can increase cranial pressure, avoid alcohol, careful w/ beta blocker, calcium channel, diuretic, NO with viagra etc. sublingual tablet and translingual spray rapid onset, short duration treat acute attack, and prophylaxis of acute a) 334 of 640 use at first sign, prior to activity known to cause pain, stored in cool, dark place sustained release slow onset, long duration long term prophylaxis against anginal attacks swallow w/o crushing or chewing- empty stomach w/ water transdermal slow onset, long duration long-term prophylaxis against attacks patches shouldn't be cut, rotate, no hair, remove w/ soap and water, remove at night topical ointment slow onset, long duration long term phrophylaxis remove prior dose before applying new dose, clean hairless area, coverw/ saran, avoid touching ointment, IV used for angina that doesn't respond to other meds, contorl BP or induce hypotension suring surgery, heart failure from acute MI use glass IV bottle, start slow and titrate up, antianginal agent: ranolazine; lower cardiac O2 demand monitor ECG for QT prolonging, elevated BP, avoid use grapefruit juice, HIV protease, macrolide antibiotics, verapamil, quinidine, digoxin, simvastatin Class 1A-- Procainamide, quinidine gluconate, quinidien sulfast, disopyramide decrease electrical conduction, automaticity, repolarization rate: used w/ supraventricular tachycardia, ventricular tachycardia, atrial flutter, atrial fibrilation: Class 1B-- LIdocaine: mexiletine, tocainide decrease electrical conduction, automaticity, repolarization rate: short term use only for ventricular dysrhythmias a) 335 of 640 Class 1C: propafenone, flecainide decrease electrical conduction, decrease excitability, increase rate or repolarlization: SVT HMG COA Reductase inhibitors: the statins decrease LDL, increase HDL, hepatotoxic, myopathy, monitor CK, no grapefruit juice, erythromycin, ketoconazole, ezetimibe, gemfibrozil,fenofibrate cholesterol absorption inhibitor: ezetimibe- decreases LDL hepatitis, myopathy, don't take w/ bile acid, , fibrates if taken w/ statin monitor for more liver issues bile-acid sequestrants: colesevelam HCL, colestipoldecrease LDL increase fiber intake, oral fluids, take other meds 4hr before admin Nicotinic acid, niacin: lower LDL, raise HDL GI distress- take w/ food, facial flushing- take aspirin 30 minutes beforeeach dose, hyperglycemia, hepatotoxicity, hyperuricemia, fibrates: gemfibrozil, fenofibrate: increase HDL GI distress, gallstones, myopathy, heaptotoxicity, increases risk of bleeding w/ warfarin, use w/ statins increase myopathy class II medications: propanolol hydrochloride, esmolol hydrochloride, acebutolol hydrochloride decreases HR, slow rate of conduction, decrease atrial ectopic stimulation: used w/ Atrial fibrillation, atrial flutter, paroxysmal SVT, hypertension, angina class III meds: Amiodarone, Dofetilide, Ibutilide, Sotalol Decrease rate of repolarization, a) 336 of 640 Decrease electrical conduction, Decrease contractility, Decrease automaticity: used w/ Conversion of atrial fibrillation -oral route, Recurrent ventricular fibrillation, Recurrent ventricular tachycardia class IV meds: verapamil, diltiazem Decrease force of contraction, Decrease heart rate, Slow rate of conduction through the SA and AV nodes: Atrial fibrillation and flutter, SVT, Hypertension, Angina pectoris adenosine Decrease electrical conduction through AV node used w/ Paroxysmal SVT, Wolff-Parkinson-White syndrome digoxin Decrease electrical conduction through AV node, Increase myocardial contraction used w/ H, atrial fibrillation and flutter, paroxysmal SVT procainamide: complications lupus- resolves w/ disconinuation, control systems w/ NSAIDs, neutropenia and thrombocytopenia, cardiotoxicity, hypotension, pregnancy risk, contraindicated w/ hypersensitivity to procaine and quinidine, myasthenia gravis, lidocaine complications CNS effects, give phenytoin to control seizures, respiratory arrest: contraindicated in stokes-adams, wolf-parkinson syndrome, severe heartblock, liver and renal dysfunction, sinus bradycardia and heart failure Propafenone: complications bradycardia, heart failure, dizziness, weakness, monitor HR, chest pain edema. contraindicated in clients w/ AV block, severe heart failure, severe hypotension, and cardiogenic shock, use cautiously w/ heart, liver,kidney, failure. respiratory orders, older clients Propranolol: complications a) 337 of 640 hypotension, bradycardia, heart failure, fatigue, contraindicated in AV clock, heart failure, bradycardia, diabetes, liver, thyroid, respiratory, Wolff-parkinson white amiodarone: complications pulmonary toxicity, sinus bradycardia and AV block, monitor BP, HF, visual disturbances, liver and thyroid dysfunction,phlebitis with IV admin, hypotension, bradycardia, contraindicated in patients w/ AV block, pregnancy risk: av block, bradycardia, newborns and infants, HF, fluid and electrolyte imbalance verapamil: complications bradycardia, hypotension, HF, constipation, pregnancy risk, contraindicated in patients w/ IV form not used w/ tachycardia, adenosine: complications sinus bradycardia, hypotension, dyspnea, flushing of face, monitor ECG- effects last 1min or less. contraindicated in second and third degree heart block, AV block, atrial flutter, atrial fibrillation Digoxin: complications bradycardia, hypotension (therapeutic level: .5-.8) nausea, vomiting, dyrhythmias, hypokalemia, contraindicated: tachycardia, fibrillation, not use AV block, bradycardia, renal disease, hypothyroidism, cardiomyopathy Procainamide: interactions avoid antidysrhythmics, anticholinergic meds, antihypertneives, advise to take as prescribed, advise not to crush or chew sustained release preparations lidocaine interactions cimetidine, beta blockers, phenytoin, monitor client for CNS depression, IV admin is usually started w/ loading dose,used for no more than 24hr propafenone interactions a) 338 of 640 may slow metabolism and cause an increase in the levels of digoxin, anticoagulants, and propranolol; quinidine and amiodarone increasetoxicity, monitor ECG, bradycardia hypotension propranolol interactions verapamil, dilitiazem have additive cardiosuprression effects, careful w/ diabetic patients; instruct clients to take apical pulse and notify provider of changes amiodarone interactions increase plasma levels, cholestyramine decreases levels of amiodarone, use cautiously w/ diuretics, beta blockers, verapamil, no grapefruit juice. may increase digoxinn toxicity-highly toxic Verapamil interactions -lol may increase med, may potentiate carbamazapine and digoxin, may cause heart failure; may cause OH- report edema or SOB Adenosine interactions methyxanthines block receptors, dipridamole uptake in inhibited, short half life- so adverse are mild and last for less than one minute. digoxin interactions antacids and metoclopramide decrease digoxin, amiodarone, quinidine, verapamil, diltiazem, propafenone, flecainide increase digoxin levers, cortico, diuretics, thiazides, amphotericin B may decrease K levels- monitor HR- report is less than 60, eat high K diet Endometiral infection usually occurs with a prolonged rupture of membranes, not vacuum-assisted births. Intenstinal gas is a common side effect of clients following a cesarean birth Cervical lacerations are common complications from a) 339 of 640 vacuum-assisted birth are rare but can include perineal, vaginal, or cervical lacerations When a client is experiencing a wound evisceration... the nurse should initially stay with the client and call for help. Next, the nurse should place saline-soaked gauze on the exposed bowels to keep the internal organs moist. The nurse should then place the client in a supine position with his hips and knees bent to relieve pressure from the open wound. Last, the nurse should take the client's vital signs to assess for changes in hemodynamics. Valproic acid can causehepatic toxicity continuous passive motion (CPM) machine Turn of the CPM machine during meals to promote comfort and dietary intake. -The affected extremity should maintain neutral alignment. Heparin is an anticoagulant that inhibits the conversation of prothrombin to thrombin. Patients on an anticoagulant drug such asheparin are at an increased risk of bleeding. -Signs of bleeding: ecchymoses, tarry stools, mucosal bleeding, and pink/ red-tinged urine. Correct method for walking upstairs with crutches 1. Hold to rail with one hand and crutches with the other hand. 2. Push down on the stair rail and the crutches and step up with the "unaffected" leg. 3. If not allowed to place weight on the "affected" leg, hop up with the "unaffected" leg. 4. Bring the "affected" leg and the crutches up beside the "unaffected" leg. a) 340 of 640 5.Remember, the "unaffected" leg goes up first and the crutches move with the "affected" leg. Droplet precautions DROPLET: "SPIDERMAn" -Sepsis -Scarlet Fever -Strep -Pertussis -Pneumonia -Parvovirus -Influenza -Diphtheria -Epiglottitis -Rubella -Mumps -Adenovirus Management: Private room/mask -A private room a rom with other clients with the same infectious disease. -Masks for providers and visitors Airborne precautions: AIRBORNE: "My Chicken Hez TB" -Measles -Chicken pox -Herpes zoster -TB Management: neg. pressure room, private room, mask, n-95 for TB. a) 341 of 640 -A private room -Masks or respiratory protection devices for caregivers and visitors. -An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known or suspected to have TB. -Negative pressure airflow exchange in the room of at least six exchanges per hour. Contact precautions CONTACT: "MRS WEE" -MRSA -RSV -Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and staph) -Wound infections -Enteric infections (C-Diff) -Eye infections (conjunctivitis) Management: gown, gloves, goggles, private room VRSA - contact and airborne precautions (private room, door closed, negative pressure) -A private room or a room with other clients with the same infection. -Gloves and gowns worn by the caregivers and visitors. Stage I pressure ulcer Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blueor purple. Stage II pressure ulcer a) 342 of 640 Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Stage III pressure ulcer Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stage IV pressure ulcer Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deeppockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material) Glasgow Coma Score is calculated by using appropriate stimuli (a painful stimulus may be necessary) and then assessing the clients response in three areas. Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice.2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken, but inappropriately. 2 = Sounds are made, but no words. a) 343 of 640 1 = Vocalization does not occur. Motor (M) - The best motor response, with responses ranging from 6 to 1 6 = Commands are followed. 5 = Local reaction to pain occurs. 4 = There is a general withdrawal to pain. 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. 1 = Motor response does not occur. Responses within each subscale are added, with the total score quantitatively describing the client's level of consciousness. E + V + M = Total GCS When verifying NG tube placement, the pH of aspirated gastric fluid should A good indication of appropriate placement is obtaining gastric contents with a pH between 0 and 4. Sodium 136-145 Potassium 3.5-5 Total Calcium9.0- 10.5 Magnesium 1.3-2.1 Phosphorus 3.0-4.5 a) 344 of 640 BUN 10-20 Creatinine males 0.6-1.2 Creatinine females 0.5-1.1 Glucos e70- 105 HcbA1c <6.5% WBC 5,000-10000 RBC men 4.7-6.1 million/mm3 RBC women 4.2-5.4 millin/mm3 Hemoglobin men 14-18 Hemoglobin women 12-16 Hematocrit men 42-52 a) 345 of 640 Hematocrit women 37-47 Platelet 150,000-400,000 pH 7.35-7.45 pC02 35-45 p02 80-100 HC0 321- 26 Normal PT= 11-12.5 seconds Normal INR= 0.7-1.8 (Therapeutic INR 2-3) Normal PTT= 30-40 seconds (Therapeutic PTT 1.5-2 x normal or control values) Digoxi n0.5- 2.0 Lithiu m0.8- 1.4 Dilantin a) 346 of 640 10-20 Theophyllin e10-20 Latex Allergies Note that clients allergic to bananas, apricots, cherries, grapes, kiwis,passion fruit, avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well. Order of Assessment I-inspection P-palpation P-percussion A-auscultation Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate. Cane Walking C-cane O-opposite A-affected L-leg Crutch walking Remember the phase "step up" when picturing a person going up stairs with crutches. The good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the stairs..... OR "up to heaven. down to hell" a) 347 of 640 Delegation RNs DO NOT delegate what they can EAT--evaluate, assess, teach Angina Precipitating Factors: 4 E's Exertion: physical activity and exercise Eating Emotional distress Extreme temperatures: hot or cold weather Arterial occlusion: 4 P's Pain Pulselessness or absent pulse Pallor Paresthesia Congestive Heart Failure Treatment: MADD DOG Morphine Aminophylline Digoxin Dopamine Diuretics Oxygen a) 348 of 640 Gasses: Monitor arterial blood gasses Heart Murmur Causes: SPASMStenosis of a valve Partial obstruction Aneurysms Septal defect Mitral regurgitation Heart Sounds: All People Enjoy the Movies Aortic: 2nd right intercostal space Pulmonic: 2nd left intercostal space Erb's Point: 3rd left intercostal space Tricuspid: 4th left intercostal space Mitral or Apex: 5th left intercostal space Hypertension Care: DIURETICDaily weight Intake and Output Urine output Response of blood pressure Electrolytes a) 349 of 640 Take pulse Ischemic episodes or TIAs Complications: CVA, CAD, CHR, CRF Shortness of Breath (SOB) Causes: 4 As+4Ps Airway obstruction Angina Anxiety Asthma Pneumonia Pneumothorax Pulmonary Edema Pulmonary Embolus Stroke Signs: FASTFace Arms Speech Time Compartment Syndrome Signs and Symptoms: 5 P's a) 350 of 640 Pain a) 351 of 640 Pallor Pulse declined or absent Pressure increased Paresthesia Shock Signs and Symptoms: CHORD ITEMCold, clammy skin Hypotension Oliguria Rapid, shallow breathing Drowsiness, confusion Irritability Tachycardia Elevated or reduced central venous pressure Multi-organ damage Hypoglycemia Signs: TIREDTachycardia Irritability Restlessness Excessive hunger a) 352 of 640 Depression and diaphoresis Hypocalcaemia Signs and Symptoms: CATS Convulsions Arrhythmias Tetany Stridor and spasms Hypokalemia Signs and Symptoms: 6 L's Lethargy Leg cramps Limp muscles Low, shallow respirations Lethal cardiac dysrhythmias Lots of urine (polyuria) Hypertension Complications: The 4 C's Coronary artery disease (CAD) Congestive heart failure (CHF)Chronic renal failure (CRF) a) 353 of 640 Cardiovascular accident (CVA): Brain attack or stroke Traction Patient Care: TRACTION a) 354 of 640 Temperature of extremity is assessed for signs of infection Ropes hang freely Alignment of body and injured area Circulation check (5 P's) Type and location of fracture Increase fluid intake Overhead trapeze No weights on bed or floor Cancer Early Warning Signs: CAUTION UPChange in bowel or bladder A lesion that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious changes in wart or mole Nagging cough or persistent hoarseness Unexplained weight loss Pernicious Anemia a) 355 of 640 Leukemia Signs and Symptoms: ANT Anemia and decreased hemoglobin Neutropenia and increased risk of infection Thrombocytopenia and increased risk of bleeding Clients Who Require Dialysis: AEIOU (The Vowels)Acid base imbalance Electrolyte imbalances Intoxication Overload of fluids Uremic symptoms Asthma Management: ASTHMA Adrenergics: Albuterol and other bronchodilators Steroids Theophylline Hydration: intravenous fluids Mask: oxygen therapy Antibiotics (for associated respiratory infections) Hypoxia: RAT (signs of early) BED (signs of late)Restlessness a) 356 of 640 Anxiety Tachycardia and tachypnea Bradycardia Extreme restlessness Dyspnea Pneumothorax Signs: PTHORAXPleuretic pain Trachea deviation Hyperresonance Onset sudden Reduced breath sounds (& dyspnea) Absent fremitus X-ray shows collapsed lung Transient incontinence Causes: DIAPERS Delirium Infection Atrophic urethra Pharmaceuticals and psychological Excess urine output a) 357 of 640 Restricted mobility Stool impaction Dealing with Constipation Constipation is difficult or infrequent passage of stools, which may be hard and dry. Causes include: irregular bowel habits, psychogenic factors, inactivity, chronic laxative use or abuse, obstruction, medications, and inadequate consumption of fiber and fluid. Encouraging exercise and a diet high in fiber and promoting adequate fluid intake may help alleviate symptoms. Dealing with Dysphagia: Dysphagia is an alteration in the client's ability to swallow. Causes include: Obstruction Inflammation Edema Certain neurological disorders Modifying the texture of foods and the consistency of liquids may enablethe client to achieve proper nutrition. Clients with dysphagia are at an increased risk of aspiration. Place the client in an upright or high-Fowler's position to facilitate swallowing. a) 358 of 640 Provide oral care prior to eating to enhance the client's sense of taste. Allow adequate time for eating, utilize adaptive eating devices, and encourage small bites and thorough chewing. Avoid thin liquids and sticky foods.Dumping Syndrome Dumping Syndrome occurs as a complication of gastric surgeries that inhibit the ability of the pyloric sphincter to control the movement of food into the small intestine. This "dumping" results in nausea, distention, cramping pains, and diarrhea within 15 min after eating. Weakness, dizziness, a rapid heartbeat, and hypoglycemia may occur. Small, frequent meals are indicated. Consumption of protein and fat at each meal is indicated. Avoid concentrated sugars. Restrict lactose intake. Consume liquids 1 hr before or after eating instead of with meals (a drydiet) Gastroesophageal Reflux Disease (GERD) GERD leads to indigestion and heartburn from the backflow of acidic gastric juices onto the mucosa of the lower esophagus. Encourage weight loss for overweight clients. a) 359 of 640 Avoid large meals and bedtime snacks. Avoid trigger foods such as citrus fruits and juices, spicy foods, and carbonated beverages. Avoid items that reduce lower esophageal sphincter (LES) pressure, such as alcohol, caffeine, chocolate, fatty foods, peppermint and spearmint flavors and cigarette smoking. Peptic Ulcer Disease (PUD) PUD is characterized by an erosion of the mucosal layer of the stomach or duodenum. This may be caused by a bacterial infection with Helicobacter pylori or the chronic use of non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen. Avoid eating frequent meals and snacks, as they promote increased gastric acid secretion. Avoid alcohol, cigarette smoking, aspirin and other NSAIDs, coffee, black pepper, spicy foods, and caffeine. Lactose intolerance Lactose intolerance results from an inadequate supply of lactase, theenzyme that digests lactose. Symptoms include distention, cramps, flatus, and diarrhea. Clients should be encouraged to avoid or limit their intake of foods high in lactose such as: milk, sour cream, cheese, cream soups, coffee creamer, chocolate, ice cream, and puddings. a) 360 of 640 Diverticulosis and Diverticulitis: A high-fiber diet may prevent diverticulosis and diverticulitis by producing stools that are easily passed and thus decreasing pressure within the colon. During acute diverticulitis, a low-fiber diet is prescribed in order to reduce bowel stimulation. Avoid foods with seeds or husks. Clients require instruction regarding diet adjustment based on the needfor an acute intervention or preventive approach. Cholecystitis Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may cause problems include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods. Otherwise, the diet is individualized to the client's needs and tolerance. Acute Renal Failure (ARF): ARF is an abrupt, rapid decline in renal function. It is usually caused bytrauma, sepsis, poor perfusion, or medications. ARF can cause hyponatremia, hyperkalemia, hypocalcemia, and hyperphosphatemia. Diet therapy for ARF is dependent upon the phase of ARF and its underlying cause. Pre-End Stage Renal Disease (pre-ESRD): Pre-ESRD, or diminished renal reserve/renal insufficiency, is a predialysis condition characterized by an increase in serum creatinine. a) 361 of 640 Goals of nutritional therapy for pre-ESRD are to: Help preserve remaining renal function by limiting the intake of protein and phosphorus. Control blood glucose levels and hypertension, which are both risk factors. Protein restriction is key for clients with pre-ESRD. Slows the progression of renal disease. Too little protein results in breakdown of body protein, so protein intake must be carefully determined. Restricting phosphorus intake slows the progression of renal disease. High levels of phosphorus contribute to calcium and phosphorus deposits in the kidneys. Dietary recommendations for pre-ESRD: Limit meat intake. Limit dairy products to ½ cup per day. Limit high-phosphorus foods (peanut butter, dried peas and beans, bran,cola, chocolate, beer, some whole grains). Restrict sodium intake to maintain blood pressure. Caution clients to use vitamin and mineral supplements ONLY when recommended by their provider. a) 362 of 640 End Stage Renal Disease (ESRD): End Stage Renal Disease (ESRD): ESRD, or chronic renal failure, occurs when the glomerular filtration rate (GFR) is less than 25 mL/min, the serum creatinine level steadily rises, ordialysis or transplantation is required. The goal of nutritional therapy is to maintain appropriate fluid status, blood pressure, and blood chemistries. A high-protein, low-phosphorus, low-potassium, low-sodium, fluidrestricted diet is recommended. Calcium and vitamin D are nutrients of concern. Protein needs increase once dialysis is begun because protein and amino acids are lost in the dialysate. Fifty percent of protein intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy). Adequate calories (35 cal/kg of body weight) should be consumed to maintain body protein stores. Phosphorus must be restricted. The high protein requirement leads to an increase in phosphorus intake.Phosphate binders must be taken with all meals and snacks. Vitamin D deficiency occurs because the kidneys are unable to convert it to its active form. This alters the metabolism of calcium, phosphorus, and magnesium and leads to hyperphosphatemia, hypocalcemia, and hypermagnesemia. a) 363 of 640 Calcium supplements will likely be required because foods high in phosphorus (which are restricted) are also high in calcium. Potassium intake is dependent upon the client's laboratory values, which should be closely monitored. Sodium and fluid allowances are determined by blood pressure, weight,serum electrolyte levels, and urine output. Achieving a well-balanced diet based on the above guidelines is a difficult task. The National Renal Diet provides clients with a list of appropriate food choices. Nephrotic Syndrome Nephrotic syndrome results in serum proteins leaking into the urine. The goals of nutritional therapy are to minimize edema, replace lost nutrients, and minimize permanent renal damage. Dietary recommendations indicate sufficient protein and low-sodium intake. Nephrolithiasis (Kidney Stones) Increasing fluid consumption is the primary intervention for the treatment and prevention of the formation of renal calculi. Excessive intake of protein, sodium, calcium, and oxalates (rhubarb, spinach, beets)may increase the risk of stone formation. Prioritization Prioritization includes clinical care coordination such as clinical decision making, priority setting, organizational skills, use of resources, time management, and evaluation of care. a) 364 of 640 Clinical decisions are made by completing a thorough assessment which will help you make good judgments later when you see a changing clinical condition. A poor initial assessment can lead to missed findings later on. Priority setting refers to addressing problems and prioritizing care. It is critical for efficient care. The RN uses his/her knowledge of pathophysiology when prioritizing interventions with multiple clients. Orders of prioritization: 1. Treat first any immediate threats to a patient's survival or safety. Ex. obstructed airway, loss of consciousness, psychological episode or anxiety attack. ABC's. 2. Next, treat actual problems. Ex. nausea, full bowel or bladder, comfort measures. 3. Then, treat relatively urgent actual or potential problems that the patient or family does not recognize. Ex. Monitoring for post-op complications, anticipating teaching needs of a patient that may be unaware of side effects of meds. 4. Lastly, treat actual or potential problems where help may be needed in the future. Ex Teaching for self-care in the home. Here are some great principles to help you as you prioritize: Systemic before local a) 365 of 640 Acute before chronic Actual before potential Listen don't assume Recognize first then apply clinical knowledge Maslow's Hierarchy of Needs: Prioritize according to Maslow with physiological and safety issues before psychological esteem issues. Variant angina (Prinzmetal's angina) Due to a coronary artery spasm, oftening occurring during periods of rest. Unstable angina Occurs with exercise or emotional stress, but it increases in occurrence, severity, and duration over time. Stable angina Occurs with exercise or emotional stress and is relieved by rest ornitroglycerin (Nitrostat). electrolyte imbalance manifestations: hypocakelmia--> flat T waves on ECG hypercalcemia--> decreased deep tendon reflexes (DTRs) hypocalcemia--> tetany hyperkalemia--> tall peaked T waves on ECG a) 366 of 640 Addison's disease Decreased aldosterone and renin Hypothyroidism Decreased triiodothyronine (T3) and thyroxine Cushing's disease Elevated cortisol Diabetes Insipidus (DI) Decreased urine specific gravity Diabetes melitus Elevated glycosylated hemoglobin (HbA1c) Syndrome of Inappropriate Secretion of Antidiuretic Hormone Increased urine osmolality Cataract Progressive and painless loss of vision Angle-closure glaucoma Rapid onset of elevated IOP macular degeneration Central loss of vision Open-angle galucoma Loss of peripheral vision Retinal detachment Sudden loss of vision without pain Common disease's manifestations a) 367 of 640 Cholecystitis--> Murphy's sign Pancreatitis--> Turner's sign Peptic Ulcer Disease--> Upper epigastric pain 1-2 hours after meals Appendicits--> Pain at McBurney's point Decorticate Decerebrate Hepatitis disease transmissions Hepatitis A--> Ingestions o contaminated food/water Hepatitis B--> Unprotected sexual contact Nonviral Hepatits--> Drug toxicity Heart Failure Symptoms: Shortness of breath, fatigue, jugular vein distention, and anS3 are signs/symptoms of heart failure resulting from the decreased pumping ability of the heart and increased fluid volume. Hypovolemic shock position: Supine with legs elevated (shock position) Below-the-knee amputation Position: The client should be placed in the prone position several times a day to prevent hip flexion contractions. Chest tube a) 368 of 640 -Continuous bubling in the water seal champers indicates an air leak. If this is observed, the nurse should attempt to located the source of the air leak and intervene accordingly (tighten the connections, replace drainage system) Compartment syndrome Symptoms: Pulselessness (late sign), Increased pain unrelieved with elevation or by pain medication Left homonymous hemianopsia has lost the left visual field of both eyes. They are unable to visualize anything to the left of midline of the body. dialysis fistula client teaching: avoid lifting heavy objects with access-site arm, avoid carrying objects that compress the extremity, avoid sleeping on top of the extremity with the access device, perform hand exercises that promote fistula maturation, check the access site atintervals following dialysis, apply light pressure if bleeding, notify the provider if the site continues to bleed after 30 min following dialysis. Chronic renal failure Diet: low-protein, low-potassium, and high-carbohydrate, as well as low-sodium and low-phosphate Synchronized cardioversion is the electrical management of choice for atrial fibrillation, supra ventricular tachycardia (SVT) and ventricular tachycardia with a pulse. Myoglobin is the earliest marker of injury to cardiac or skeletal muscle and levels no longer evident after 24 hr. Troponin I A positive Troponin I indicates damage to cardiac tissues and level are no longer evident in the blood after 7 days. a) 369 of 640 Hyperglycemia -Test urines for ketones and report if outside the expected reference range atropine blocks the cardiac muscarinic receptors and inhibits the parasympathetic nervous system. The blockage of parasympathetic activity results in an increased heart rate. When the heart rate increases, cardiac output will also increase. Constant bubbling in a water seal chamber (of a chest tube) is an indication of an air leak Cleft lip: nursing care plan (postoperative)—"CLEFT LIP"Crying, minimize Logan bow Elbow restraints Feed with Brecht feeder Teach feeding techniques; two months of age (average age at repair) Liquid (sterile water), rinse after feeding Impaired feeding (no sucking)Position—never on abdomen Complication of severe preeclampsia—"HELLP" syndromeHemolysis Elevated Liver enzymes a) 370 of 640 Low Platelet count Dystocia: general aspects (maternal)—"4P's" Powers Passageway Passenger Psych Infections during pregnancy—"TORCH" Toxoplasmosis Other (hepatitis B, syphilis, group B beta strep) Rubella Cytomegalovirus Herpes simplex virus IUD: potential problems with use— "PAINS"Period (menstrual: late, spotting, bleeding) Abdominal pain, dyspareunia Infection (abnormal vaginal discharge) Not feeling well, fever or chills String missing a) 371 of 640 Newborn assessment components—"APGAR" Appearance Pulse Grimace Activity Respiratory effort Obstetric (maternity) history— "GTPAL"Gravida Term Preterm Abortions (SAB, TAB)Living children Oral contraceptives: Signs of potential problems— "ACHES"Abdominal pain (possible liver or gallbladder problem) Chest pain or shortness of breath (possible pulmonary embolus) Headache (possible hypertension, brain attack) Eye problems (possible hypertension or vascular accident) Severe leg pain (possible thromboembolic process) Preterm infant: Anticipated problems— a) 372 of 640 "TRIES"Temperature regulation (poor) a) 373 of 640 Resistance to infections (poor) Immature liver Elimination problems (necrotizing enterocolitis [NEC]) Sensory-perceptual functions (retinopathy of prematurity [ROP]) VEAL CHOP-which relates to fetal heart rate. Variable decels => Cord compression (usually a change in mother's position helps) Early decels => Head compression (decels mirror the contractions; this isnot a sign of fetal problems) Accelerations => O2 (baby is well oxygenated-this is good) Late decels => Placental utero insufficiency (this is bad and means there is decreased perfusion of blood/oxygen/nutrients to the baby). Nine-point Postpartum Assessment...BUBBLEHERB- Breasts U- Uterus BBladder B- Bowel functionLLochia E- Episiotomy H- Hemorrhoids E- Emotional Status R- Respiratory System Considerations for the pregnant client Admittance of a pregnant client to a medical-surgical unit: a) 374 of 640 You may have a pregnant client admitted with a diagnosis unrelated toher pregnancy and, therefore, she may be admitted to a general medical-surgical floor. A mnemonic to assist you in performing important assessment elements for these clients is FETUS. * F: Document fetal heart tones every shift. To assess fetal heart tones, usea handheld Doppler ultrasound and place it in an area corresponding to uterine height. For example, for a client who's less than 20 weeks' pregnant, the most likely area to find fetal heart tones is at the pubic hairline or the symphysis pubis. For a client whose pregnancy is more advanced, such as at 24 weeks, the fetal heart rate can most probably be heard midline between the symphysis pubis and the umbilicus. As the pregnancy advances in weeks, fetal heart tones can be heard closer to and possibly above the umbilicus. * E: Provide emotional support. Pregnant women who are experiencing unexpected medical conditions are at a high level of anxiety related to how the current medical problem may affect the fetus. You should take extra care to alleviate and reduce your client's anxiety by explaining all medications and treatments. Additionally, be prepared to listen for fetal heart tones anytime the client requests it to further reduce her worry of the fetus' well being. * T: Measure maternal temperature. Because your client's core body temperature is higher than you can detect through oral or tympanic thermometers, be alert to the presence of a fever. A high maternal a) 375 of 640 temperature can lead to fetal tachycardia and distress. An order for antipyretics on admission to ensure their quick availability will be a prudent request you should make to the admitting physician. * U: Ask about uterine activity or contractions. Make it a normal part of your routine to ask about any type of uterine pain, tightening, or discomfort throughout your shift. Be aware that early contractions often present as lower back pain. Don't attribute complaints of lower back pain to the hospital bed. If your client reports any unusual activity, take care to softly palpate the lower abdomen for periods of greater than 2 minutes while conversing with her. Watch for subtle changes of facial expression while simultaneously detecting a change in uterine tone. If contractions are suspected, your client will need to be monitored with continuous fetal monitoring in the labor and delivery unit. * S: Assess for the presence of and changes in sensations of fetal movement. After 20 weeks' gestation, all women should be able to report feeling the fetus move. This is an important assessment to perform and document at least every shift, easily accomplished by asking"How often are you feeling the baby move?" By asking this as an open-ended question, you'll receive more information about the quantityof fetal movement such as, "I haven't felt the baby move as much as usual today." Admittance of a postpartum client to a medical-surgical unit There are times when a woman may be hospitalized during the postpartum period for a medical condition. When this occurs, she'll mostlikely be placed on a general medical-surgical unit. Her admission will a) 376 of 640 cause you to ask: "What's normal during the weeks following the birth of a baby?" * Breasts. Within the first 24 hours postpartum, colostrum appears and is followed by breast milk within the first 72 hours. Breast engorgement is most likely to occur around day 4 postpartum. The engorged breast will appear full, taut, and even shiny. Although this is normal, it may be very uncomfortable for your client. In contrast, a woman with mastitis will usually run a fever higher than 100° F, report feeling "ill," and have one breast that's affected (firm, inflamed, swollen, and exquisitely tender to touch). If your client is breastfeeding her newborn, she'll require a breast pump. Depending on the medications ordered, the milk may need to be disposed of and not used for the baby. * Lochia. Sometimes women will experience lochia (vaginal discharge) untilthe time of their 6-week postpartum visit. Immediately after delivery, thelochia is red and heavy enough to require a pad change every 1 to 2 hours. By 7 days postpartum, the lochia should be lighter in color (pink to red) and amount, requiring a pad change every 4 hours. Lochia that becomes heavier, has a foul odor, and is accompanied by pelvic pain isn't a normal finding and requires immediate intervention. * Perineal care. For the first 2 weeks following delivery, clients will need to perform perineal hygiene as taught during the immediate postpartum period. This may include perineal water rinses following elimination using warm water or medicinal rinses, use of sitz baths, and comfort medications to the perineal and anal area. a) 377 of 640 * Cesarean section. If your client delivered her baby via cesarean section, continued assessment of the surgical incision is warranted for the first 2 to 3 weeks postpartum. Redness and warmth around the incision, excessive bruising around the incision, or incisional drainage requires immediate intervention. If the surgeon used staples to close the incision, they're usually removed approximately 5 days post-delivery. Remember, the hospitalized postpartum client is likely to be very emotional. Not only will she be experiencing the normal hormonal fluctuations of the postpartum period, she'll may also be distraught leaving her newborn at home and feeling that she's missing bonding time with her child. Visitation between the mother and her infant may be very limited to minimize the infant's risk of infection, but visits should be arranged if at all possible. Placenta Previa (PP) versus Abruptio Placenta (AP) Problem: PP--> Low implantation of the placenta AP--> Premature separation of the placenta Incidence: PP--> It occurs in approximately 5 in every 1000 pregnancies AP--> It occurs in about 10% of pregnancies and is the most common cause of perinatal death Risk factors: PP--> increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestation, a) 378 of 640 AP--> high parity, advanced maternal age, a short umbilical cord, chronic hypertensive disease, pregnancy-induced hypertension, direct trauma, vasoconstriction from cigarette use, thrombic conditions that lead to thrombosis such as autoimmune antibodies Bleeding: PP--> Always present AP--> May or may not be present Color of blood in bleeding episodes: PP--> Bright redAP--> Dark red Pain during bleeding: PP--> Painless AP--> Sharp, stabbing pain Management: PP--> Place the woman immediately on bed rest in a side-lyon position. Weight perineal pads. NEVER attempt a pelvic or rectal examination because it may initiate massive blood loss. AP--> Fluid replacement. Oxygen by mask. Monitor FHR. Keep the womanin a lateral position. DO NOT perform any vaginal or pelvic examinations or give enema. Pregnancy must be terminated because the fetus cannot obtain adequate oxygen and nutrients. If birth does not seem imminent, cesarean birth is method of choice for delivery. Common Thyroid Medications Levo thyro xine (Syn thro id,Levo thro id)Lio thyro nien (Cytomel) Liotrix ( Thyro lar) a) 379 of 640 Thyroid ( Thryoid USP) Antithyroid Medications (hyperthyroidism) Antithyroid medications are used to block (anti) the thyroid hormones. Antithyroid medications block (anti) the conversion of T4 into T3. Used to treat clients with Graves Disease, thyro toxicosis. Antithryoid medications are prescribed for clients who have an overactive thyroid or hyperthyroidism. In hyperthyroidism....everything is HIGHHHHHHH(HYPERRRRRRRRR) Clients that are prescribed this medication need to take radioactivity precautions. Common Antithyroid Medications: Propylthiouracil (PTU) Thyroid-Radioactive Iodine (hyperthyroidism) At high doses, thyroid radioactive iodine destroys thyroid cells. This drug is used for clients who have thyroid cancer and an over active thyroid (hyperthyroidism). Thyroid-NonRadioactive Iodine (hyperthyroidism) This medication creates a high level of iodine that will reduce iodine uptake by the thyroid gland. It inhibits the thyroid hormone production and blocks the release of thyroid hormones into the bloodstream. This medication tastes nasty; has a metallic taste! Clients are to drink this medication through a straw to prevent tooth discoloration. Radioactivity precautions are not necessary due to this drug is nonradioactive. Oral Hypoglycemic Agents These medications promote insulin release from the pancreas. Clientswho are prescribed oral hypoglycemic agents do not produce enough a) 380 of 640 insulin to lower their blood glucose (blood sugar) levels. Prescribed for clients with type 2 Diabetes Mellitus. Common Oral Hypoglycemic Agents: glipizide( Gluco trol, Gluco trolXL). See the form of glucose in the drug name? chlorpropamide ( Diab ines).See the form of Diabetes in the drug name? glyburide ( Diab inese,Micronase). See the form of Diabetes in the drug name? metforminHC1 ( Gluco phage). See the form of glucose in the drug name? For Insuline Overdose Common medication for insulin overdose: Gluc agon (see the form of glucose in the drug name?) Glucagon (or glucose) is needed to increase blood glucose or blood sugar. Anterior Pituitary Hormons/Growth Hormones These medications stimulate growth. Are used to treat growth hormone deficiencies. Use cautiously in clients who have Diabetes Mellitus since these medications cause hyperglycemia because of the decreased use of glucose. Common Anterior Pituitary Hormones/Growth Hormone Agents: somatropin somatrem(Protropin) a) 381 of 640 Posterior Pituitary Hormones/Antidiuretic Hormone This medication promotes the reabsorption of water within the kidneys; causes vaso constriction due to the contraction of vascular smooth muscle. Common Posterior Pituitary Hormones/Antidiruetic Hormones: desmopressin (DDAVP, stimate) vaso pressin (Pitressin synthetic) (See the form of vaso in the drug name, for vaso constriction) Anticonvulsants The anticonvulsants are medications used for the treatment of epileptic seizures. These meds suppress the rapid and firing of neurons in the brain that start a seizure. Drugs for all types of seizures, except petit mal: CaPhe like cafe in French CA rbamazepine PHE nytoin/Phenobarbital Drugs for petit mal seizures: ValEt Val proic AcidEt hosuximide Phenytoin: adverse effects a) 382 of 640 P - interactions H irsutism E nlarged gumsN ystagmus Y ellow-browning of skinT eratogenicity O steomalacia I nterference with B metabolism (hence anemia) N europathies: vertigo, ataxia, headache All anti-epileptic drugs can be remembered by this mnemonic: Dr.BHAISAB's New PC. D ...Deoxy barbiturates B ...Barbiturates H....Hydantoin A....Aliphatic carb acids I ... Iminostilbenes S ...Succinimides a) 383 of 640 B... Benzodiazepines (BZD's) N....Newer drugs P ... Phenyltriazines C.. Cyclic gaba analogues Antiparkinsonian An antiparkinson, or antiparkinsonian medications are used for clients diagnosed with Parkinson's Disease. These medications increase dopamine activity or reduce acetylcholine activity in the brain. They do not halt the progression of the disease. These medications offer symptomatic relief. Anti-Parkinsonian Drugs include: A Cat Does Like Milk!A nticholinergic Agents C OMT Inhibitors (catechol-O-methyltransferase); An enzyme involved indegrading neurotransmitters. D opamine Agonists L evodopa M AO-B Inhibitors Opthalmic Ophthalmic medications are drugs used for the eye. These medications are typically prescribed for clients who have Glaucoma, Macular a) 384 of 640 Degeneration. Other ophthalmic medications are used to treat allergic a) 385 of 640 conjunctivitis, inflammatory disorders, dyes to visualize the eye, and to treat infections or viruses. Beta-Adrenergic Blocking Agents Prescribed for clients who have open-angle glaucoma. These agents decrease the production of aqueous humor. Block beta 1and beta 2 receptors. Common Beta-Adrenergic Ophthalmic Blocking Agents: beta xolos ( Bet optic ) (see the form of beta in the drug names?) See optic in Betoptic? Opthalmic medication. levo beta xolol ( Beta xon) (see the form of beta in the drug names?) levobunolol ( Beta gan) (see the form of beta in the drug name?) timolol ( Bet imol) (see the form of beta in the drug name?) Prostaglandin Analogs First line treatment for glaucoma. Fewer side effects and just as effective as the beta-adrenergic Ophthalmic blocking agents. These drugs lower IOP by facilitating aqueous humor outflow by relaxing the ciliary muscle. Common Prostaglandin Analogs: latanoprost (Xal atan ) (see the suffix atan in this drug and the drug below, they are the same) a) 386 of 640 Travoprost (trav atan ) (see the suffix atan in this drug and the drug above; they are the same) Alpha2-Adrenergic Agonists These drugs lower IOP by reducing aqueous humor production and by increasing outflow. Also delays optic nerve degeneration and protects retinal neurons from death. Common Alpha2-Adrenergic Agonists: Brimon idine (Alphagan) (see the similarities with idine in the name of the drug) Apraclon idine (Iop idine ) (see the similarities with idine in both of the names of the drug) Direct Acting Cholinergic Agonist/Muscarinic Agonist (parasympathomimetic agent) These drugs stimulate the cholinergic receptors in the eye, constricts the pupil (miosis), and contraction of the ciliary muscle. IOP is reduced by the tension generated by contracting the ciliary muscle and promotes widening of the spaces within the trabecular meshwork, thereby facilitating outflow of aqueous humor. Common Direct Acting Cholinergic Agonist Agents: Pilocarpine Key points of ophthalmic medications: · Cylo plegics are drugs that cause paralysis of the ciliarymuscle...plegic-like paraplegic, paralysis a) 387 of 640 · Mydriatics are drugs that dilate the pupil. · Drug therapy for glaucoma is directed at reducing elevated IOP, by increasing aqueous humor outflow or decreasing aqueous humor production. · Oculus Dexter: OD (right eye) · Oculus Sinister: OS (left eye) · Oculus Uterque: OU (both eyes) Remember BAD POCC: Ophthalmic Medication Classes for treatment of Glaucoma B -beta adrenergic blocking agents A -Alpha-Adrenergic Agonists D -Direct Acting Cholinergic AgonistsP -Prostaglandin Analogs O -Osmotic Agents C -Carbonic Anhydrase Inhibitors C -Cholinesterase Inhibitor; An indirect acting Cholinergic Agonist Remember BAD POCC for key points or side effects of Opthalmic Medications: B -Blurred vision a) 388 of 640 A -Angle closure glaucoma (medications are used for this kind of glaucoma) D -Dry eyes P -Photophobia O -Ocular pressure (used to treat OP from glaucoma) C -Can Cause systemic effects C -Ciliary muscle constriction Gestational diabetes mellitus Impaired tolerance to glucose with the first onset or recognition during pregnancy Hyperemesis Gravidarum Severe morning sickness with unrelenting, excessive nausea or vomitingthat prevents adequate intake of food and fluids HELLP syndrome A variant of gestational hypertension where hematologic conditions coexist with severe preeclampsia and hepatic dysfunction. Gestational hypertension Hypertension beginning after the 20th week of pregnancy with noproteinuria. Mild preeclampsia Hypertension beginning after the 20th week of pregnancy with 1 to 2+ proteinuria and a weight gain of more than 2 kg per week in the second and third trimesters. a) 389 of 640 Eclampsia Severe preeclampsia symptoms with seizure activity or coma Taking in phase 24-48 hours after birth: dependent, passive; focuses on own needs; excited, talkative Taking hold phase focuses on maternal role and care of the newborn; eager to learn; maydevelop blues Letting go phase Focuses on family and individual roles Cephalopelvic disproportion When the fetus has a head size, shape or position that does not allow for passage through the pelvis. Presentation Includes cephalic, breech and shoulder. Longitudinal lie The fetal long axis is parallel to the mother's long axis. The fetus is either in a breech or vertex presentation Duration The amount of time elapsed from the beginning of one contraction to theend of the same contraction. Intensity The strength of the uterine contraction. Transverse lie a) 390 of 640 The long axis of the fetus is at a right angle to the mother's long axis. This is incompatible with a vaginal delivery if the fetus remains in this position Frequency The amount of time from the beginning of one contraction to the beginning of the next contraction Regularity The amount of consistency in the frequency and intensity of contractions. Station The relationship of the presenting part to the maternal ischial spines thatmeasures the degree of descent of the fetus. missing birth control pills... In the event of a client missing a dose the nurse should instruct the client that if one pill is missed to take as soon as possible. If two or three pills are missed the client should follow the manufacturer's instructions and use an alternative form of contraception. pediatric acetaminophen levels >200 mcg/ml pediatric carbon dioxide cord--> 14- 22premature 1 week - ->14-27 newborn --> 13-22 infant, child --> 20-28 pediatric chloride level Cord --> 96-104 Newborn --> 97-110 Child --> 98-106 a) 391 of 640 Conjugated direct Bilirubin level 0.0-0.2 mg/dl pediatric creatinine level cord --> 0.6-1.2 newborn --> 0.3-1.0 infant 0.2-0.4 child --> 0.3-0.7 adolescent --> 0.5-1.0 pediatric Digoxin toxic concentration > 2.5 ng/ml pediatric Glucose (Serum) Newborn, 1 day --> 40 to 60 Newborn, > 1 day --> 50 to 90 Child --> 60 to 100 pediatric Hematocrit levels 1 day --> 48-69% 2 day --> 48-75% 3 day --> 44-72 % 2 month --> 28-42 % 6- 12 year --> 37-49% 12- 18 year Male --> 37-49% 12-18 year Female --> 36-46% Antigout Medications - What is gout? Gout is a type of arthritis. In healthy people the body breaks down dietary purines and produces uric acid. The uric acid dissolves and is excreted via the kidneys. In individuals affected with gout the body eitherproduces too much uric acid or is unable to excrete enough uric acid and it builds up. High uric acid levels results in urate crystals which can now a) 392 of 640 collect in joints or tissues. This causes severe pain, inflammation and swelling. Treatment is both lifestyle adjustment and medication. Medications First Line: NSAIDs and prednisone (Deltasone) Purpose: Used as a first line defense to treat the pain and inflammationof gout attacks. Colchicine (Colgout): Purpose: Treat the inflammation and pain associated with gout. Just like NSAIDs, these meds can lead to GI distress and should be taken with foods. HINT: The word gout is right in the name Colgout. Allopurinol (Zyloprim): Purpose: This is the only medical preventative treatment for gout. Allopurinal prevents uric acid production. This can be an effective means of preventing gout attacks when diet alone is not effective. HINT: Examine the name allopurinol and you can see the word PURINE in the middle of the name. Note: There are many drug and food interactions associated with allopurinol: a) 393 of 640 Potential serious interactions with the use of saliscylates, loop diuretics, phenylbutazamines and alcohol and potential for drug interactions with Warfarin (Coumadin). Teach client with gout to avoid the following: · Anchovies, sardine in oil, fish roe, herring · Yeast · Organ meat (liver, kidneys, sweetbreads) · Legumes (dried beans and peas) · Meathextracts (gravies and consommé) · Mushrooms, spinach, asparagus, cauliflower Anti-reabsorptives What is anati-reabsorptive? Bone is a living organ which is continually being removed (resorbed) and rebuilt. Osteoporosis develops when there is more resorption than rebuilding. Antiresorptive medications are designed to slow bone removal and or improve bone mass. Treating and preventing osteoporosis can involve lifestyle changes and sometimes medication. Lifestyle change includes diet and exercise, and fall prevention. Prevention and treatment of osteoporosis involve medications that work by preventing bone breakdown or promote new bone formation. Medications a) 394 of 640 Bisphosphonates prevent the loss of bone mass Alendronate (Fosamax) Monthly used to treat and prevent osteoporosis in menopausal women. Facts: The benefits of Fosamax can even be seen in elderly women over 75 years of age. Hint: Fosamax has been associated with severe esophagitis and ulcers of the esophagus. Should be avoided in clients with history of gastric ulcers. Risedronate (Actonel): This is a newer drug and less likely to cause esophageal irritation Hint: Teach clients taking either drug to take on an empty stomach with at least 8 ounces (240 ml) of water, while sitting or standing. This minimizes the chances of the pill being lodged in the esophagus. Clients should also remain upright for at least 30 minutes after taking these pills to avoid reflux in to the esophagus. For those clients who cannot tolerate the esophagus side effects of Fosamax, estrogen, etidronate (Didronel), and calcitonin are possiblealternatives. Teriparatide (Forteo): It acts like parathyroid hormone and stimulates osteoblasts, thus increasing their activity. Promotes bone formation. Facts: This drug is associated with a risk of bone tumors so is only used when the benefits outweigh the risks. Antirheumatics What is rheumatoid arthritis? a) 395 of 640 Rheumatoid arthritis (RA) is a chronic disease that results in inflammation of the joints and surrounding tissues. RA affects the lining of the joints and the painful swelling can result in bone erosion and joint deformities.It is the small joints in hands and feet are most often affected. Treatment is designed to provide symptom relief and some delay in progression of the disorder but not a cure. Medications Disease-modifying Antirheumatic drugs (DMARDs), glucocorticoids, and non-steroidal anti-inflammatory drugs (NSAIDs) may be used individuallyor in combination to manage this chronic disorder. The major categories of antirhematics are: DMARDs I - Major Nonbiologic DMARDs · Cytotoxic medications: Methotrexate (Rheumatrex), leflunomide (Arava) · Antimalarial agents: Hydroxychloroquine (Plaquenil) · Anti-inflammatory medication: Sulfasalazine (Azulfidine) · Tetracycline antibiotic: Minocycline (Minocin)DMARDs II - Major Biologic DMARDs · Etanercept (Enbrel) · Infliximab (Remicade) · Adalimumab (Humira) · Rituximab (Rituxan) a) 396 of 640 · Abatacept (Orencia) DMARDs III - Minor nonbiologic and biologic DMARDs · Gold salts: Aurothioglucose (Solganal) · Penicillamine (Cuprimine, Depen) · Cytotoxic medications: Azathioprine (Imuran), cyclosporine(Sandimmune, Gengraf, Neoral) · Glucocorticoids: · Prednisone (Deltasone), prednisolone (Prelone) ● NSAI DsHints: DMARDs slow joint degeneration and progression of rheumatoid arthritis. Glucocorticoids and NSAIDs provide symptom relief from inflammation and pain. Rheumatrex ( methotrexate ) is the most commonly used DMARD. This is because it has been shown to work as well or better than any other single medicine. It is also relatively inexpensive and generally safe. Methotrexate has many food and drug interactions especially affect digoxin and phenytoin. Very difficult to absorb and should be taken on an empty stomach. a) 397 of 640 Taking folic acid helps reduce some of the side effects. Methotrexate's biggest advantage could be that it has been shown to be safe to take forlong periods of time and can even be used in children. Antineoplastics Antineoplastics are used combat cancerous cells. There are many kinds of anti-cancer drugs with a variety of actions. But in simple terms this category of drugs attack cells that multiply and divide. This very action which can kill cancer cells can also do the same to healthy dividing cells. This is especially true of cells that need a steady supply of new cells such as skin, hair and nails. There are over 90 different kinds of chemotherapy agents and differentdrugs cause different side effects Chemotherapy is associated with a variety of side effects: § Nausea and vomiting § Diarrhea and or constipation § Alopecia § Anorexia § Fatigue and exhaustion § Mouth sores § Easy bruising Medications Fluorouracil (5-fluorouracil, 5-FU) Warning - Hazardous drug! a) 398 of 640 5-FUis one of the oldest chemotherapy drugs and is used against a varietyof cancers. Following are some of the most common and important ill effects: · Soreness of the mouth, difficulty swallowing · Diarrhea · Stomach pain · Low platelets · Anemia · Sensitive skin (to sun exposure) · Excessive tear formation from the eyes Nursing Hints: Be aware of the importance of leucovorin rescue with fluorouracil therapy, if prescribed. · The best treatment for extravasation is prevention. · Extravasation can cause pain, reddening, or irritation on the arm with the infusion needle. In severe cases in can lead to tissue necrosis and even loss of an extremity. · Check infusion site frequently · Stop infusion immediately if suspected a) 399 of 640 · Slowly aspirate back blood back from the arm · Elevate arm and rest in elevated position · Check institution policies on how to remove catheter Oral hypoglycemics What is diabetes? Diabetes is a disorder that affects glucose metabolism. Type 1 diabetes: The client either makes no insulin or not enough insulin. Type 2 diabetes: The client makes enough insulin at least early in the disease but is unable to transport glucose from the blood into the cells. In both cases, the individual is unable to metabolize glucose. The purpose of oral hypoglycemics is to assist with glucose metabolism. Medications There are four classes of hypoglycemic drugs: · Sulfonylureas Tolbutamide (Orin ase); glyburide; Micron aseStimulates insulin production Associated with weight gain · Biguanide: Metformin o First line drug in type 2 diabetes a) 400 of 640 o Reduces the production of glucose within the liver o Associated with modest weight loss o Less likely to cause hypoglycemia. o Significant lipid-lowering activity. · Thiazolidinediones o Reverses insulin resistance o Increases glucose uptake and decreased glucose production o Associated with severe liver damage · Alpha-glucosidaseinhibitors. o Acarbose (Precose) o Reduces the absorption of dietary glucose o Associated with flatulence and diarrhea Hints: No matter which class the client will be taking there is always the risk of hypoglycemia Be sure to teach client how to recognize early signs and symptoms of hypoglycemia as well as appropriate interventions. Mental Status Exam a) 401 of 640 All clients should have a Mental Status Exam, which includes: Level of consciousnessPhysical appearance Behavior Cognitive and intellectual abilities The nurse conducts the MSE as part of his or her routine and ongoing assessment of the client. Changes in Mental Status should be investigated further and the providernotified. There are two types of mental health hospitalizations: Voluntary commitment and involuntary or civil commitment. Involuntary commitment is against the client's will. Despite that, unless proven otherwise, clients are still considered competent and have the right torefuse treatment. Use the following communication tips when answering questions on NCLEX: * If the client is anxious or depressed -use open-ended, supportive statements * If the client is suicidal - use direct, yes or no questions to assess suicide risk * If the client is panicked - use gentle guidance and direction * If the client is confused - provide reality orientation * If the client has delusions / hallucinations / paranoia - acknowledge these, but don't reinforce * If the client has obsessive / compulsive behavior - communicate AFTER the compulsive behavior * If the client has a personality or cognitive disorder - be calm and matter-of-fact ECT a) 402 of 640 The most common type of brain stimulation therapy is electronconvulsive therapy or ECT. ECT is generally performed for major depressive disorders,schizophrenia or acute manic disorders. Most clients receive therapy three times a week for two to three weeks. Prior to ECT, carefully screen the client for any home medication use. Lithium, MAOIs and all seizure threshold medications should be discontinued two weeks prior to ECT. After therapy, reorient the client as short term memory loss is common. Anxiety disorders Anxiety disorders are common mental health disorders. Generalized Anxiety Disorder, Panic Disorder, Phobias, Obsessive Compulsive Disorder,and Posttraumatic stress disorder (PTSD) are all considered types of anxiety disorders. Assess the client for risk factors, triggers and responses. Depressive disorders A classic symptom of depression is change in sleep patterns, indecisiveness, decreased concentration, or change in body weight. Any client who shows these signs or symptoms should be asked if they have suicidal ideation. Teach clients to never discontinue anti-depressants suddenly. Bipolar disorders Bipolar disorders are mood disorders with periods of depression and mania. Clients have a high risk for injury during the manic phase related to decreased sleep, feelings of grandiosity and impulsivity. Hospitalization is often required and nurses should provide for client safety. abuse There are several different types of abuse, including physical, sexual, or emotional. Abuse tends to be cyclic, following a pattern on tension building, battering and honeymoon phase. When test questions appear related to abuse, look for the phase to determine the correct response. violent clients a) 403 of 640 For the aggressive or violent client, setting boundaries and limits on behavior are important. The nurse should maintain a calm approach anduse short, simple sentences. SSRI's SSRIs: Selective Serotonin Reuptake Inhibitors. These medications includeCitalopram (Celexa), Fluoxetine (Prozac), or Sertraline (Zoloft). The client should avoid using St. John's Wort with these medications, and should eat a healthy diet while on these medications. TCAs TCAs: Tricyclic Antidepressants. Amitriptyline (Elavil) is an example. Anticholinergic effects and orthostatic hypotension may occur. MAOIs MAOIs: Monoamine Oxidase Inhibitors. Phenelzine (Nardil) is an example. Hypertensive crisis may occur with tyramine food ingestion, so care must be taken to avoid these substances. Educate the client to avoid all medications until discussed with provider. Atypical antidepressants Atypical antidepressants. Bupropion (Wellbutrin) is the most common example. Appetite suppression is a common side-effect. Headache anddry mouth may be severe and client should notify the provider if this occurs. Atypical antidepressants should not be used with clients with seizure disorders. SNRI's Serotonin Norepinephrine Reuptake Inhibitors. Common SNRIs include Venlafaxine (Effexor) and Duloxetine (Cymbalta). Adverse effects may include nausea, weight gain, and sexual dysfunction. Antagonists In order to understand how antagonist drugs work, you need to understand how agonist drugs produce therapeutic effects. Agonists are a) 404 of 640 simply drugs that allow the body's neurotransmitters, hormones, and other regulators to perform the jobs they are supposed to perform. Morphine sulfate, codeine, and meperidine (Demerol) are opioids agonists that act on the mu receptors to produce analgesia, respiratory depression, euphoria, and sedation. These drugs also work on kappa receptors, resulting in pain control, sedation and decreased GI motility. Antagonists, on the other hand, are drugs that prevent the body from performing a function that it would normally perform. To quote William Shakespeare & the US Army, these drug classes allow the body's functions "to be or not to be...all that they can be". Common uses of antagonists: · Treatment of opioids overdose, reversal of effects of opioids, or reversal of respiratory depression in an infant · Example: a post-operative client receiving morphine sulfate for pain control experiences respiratory depression and is treated with naloxone (Narcan) Nursing Interventions for antagonists: · Monitor for side/adverse effects · Tachycardia and tachypnea · Abstinence syndrome in clients who are physically dependent on opioids agonists · Monitor for symptoms to include cramping, hypertension, and vomiting · Administer naloxone by IV, IM or subcutaneous routes, not orally a) 405 of 640 · Be prepared to address client's pain because naloxone will immediately stop the analgesia effect of the opioid the client had taken · When used for respiratory depression, monitor for return to normal respiratory rate (16-20/min for adults; 40-60/min for newborns) Antidotes Antidotes are agents given to counteract the effects of poisoning relatedto toxicity of certain drugs or substances. Antidotes are extremely valuable, however most drugs do not have a specific antidote. Atropine--> is the antidote for muscarinic agnostic and cholinesterase inhibitors: Bethanechol (Urecholine), Neostigmine (Prostigmin) Physostigmine (Antilirium)--> is the antidote for anticholinergic drugs, atropine. Digoxin immune Fab (Digibind)--> is the antidote for digoxin, digitoxin Vitamin K--> is the antidote for Warfarin (Coumadin) Protamine sulfate--> is the antidote for Heparin Glucagon--> is the antidote for insulin-induced hypoglycemia Acetylcysteine (Mucomyst)--> is the antidote for acetaminophen (tylenol) Bronchodilators Bronchodilators are used to treat the symptoms of asthma that result from inflammation of the bronchial passages, but they do not treat the inflammation. Therefore, most clients with asthma take an inhaled glucocorticoid concurrently to provide the best outcomes. The two most common classes of bronchodilators are beta2-adrenergicagonists and methylxanthines. a) 406 of 640 Beta2-adrenergic agonists : act upon the beta2-receptors in the bronchial smooth muscle to provide bronchodilation and relieve spasm of the bronchial tubes, inhibit release of histamines and increase motility of bronchial cilia. These short-acting preparations provide short-term relief during an asthma exacerbation, while the long-acting preparations provide long-term control of asthma symptoms. The generic names for the inhaled form of these drugs end in"terol" = " T aking E ases R espiratory distress o r L abored breathing" · Albu terol (Proventil, Ventolin) · Formo terol (Foradil Aerolizer) · Salme terol (Serevent) The brand names of some drugs in this class provide a hint as well because they contain the words "vent " or " breth " referring to ventilation or breathing: · Albuterol (Pro vent il, Vent olin) · Salmeterol (Sere vent ) · Terbutaline ( Breth ine) Nursing interventions and client education: · Short-acting inhaled preparations of albuterol (Proventil, Ventolin) can cause systemic effects of tachycardia, angina, and tremors. · Monitor client's pulse rate before, during, and after nebulizer or inhaler treatments a) 407 of 640 · Long-acting inhaled preparations can increase the risk of severe asthma or asthma-related death if used incorrectly—mainly if used without concurrent inhaled glucocorticoid use · Oral preparations can cause angina pectoris or tachydysrhythmias with excessive use · Instruct clients to report chest pain or changes in heart rate/rhythm to primary care provider · Client should be taught proper procedure when using metered dose inhaler (MDI) and spacer · If taking beta2-agonist and inhaled glucocorticoid concurrently, take the beta2-agonist first to promote bronchodilation which will enhance absorption of the glucocorticoid · Advise client not to exceed prescribed doses · Advise client to observe for signs of impending asthma attacks and keep log of frequency and intensity of attacks · Instruct to notify primary care provider if there is an increase in frequency or intensity of asthma attacks Methylxanthines: cause bronchial smooth muscle relaxation resulting in bronchodilation. Theophylline (Theolair) is the prototype medication and is used for long-term control of chronic asthma Nursing interventions: a) 408 of 640 · Monitor serum levels for toxicity at levels >20 mcg/mL · Mild toxicity can cause GI distress and restlessness · Moderate to severe toxicity can cause dysrhythmias and seizures · Educated client regarding potential medication and food interactions that can affect serum theophylline levels · Caffeine, cimetidine (Tagamet), and ciprofloxacin (Cipro) can increaselevels · Phenobarbital and phenytoin can decrease levels ACE inhibitors ACE inhibitors block the production ofangiotensin II which results in vasodilation, sodium and water excretion, and potassium retention. Drugs in this class are used for treating heart failure, hypertension, myocardial infarction, and diabetic or nondiabetic nephropathy. Clientstaking captopril (Capoten) should be instructed to take med at least 1 hour before meals; all other ACE inhibitors are not affected by food. The generic names of ACE inhibitors end in "pril": · Capto pril (Capoten) · Enala pril (Vasotec) · Fosino pril (Monopril) · Lisino pril (Prinivil) · Rami pril (Altace) a) 409 of 640 Side/adverse effects include: · Orthostatic hypotension with first dose · Instruct client to monitor BP for at least 2 hours after first dose · Cough, rash or altered or distorted taste (dysgeusia) · Instruct client to notify health care provider · Angioedema · Treated with epinephrine and symptoms will resolve once medication is stopped · Neutropenia is rare but serious with captopril (Capoten) · Instruct client to report signs of infection Hyperkalemia can be life-threatening Monitor potassium levels to maintain normal range of 3.5-5.0 mEq/L Medication/food interactions: · Concurrent use with diuretics can lead to first-dose orthostatic hypotension · Concurrent use with other antihypertensives can lead to increase effect resulting in hypotension · Concurrent use with potassium supplements or potassium-sparing diuretics increases the risk of hyperkalemia a) 410 of 640 · Concurrent use with lithium can increase serum lithium levels, leading to lithium toxicity · Concurrent use with NSAIDs can decrease the therapeutic effects of the ACE inhibitor Vasodilators Blood Transfusion - Types of reactions and onset Acute hemolytic - immediate Febrile - 30 min to 6 hr after transfusion Mild allergic - During or up to 24 hr after transfusion Anaphylactic - immediate Blood Transfusion Reaction - MedicationsAntipyretics (acetaminophen [Tylenol]) - febrile Antihistamines (diphenhydramine [Benadryl]) - mild allergic Antihistamines, corticosteroids, vasopressors - anaphylactic Blood Transfusion - Potential ComplicationsCirculatory overload: Administer oxygen. Monitor vital signs. Slow the infusion rate. Administer diuretics as prescribed. Notify the provider immediately a) 411 of 640 Blood Transfusion - Sepsis and septic shock Maintain patent airway. Administer oxygen. Administer antibiotics as prescribed. Obtain blood samples for culture. Administer vasopressors in late phase. Elevate client's feet. Assess for disseminated intravascular coagulation. Digoxin - Take apical pulse for 1 min, and monitor laboratory levels for signs of toxicity. Digoxin - Instruct the client not to take medication within 2 hr of eating, and teach client how to take an apical pulse for 1 min. Sodium polystyrene - Instruct the client to take a mild laxative if constipated, and teach how to take blood pressure Sodium polystyrene - Monitor for hypokalemia, and restrict sodium intake. Epoetin alfa - Instruct the client about having blood tests twice a week and how to take blood pressure. Epoetin alfa - Administer by subcutaneous route, and monitor for hypertension. Ferrous sulfate - Instruct the client to take medication with food and that stools will be dark in color. Ferrous sulfate - Administer following dialysis and with a stool softener Aluminum hydroxide gel - Avoid administering if client has gastrointestinal disorders; administer a stool softener with this medication Aluminum hydroxide gel - Instruct the client to report constipation to the provider and to take 2 hr before or after receiving digoxin. a) 412 of 640 Furosemide - Monitor intake and output and blood pressure. Furosemide - Instruct the client to weigh self each morning and to notify provider of light - headedness, excess thirst, and unusual coughing Asthma - Combination agents (bronchodilator and anti-inflammatory) Ipratropium and albuterol (Combivent) Fluticasone and salmeterol (Advair) If prescribed separately for inhalation administration at the same time, administer the bronchodilator first in order to increase the absorption of the anti-inflammatory agent ASTHMA- Encourage the client to drink plenty of fluids to promote hydration. Encourage the client to take prednisone with food. Advise client to use this medication to prevent asthma, not for the onsetof an attack. Encourage client to avoid persons with respiratory infections. Use good mouth care. Do not stop the use of this type of medication suddenly. Short-acting beta2 agonists, such as albuterol (Proventil, Ventolin) Provide rapid relief of acute symptoms and prevent exercise-induced asthma. a) 413 of 640 Anticholinergic medications, such as ipratropium (Atrovent), block the parasympathetic nervous system. This allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions. These medications are long-acting and used to prevent bronchospasms Ipratropium - Advise the client to suck on hard candies to help relieve dry mouth; increase fluid intake; and report headache, blurred vision, or palpitations, which may indicate toxicity of ipratropium. Ipratropium - Observe the client for dry mouth. Monitor the client's heart rate Methylxanthines, such as theophylline (Theo-24), require close monitoring of serum medication levels due to a narrow therapeutic range. Use only when other treatments are ineffective. Theophylline - Monitor the client's serum levels for toxicity. Side effectswill include tachycardia, nausea, and diarrhea Short-acting beta2 agonists, such as albuterol (Proventil, Ventolin), provide rapid relief of acute symptoms and prevent exercise-induced asthma. Albuterol - Watch the client for tremors and tachycardia. Salmeterol - Asthma Salmeterol - Advise client to use to prevent an asthma attack and not at the onset of an attack Combination agents (bronchodilator and anti-inflammatory) Ipratropium and albuterol (Combivent) a) 414 of 640 Fluticasone and salmeterol (Advair) If prescribed separately for inhalation administration at the same time, administer the bronchodilator first in order to increase the absorption of the anti-inflammatory agent Nursing Interventions/Client Education Watch the client for decreased immune function. Monitor for hyperglycemia. Omalizumab can cause anaphylaxis. Advise the client to report black, tarry stools. Observe the client for fluid retention and weight gain. This can be common. Monitor the client's throat and mouth for aphthous lesions (cold sores). Nontunneled percutaneous central catheter: Description - 15 to 20 cm in length with one to three lumens Length of use - short-term use only Insertion location - subclavian vein, jugular vein; tip in the distal third of the superior venacava Indications - administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition Peripherally inserted central catheter Description - 40 to 65 cm with single or multiple lumens Length of use - up to 12 months a) 415 of 640 Insertion location - basilic or cephalic vein at least one finger's breadth below or above the antecubital fossa; the catheter should be advanced until the tip is positioned in the lower one-third of the superior vena cava. Peripherally inserted central catheter - PICC Indications - administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition Tunneled percutaneous central catheter For long-term use. Indications - Frequent and long-term need for vascular access Insertion location - A portion of the catheter lies in a subcutaneous tunnel separating the point where the catheter enters the vein from where it enters the skin with a cuff. Tissue granulates into the cuff to provide a mechanical barrier to organisms and an anchoring for the catheter. Implanted port :a 1 year or more. Description - Port is comprised of a small reservoir covered by a thick septum. Indications - Long-term (a year or more) need for vascular access; commonly used for chemotherapy. a) 416 of 640 Apply local anesthetic to skin if indicated. Palpate skin to locate the port body septum to ensure proper insertion of the needle Clean the skin with alcohol for at least 3. Apply local anesthetic to skin if indicated. Palpate skin to locate the port body septum to ensure proper insertion of the needle. seconds and allow to dry prior to insertion of the needle. Access with a noncoring (Huber) needle. Occlusion is a blockage in the access device that impedes flow. Nursing Actions Flush the line at least every 12 hr (3 mL for peripheral, 10 mL forcentral lines) to maintain patency Infiltration and Extravasation Infiltration is fluid leaking into surrounding subcutaneous tissue, andextravasation is unintentional infiltration of a vesicant medication that causes tissuedamage A bone marrow Biopsy is commonly performed to diagnose causes of blood disorders, such as a) 417 of 640 anemia or thrombocytopenia, or to rule-out diseases, such as leukemia and other cancers, and infectionA bone marrow Pre Ensure that the client has signed the informed consent form. Position the client in a prone or side-lying position. Intra Administer sedative medication. Assist with the procedure. Apply pressure to the biopsy site. Place a sterile dressing over the biopsy site. A bone marrow - Post Monitor for evidence of infection and bleeding. Apply ice to the biopsy site. Administer mild analgesics; avoid aspirin or medications that affect clotting Potential Complications: a) 418 of 640 Bleeding and infection Client Education: A bone marrow: Explain the procedure to be performed: use of local anesthesia, sensation of pressure or brief pain. Report excessive bleeding and evidence of infection to the provider. Check the biopsy site daily. It should be clean, dry and intact. If there are sutures, return in 7 to 10 days for removal. Insulin glargine Insulin glargine, a long-acting insulin, does not have a peak effect time, but is fairly stable in effect after metabolized NPH NPH insulin has a peak effect around 6 to 14 hr following administration. Regular insulin Regular insulin has a peak effect around 1 to 5 hr following administration Insulin lispro Insulin lispro has a peak effect around 30 min to 2.5 hr following administration Repaglinide should not be taken just before bedtime; Repaglinide is not taken upon awakening in the morning Repaglinide causes a rapid, short-lived release of insulin. The client should take this medication within 30 min before each meal so that insulin is available when food is digested a) 419 of 640 Pramlintide delays oral medication absorption, so oral medications should be taken 1 to 2 hr after pramlintide injection Pramlintide should not be mixed in a syringe with any type of insulin Pramlintide can cause hypoglycemia, especially when the client also takes insulin, so it is important to eat a meal after injecting this medication. Unused medication in the open pramlintide vial should be discarded after 28 day' Unused medication in the open pramlintide vial should be discarded after28 day Acarbose can cause liver toxicity when taken long-term. Liver function tests should be monitored periodically while the client takes this medication Exenatide is prescribed along with an oral antidiabetic medication, such as metformin or a sulfonylurea medication, for clients who have type 2 diabetes mellitus to improve diabetes control. Exenatide improves insulin secretion by the pancreas, decreases secretion of glucagon, and slows gastric emptying Exenatide A/E: GI effects, such as nausea and vomiting Pancreatitis manifested by acute abdominal pain and possibly severe vomiting Hypoglycemia, especially when taken concurrently with a sulfonylurea medication, such as glipizide Exenatide a) 420 of 640 The nurse should monitor daily blood glucose testing by the client, periodic HbA1c tests, and periodic kidney function testing. Exenatide should be used cautiously in clients who have any renal impairment. Instruct client how to inject exenatide subcutaneously. Teach client to take exenatide within 60 min before the morning and evening meal but not following the meal. Advise client to withhold exenatide and notify the provider for severe abdominal pain. Teach the client how to recognize and treat hypoglycemia. Exenatide Teach the client that exenatide should not be given within 1 hr of oral antibiotics, acetaminophen, or an oral contraceptive due to its ability to slow gastric emptying Type 1 diabetes mellitus is an autoimmune dysfunction involving the destruction of beta cells, which produce insulin in the islets of Langerhans of the pancreas. Immune system cells and antibodies are present in circulation and may also be triggered by certain genetic tissue types or viral infections. Type 1 diabetes mellitus usually occurs at a young age, and there are no successful interventions to prevent the disease. Diabetic Screening: risk factors - obesity, hypertension, inactivity, hyperlipidemia, cigarette smoking, genetic history, elevated C-reactive protein (CRP), ethnic group, and women who have delivered infants weighing more than 9 lb ADA - recommends screening a client who has a BMI greater than 24 and age greater than 45 years, or if a child is overweight and has additional risk factors. a) 421 of 640 Rapid-acting diuretics, such as furosemide (Lasix) and bumetanide (Bumex), promote fluid excretion. Morphine decreases sympathetic nervous system response and anxiety and promotes mild vasodilation. Risk Factors: Obesity, physical inactivity, high triglycerides (greater than 250 mg/dL), and hypertension may lead to the development of insulin resistance and type 2 diabetes. Pancreatitis and Cushing's syndrome are secondary causes of diabetes. Vision and hearing deficits may interfere with the understanding of teaching, reading of materials, and preparation of medications. Tissue deterioration secondary to aging may impact the client's ability to prepare food, care for self, perform ADLs, perform foot/wound care, and perform glucose monitoring. Vasodilators (nitroglycerin, sodium nitroprusside) decrease preload and afterload. Inotropic agents, such as digoxin (Lanoxin) and dobutamine (Dobutrex), improve cardiac output. Older adult clients may not be able to drive to the provider's office, grocery store, or pharmacy. Assess support systems available for older adult clients. A fixed income may mean that there are limited funds for buying diabetic supplies, wound care supplies, insulin, and medications. This may result in complications. a) 422 of 640 Hyperglycemia - blood glucose level usually greater than 250 mg/dL. Polyuria (excess urine production and frequency) from osmotic diuresis olydipsia (excessive thirst) due to dehydration Loss of skin turgor, skin warm and dry Dry mucous membranes Weakness and malaise Rapid weak pulse and hypotension Polyphagia (excessive hunger and eating) caused from inability of cells to receive glucose (cells are starving); Client may display weight loss.Metabolic acidosis. Kussmaul respirations - Other: acetone/fruity breath odor ; headache, nausea, vomiting, abdominal pain, inability to concentrate, decreased level of consciousness, and seizures leading to coma. Rapid-acting insulin Lispro insulin (Humalog), aspart insulin (Novolog), glulisine insulin(Apidra). Administer before meals to control postprandial rise in blood glucose. Onset is rapid, 10 to 30 min depending on which insulin is administered. Administer in conjunction with intermediate- or long-acting insulin to provide glycemic control between meals and at night. Short-acting insulin Regular insulin (Humulin R, Novolin R). a) 423 of 640 Administer 30 to 60 min before meals to control postprandial hyperglycemia. Available in two concentrations. U-500 is reserved for the client who has insulin resistance and is never administered IV. U-100 is prescribed for most clients and may be administered IV Intermediate-acting insulin NPH insulin (Humulin N), detemir insulin (Levemir). Administered for glycemic control between meals and at night. Administer NPH insulin subcutaneous only and as the only insulin tomix with short-acting insulin. Long-acting insulin Glargine insulin (Lantus) Administered once daily, anytime during the day but always at the same time each day. Glargine insulin forms microprecipitates that dissolves slowly over 24 hr and maintains a steady blood sugar level withno peaks or troughs. Diabetic neuropathy Caused from damage to sensory nerve fibers resulting in numbness and pain. Is progressive, may affect every aspect of the body, and can lead to ischemia and infection. Monitor blood glucose levels to keep within an acceptable range to slow progression. ■Provide foot care. Diabetic nephropathy Damage to the kidneys from prolonged elevated blood glucose levelsand dehydration Nursing Actions Monitor hydration and kidney function (I&O, serum creatinine). Report an hourly output of less than 30 mL/hr. a) 424 of 640 DKA Lack of sufficient insulin related to undiagnosed or untreated type 1diabetes mellitus or nonadherence to a diabetic regimen Reduced or missed dose of insulin (insufficient dosing of insulin or error in dosage) Any condition that increases carbohydrate metabolism, such as physical or emotional stress, illness, infection (No. 1 cause of DKA), surgery, or trauma that requires an increased need for insulin ☐Increased hormone production (e.g., cortisol, glucagon, epinephrine) stimulates the liver to produce glucose and decreases the effect of insulin. Hypothyroidism Condition in which there is an inadequate amount of circulating thyroid hormones triiodothyronine (T3) and thyroxine (T4), causing a decrease in metabolic rate that affects all body systems. The older adult is at risk for altered metabolism of medication due to decreased kidney and liver function because of the aging process. The older adult may have visional alterations; yellowing of lens,decreased depth perception, cataracts, which can affect ability to read information and attend to medication administration. Hypothyroidism is also classified by age of onset. Cretinism - Cretinism is a state of severe hypothyroidism found in infants. When infants do not produce normal amounts of thyroid hormones, central nervous system development and skeletal maturation are a) 425 of 640 altered, resulting in retardation of cognitive development, physical growth, or both. Juvenile hypothyroidism - Juvenile hypothyroidism is most often caused by chronic autoimmune thyroiditis and affects the growth and sexual maturation of the child. Clinical manifestations are similar to adult hypothyroidism, and the treatment reverses most of the clinical manifestations of the disease. Adult hypothyroidism: Because older adult clients who have hypothyroidism may have manifestations that mimic the aging process, hypothyroidism is often undiagnosed in older adult clients, which can lead to potentially serious adverse effects from medications (sedatives, opiates, anesthetics) Hypothyroidism - S/S: Early findings; Fatigue, lethargy, irritabililyIntolerance to cold Constipation ; Weight gain without an increase; in caloric intake; Pale skin; Thin, brittle fingernails;Depression; Thinning hair; Joint and/or muscle pain; Early findings Fatigue, lethargy, irritabililyIntolerance to cold Constipation Weight gain without an increase in caloric intake Pale skin Thin, brittle fingernailsDepression Thinning hair Joint and/or muscle pain a) 426 of 640 Hypothyroidism: - Late findings: Bradycardia, hypotension, dysrhythmias; Slow thought process and speech; Hypoventilation, pleural effusion Thickening of the skin; Thinning of hair on the eyebrows; Dry, flaky skin; Swelling in face, hands, and feet (myxedema [non-pitting, mucinous edema]); Decreased acuity of taste and smell; Hoarse, raspy speech; Abnormal menstrual periods (menorrhagia/amenorrhea) and decreasedlibido; Laboratory Tests - The expected reference range for T3 is 70 to 205 ng/dL, and the expected reference range for T 4 is 4 to 12 mcg/dL.) Radioactive iodine (131 I) is administered orally 24 hr prior to a thyroid scan. The thyroid absorbs the radiation, which results in destruction of cells that produce thyroid hormone Client Education: Advise the client that the effects of the therapy may not be evident for 6to 8 weeks. Advise the client to take medication as directed. Advise female clients to avoid becoming pregnant for 6 months. Do not use same toilet as others for 2 weeks, sit down to urinate, and flush toilet three times. Take a laxative 2 to 3 days after treatment to rid the body of stool contaminated with radiation. a) 427 of 640 Wear clothing that is washable, wash clothing separate from clothing of others, and run the washing machine for a full cycle after washing contaminated clothing. Advise the client to avoid infants or small children for 2 to 4 days afterthe procedure. Avoid contamination from saliva, do not share a toothbrush, and use disposable food service items (paper plates). Teach the client that thyroid replacement therapy is usually lifelong. - Therapeutic Use Levothyroxine replaces T4 and is used as thyroid hormone replacement therapy. Replacement of T4also raises T3 levels, because some T4 is converted into T3. Adverse effects are essentially the same as manifestations ofhyperthyroidism: cardiac symptoms, such as hypertension and angina pectoris; insomnia, anxiety; weight loss; heat intolerance; increased body temperature; tremors; and menstrual irregularities Nursing Care: Adverse effects include cardiac effects, chest pain, hypertension, and palpitations, especially in older adults The nurse should monitor thyroid function tests: T3, T4, and TSH Teach the client to take levothyroxine on an empty stomach, usually 1 hr before breakfast. Teach the client that thyroid replacement therapy is usually lifelong. Monitor for adverse effects that indicate that the dosage needs to bereduced. a) 428 of 640 TPN provides a nutritionally complete solution. It can be used when caloric needs are very high, when the anticipated duration of therapy is greater than 7 days, or when the solution to be administered is hypertonic (composed of greater than 10% dextrose). It can only be administered in acentral vein. PPN can provide a nutritionally complete solution. However, it is administered into a peripheral vein, resulting in a limited nutritional value. It is indicated for clients who require short-term nutritional support with fewer calories per day. The solution must be isotonic and contain no more than 10% dextrose and 5% amino acids Identify three complications of TPNRelated Content 1 - Infection and sepsis Monitor for manifestations of fever, chills, increased WBCs,and redness around catheterinsertion site. 2 - Hyperglycemia Administer sliding scale insulinor plan for insulin to be added to the TPN solution. Monitor blood glucose 3 - Hypoglycemia a) 429 of 640 Inform the provider and plan to give additional dextrose. Monitor frequent blood glucose. Hypoglycemia - S/S Weight gain greater than 1 kg/day Inform the provider and anticipate a decrease in the concentration, rate of administration or volume of lipid emulsion. Monitor the client's intake of oral nutrients MS is an autoimmune disorder characterized by the development of plaque in the white matter of the central nervous system. Plaque damages the myelin sheath and interferes with impulse transmission between the CNS and the body. Diagnostic Procedures Laboratory Tests: Cerebrospinal fluid analysis. Diagnostic Procedures: MRI of the brain and spine Medication - MS Immunosuppressive agents such as azathioprine (Imuran) and cyclosporine (Sandimmune) - Long-term effects include increased risk for infection, hypertension, and kidney dysfunction. Corticosteroids such as prednisone - Increased risk for infection, hypervolemia, hypernatremia, hypokalemia, GI bleeding, and personality changes. a) 430 of 640 Antispasmodics such as dantrolene (Dantrium), tizanidine (Zanaflex), baclofen (Lioresal) and diazepam (Valium) are used to treat muscle spasticity. Corticosteroids such as prednisone Report increased weakness and jaundice to provider. Avoid stopping baclofen abruptly. Immunomodulators such as interferon beta (Betaseron) are used toprevent and treat relapses Anticonvulsants such as carbamazepine (Tegretol) are used for paresthesia. Stool softeners such as docusate sodium (Colace) are used for constipation Anticholinergics such as propantheline are used for bladder dysfunction. Beta-blockers such as primidone (Mysoline) and clonazepam (Klonopin) are used for tremors Amyotrophic lateral sclerosis (ALS) is a degenerative neurological disorder of the upper and lower motor neurons that results in deterioration and death of the motor neurons. This results in progressive paralysis and muscle wasting that eventually causes respiratory paralysis and death. Cognitive function isnot usually affected Death usually occurs due to respiratory failure within 3 to 5 years of the initial manifestations. The cause of ALS is unknown, and there isno cure. Physical Assessment Findings: Muscle weakness - usually begins in one part of the body Muscle atrophy; a) 431 of 640 Dysphagia ; Dysarthria; Hyperreflexia of deep tendon reflexes; Laboratory Tests - Increased creatine kinase (CK-BB) levelDiagnostic Procedures Electromyogram (EMG) - Reduction in number of functioning motor unitsof peripheral nerves Muscle biopsy - Reduction in number of motor unitsof peripheral nerves and atrophic muscle fibers ALS - Medication : Riluzole (Rilutek) is a glutamate antagonist that can slow the deterioration of motor neurons by decreasing the release of glutamic acid Baclofen (Lioresal), dantrolene sodium (Dantrium), diazepam (Valium) ■ Antispasmodics are used to decrease spasticity. Nursing Considerations: Monitor liver function tests - hepatotoxic risk. Assess for dizziness, vertigo, and somnolence. Complications: ALS: Pneumonia can be caused by respiratory muscle weakness and paralysis contributing to ineffective airway exchange. Nursing Actions - Assess respiratory status routinely and administer antimicrobial therapy as indicated. Complications: ALS: Respiratory failure may necessitate mechanical ventilation. Nursing Actions - Assess respiratory status and be prepared to provide ventilatory support as needed per the client's advance directives. a) 432 of 640 Myasthenia gravis (MG) is a progressive autoimmune disease that produces severe muscular weakness. It is characterized by periods of exacerbation and remission. Muscle weakness improves with rest and worsens with increased activity. Myasthenia gravis (MG) It is caused by antibodies that interfere with the transmission of acetylcholine at the neuromuscular junction Assessment: Myasthenia gravis Risk factors associated with rheumatoid arthritis, scleroderma, and systemic lupus erythematosus Subjective Data: Progressive muscle weakness; Diplopia; Difficulty chewing and swallowing; Respiratory dysfunction; Bowel and bladder dysfunction; Poor posture; Fatigue after exertion Objective Data: Physical Assessment Findings; Impaired respiratory status (difficulty managing secretions, decreased respiratory effort); Decreased swallowing ability Decreased muscle strength, especially of the face, eyes, and proximalportion of major muscle groups Incontinence Drooping eyelids - unilateral or bilateral Tensilon testing: Baseline assessment of the cranial muscle strength is done. a) 433 of 640 Edrophonium (Tensilon) is administered Medication inhibits the breakdown of acetylcholine, making it available for use at the neuromuscular junction. MG - Atropine Have atropine available, which is the antidote for edrophonium (bradycardia, sweating, and abdominal cramps). Therapeutic Procedures Plasmapheresis removes circulating antibodies from the plasma. This is usually done several times over a period of days and may continue on a regular basis for some clients. Monitor for the possible complications of hypovolemia, hypokalemia, and hypocalcemia. ■ Client Education - Instruct the client that the procedure will typically last 2 to 5 hr. Electromyography Shows the neuromuscular transmission characteristics of MG. Decrease in amplitude of the muscle is demonstrated over a series of consecutive muscle contractions Surgical Interventions Thymectomy - removal of the thymus gland is done to attain better control or complete remission. May take months to years to see results due to the life of the circulating T cells. Complications: ● Myasthenic crisis and cholinergic crisis; Myasthenic crisis occurs when the client is experiencing a stressor that causes an exacerbation of MG, such as infection, or is taking inadequate amounts of cholinesterase inhibitor. a) 434 of 640 Cholinergic crisis occurs when the client has taken too much cholinesterase inhibitor. Complications: The manifestations of both can be very similar (muscle weakness, respiratory failure). The client's highest risk for injury is due to respiratory compromise and failure. MYASTHENIC CRISIS Undermedication: Respiratory muscle weakness - mechanical ventilation Myasthenic findings (weakness, incontinence, fatigue) › Hypertension; › Temporary decrease of findings with administration of Tensilon; CHOLINERGIC CRISIS: Overmedication Muscle twitching to the point of respiratory muscle weakness - mechanical ventilation › Cholinergic manifestations - hypersecretions (nausea, diarrhea, respiratory secretions) and hypermotility (abdominal cramps) Cholinergic manifestations - hypersecretions (nausea, diarrhea, respiratory secretions) and hypermotility (abdominal cramps) Hypotension › Tensilon has no positive effect on manifestations, andcan actually worsen findings (more anticholinesterase - a) 435 of 640 more cholinergic manifestations). › Manifestations decrease with the administration of an anticholinergic medication, such as atropine. MIXED CRISIS: › Clients may experience mixed crisis when myasthenic crisis is overtreated with anticholinesterase drugs. › Manifestations include dyspnea, dysphagia, dysarthria, restlessness, apprehension, salivation, and lacrimation. Provide small, frequent, high-calorie meals and schedule at times when medication is peaking. Have the client sit upright when eating, and use thickener in liquids as necessary. MS - Nursing Care : Assess and intervene as needed to maintain a patent airway (muscleweakness of diaphragm, respiratory, and intercostal muscles). Use energy conservation measures. Allow for periods of rest. Assess swallowing to prevent aspiration. Keep oxygen, endotracheal intubation, suctioning equipment, and a bag valve mask available at theclient's bedside. Apply a lubricating eye drop during the day and ointment at night if the client is unable to completely close his eyes. The client may also need to patch or tape his eyes shut at night to prevent damage to the cornea. Encourage the client to wear a medical identification wristband or necklace at all times. Administer medications as prescribed and at specified times Leukopenia is a total WBC count of less than 4,500/mm3. It may indicate a compromised inflammatory response or viral infection. Leukocytosis- WBC count of greater than 10,000/mm3. It may indicate an inflammatory response to a pathogen or a disease process a) 436 of 640 Neutropenia is a neutrophil count of less than 2,000/mm3. Neutropenia occurs in clients who are immunocompromised, are undergoing chemotherapy, or have a process that reduces the production of neutrophils. A client who has neutropenia is at an increased risk for infection. During the test, various radiolabeled allergens are exposed to the client's blood, and the amount of the client's immunoglobulin E (IgE) that is attracted to each specific allergen is measured according to standardized values. If an allergen is not attracted, this is considered a negative result. If a client's IgE is attracted to an allergen, the amount is measure on a scaleof 0 to 5, with the higher number indicating a higher level from sensitivity. AIDS - Nursing Care: Assess risk factors (sexual practices, IV drug use). ◯Monitor fluid intake/urinary output. ◯Obtain daily weights to monitor weight loss. ◯Monitor nutritional intake. ◯Monitor electrolytes. ◯Assess skin integrity (rashes, open areas, bruising). ◯Assess the client's pain status. ◯Monitor vitalsigns (especially temperature). ◯Assesslung sounds/respiratory status(diminished lung sounds). ◯Assess neurologicalstatus (confusion, dementia, visual changes). Systemic lupus erythematosus (SLE) is an autoimmune disorder in whichan atypical immune response results in chronic inflammation and destruction of healthy tissue. In autoimmune disorders, small antigens may bond with healthy tissue. The body then produces antibodies that attack the healthy tissue. This may be triggered by toxins, medications, bacteria, and/or viruses. Subjective Data: SLE a) 437 of 640 ◯Fatigue/malaise ◯Alopecia ◯Blurred vision ◯Malaise ◯Pleuritic pain ◯Anorexia/weight loss ◯Depression ◯Joint pain, swelling, tenderness Butterfly Rash › Raynaud's Syndrome Objective Data - SLE ■ Fever (also a major symptom of exacerbation) ■ Anemia ■ Lymphadenopathy ■ Pericarditis (presence of a cardiac friction rub or pleural friction rub) ■ Raynaud's phenomenon (arteriolar vasospasm in response tocold/stress) ■ Findings consistent with organ involvement (kidney, heart, lungs,and vasculature) ■Butterfly rash on face Systemic manifestations ☐Hypertension and edema (renal compromise) ☐Urine output (renal compromise) ☐Diminished breath sounds (pleural effusion) ☐Tachycardia and sharp inspiratory chest pain (pericarditis) ☐Rubor, pallor, and cyanosis of hands/feet (vasculitis/vasospasm, Raynaud's phenomenon) ☐Arthralgias, myalgias, and polyarthritis (joint and connective tissue involvement) ☐Changes in mental status that indicate neurologic involvement (psychoses, paresis, seizures) ☐BUN, serum creatinine, and urinary a) 438 of 640 output for renal involvement a) 439 of 640 Objective Data - SLE ◯Physical Assessment Findings Fever (also amajor manifestation ofexacerbation) Pericarditis (cardiac or pleural friction rub may be present) Anemia Lymphadenopathy Raynaud's phenomenon (arteriolar vasospasm in response to cold/stress) Findings consistent with organ involvement (kidney, heart, lungs and vasculature) Butterfly rash on face Medications: ◯NSAIDs ◯Corticosteroids (prednisone [Deltasone]) ■ Immunosuppressant agents - methotrexate and azathioprine (Imuran) ■ Nursing Considerations - Monitor for fluid retention, hypertension, andrenal dysfunction. ■ Client Education - Do not stop taking steroids or decrease the doseabruptly. ◯Immunosuppressant agents - methotrexate and azathioprine (Imuran) ◯Client Education: a) 440 of 640 ■ Avoid UV and sun exposure. ■ Use mild protein shampoo and avoid harsh hair treatments. ■ Use steroid creams for skin rash. ■ Report peripheral and periorbital edema promptly / signs of infectionrelated to immunosuppression. Avoid crowds and individuals who are sick, because illness can precipitate an exacerbation. ■ Educate client of childbearing age regarding risks of pregnancy withlupus and treatment medications. Rheumatoid arthritis - RA is an autoimmune disease that is precipitated by WBCs attacking synovial tissue. The WBCs cause the synovial tissue tobecome inflamed and thickened. The inflammation can extend to the cartilage, bone, tendons, and ligaments that surround the joint. Joint deformity and bone erosion may result from these changes, decreasing the joint's range of motion and function. Chemotherapy : Pathophysiology of the Problem; Alopecia occurs as an adverse effect of chemotherapy medications. They interfere with the life cycle of rapidly proliferating cells, such as those found in hair follicles, resulting in hair loss S/S Pain at rest and with movement ◯Morning stiffness ◯Pleuritic pain (pain upon inspiration) ◯Xerostomia (dry mouth) ◯Anorexia/weight loss ◯Fatigue ◯Paresthesias a) 441 of 640 ◯Recent illness/stressor ◯Joint pain ◯Lack of function ● Objective Data ◯Joint swelling and deformity ■ Joint swelling, warmth, and erythema. ■ Finger, hands, wrists, knees, and foot joints are generallyaffected. interphalangeal and metacarpophalangeal joints. ■ Joints may become deformed merely by completing ADLs. ■ Ulnar deviation, swan neck, and boutonnière deformities are commonin the fingers. Client Education: Wear hats, turbans, and wigs. Avoid the use of damaging hair-care measures, such as electric rollers and curling irons, hair dye, and permanent waves. Use a soft hair brush or wide-tooth comb for grooming. Avoid sun exposure. Use a diaper rash ointment or cream for itching. Alopecia is temporary, and hair will return when chemotherapy isdiscontinued Corticosteroids (prednisone) are strong anti-inflammatory medications that may be given for acute exacerbations or advanced forms of the disease. They are not given for long-term therapy due to significant adverse effects (osteoporosis, hyperglycemia, immunosuppression, cataracts). Nursing Care: ◯Apply heat or cold to the affected areas as indicated based on clientresponse. ■ Morning stiffness (hot shower) ■ Pain in hands/fingers (heated paraffin) a) 442 of 640 ■ Edema (cold therapy) Monitor the client for indications of fatigue. ◯Teach the client measuresto ■ Maximize functional activity ■ Minimize pain ■ Monitor skin closely ■ Conserve energy (space out activities, take rest periods, ask foradditional assistance when needed) ■ Promote coping strategies ■ Encourage routine health screenings Disease modifying anti-rheumatic drugs (DMARDs) ■ DMARDs work in a variety of ways to slow the progression of RA andsuppress the immune system's reaction to RA that causes pain and inflammation Relief of symptoms may not occur for several weeks. ■ Antimalarial agent - hydroxychloroquine (Plaquenil) ■ Antibiotic - minocycline (Minocin) ■ Sulfonamide - sulfasalazine (Azulfidine) Sjögren's syndrome (triad of symptoms - dry eyes, dry mouth, and dry vagina) ◯Caused by obstruction of secretory ducts and glands ■ NSG CARE: Provide the client with eye drops and artificial saliva, and recommend vaginal lubricants as needed. ■ Provide fluids with meals. Plasmapheresis: ■ Removes circulating antibodies from plasma, decreasing attacks on theclient's tissues ◯May be done for a severe, life-threatening exacerbation Total joint arthroplasty - RA a) 443 of 640 ■ Surgical repair and replacement of a joint may be done for a severelydeformed joint that has not responded to medication therapy. Nursing Interventions: Discuss the impact of alopecia on self-image. Encourage the client to express feelings. Recommend use of information from the American Cancer Society on managing alopecia. Provide referral to a cancer support group. Nausea and vomiting/anorexia ■ Many of the medications used for chemotherapy are emetogenic (induce vomiting) or cause anorexia as well as an altered taste in the mouth. ■ Serotonin blockers, such as ondansetron (Zofran), have been found to be effective and are often administered with corticosteroids, phenothiazines, and antihistamines. ■ Nursing Actions ☐ Administer antiemetic medications at times that are appropriate for a chemotherapeutic agent (prior to treatment, during treatment, after treatment). ☐ Administer antiemetic medications for several days after each treatmentas needed. ☐ Remove vomiting cues, such as odor and supplies associated with nausea. ☐ Implement nonpharmacological methods to reduce nausea (visual imagery, relaxation, acupuncture, distraction). ☐ a) 444 of 640 Perform calorie counts to determine intake. Provide liquid nutritional supplements as needed. Add protein powders to food or tube feedings. ☐ Administer megestrol (Megace) to increase the appetite if prescribed. ☐ Assess for findings of dehydration or fluid and electrolyte imbalance. ☐ Perform mouth care prior to serving meals to enhance the client's appetite Encourage the use of plastic eating utensils, sucking on hard candy, and avoiding red meats to prevent or reduce the sensation of metallic taste Instruct the client to avoid the use of damaging hair-care measures, such as electric rollers and curling irons, hair dye, and permanent waves. Use of a soft hair brush or wide-tooth comb for grooming ispreferred. ☐ Suggest that the client cut her hair short before treatment to decreaseweight on the hair follicle. ☐ After hair loss, the client should protect the scalp from sun exposure and use a diaper rash ointment/cream for itching. Alopecia is an adverse effect of certain chemotherapeutic medications related to their interference with the life cycle ofrapidly proliferating cells. ■ Nursing Actions ☐ Discuss the impact of alopecia on self-image. Discuss options such as hats, turbans, and wigs to deal with hair loss. ☐ ☐ a) 445 of 640 Recommend soliciting information from the American Cancer Society regarding products for clients experiencing alopecia. ☐ Inform client that hair loss occurs 7 to 10 days after treatment begins (select agents). Encourage client to select hairpiece before treatment starts. ☐ Reinforce that alopecia is temporary, and hair should return when chemotherapy is discontinued Mucositis (stomatitis) is inflammation of tissues in the mouth, such as the gums, tongue, roof and floor of the mouth, and inside the lips and cheeks. ■ Nursing Actions ☐ Examine the client's mouth several times a day, and inquire about thepresence of oral lesions. ☐ Document the location and size of lesions that are present. Lesions should be cultured and reported to the provider. ☐ Avoid using glycerin-based mouthwashes or mouth swabs. Nonalcoholic, anesthetic mouthwashes are recommended. ☐ Administer a topical anesthetic prior to meals. ☐ Discourage consumption of salty, acidic, or spicy foods. ☐ Offer oral hygiene before and after each meal. Use lubricating or moisturizing agents to counteract dry mouth. ■ Client Education ☐ a) 446 of 640 Encourage the client to rinse mouth with a solution of half 0.9% sodium chloride and half peroxide at least twice a day, and to brush teeth usinga soft-bristled toothbrush. ☐ Instruct client to take medications to control infection as prescribed (nystatin [Mycostatin], acyclovir [Zovirax]). ☐ Encourage the client to eat soft, bland foods and supplements that are high in calories (mashed potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream, frozen yogurt, bananas, and breakfast mixes) Anemia and thrombocytopenia occur secondary to bone marrow suppression (myelosuppression). ■ Nursing Actions for Anemia ☐ Monitor for fatigue, pallor, dizziness, and shortness of breath. ☐ Help the client manage anemia-related fatigue by scheduling activities with rest periods in between and using energy saving measures (sitting during showers and ADLs). ☐ Administer erythropoietic medications such as epoetin alfa (Epogen) and antianemic medications such as ferrous sulfate (Feosol) as prescribed. ☐ Monitor Hgb values to determine response to medications. Be prepared to administer blood if prescribed. Nursing Actions for Thrombocytopenia ☐ Monitor for petechiae, ecchymosis, bleeding of the gums, nosebleeds, and occult or frank blood in stools, urine, or vomitus. a) 447 of 640 Institute bleeding precautions (avoid IVs and injections, apply pressure for approximately 10 min after blood is obtained, handle client gently and avoid trauma). ☐ Administer thrombopoietic medications such as oprelvekin (Interleukin 11, Neumega) to stimulate platelet production. Monitor platelet count, and be prepared to administer platelets if the count falls below 30,000/mm 3 . ■ Client Education ☐ Instruct the client and family how to manage active bleeding. ☐ Instruct the client about measures to prevent bleeding (use electric razor and soft-bristled toothbrush, avoid blowing nose vigorously, ensure that dentures fit appropriately). ☐ Instruct the client to avoid the use of NSAIDs. ☐ Teach the client to prevent injury when ambulating (wear closed-toes shoes, remove tripping hazards in the home) and apply cold if injury occurs Pacemaker Fixed rate (asynchronous) - Fires at a constant rate without regard for the heart's electrical activity. Demand mode (synchronous) - Detects the heart's electrical impulses and fires at a preset rate only if the heart's intrinsic rate is below a certain level. Pacemaker response modes include the following: Pacemaker activity is **inhibited/does not fire. a) 448 of 640 Pacemaker activity is **triggered/fires when intrinsic activity is sensed. Can overpace a **tachydysrhythmia and/or deliver an electrical shock. Permanent pacemaker: Incision using a local anesthetic and IV sedation. The pacemaker may be reprogrammed externally after procedure. The pacemaker battery will last about 10 years. The pacemaker pulse generator must be replaced when this occurs. POST -OP: Maintain the client's safety. Ensure that all electrical equipment has grounded connections. Remove any electrical equipment that is damaged. Make sure all equipment is grounded with a three-pronged plug. Wear gloves when handling pacemaker leads. For a temporary pacemaker Unattached pacemaker wires can cause cardiac arrhythmias or ventricular fibrillation, even when not attached to pacemaker generator. a) 449 of 640 Permanent pacemaker discharge teaching Permanent pacemaker teaching: Carry a pacemaker identification card at all times. Secure the pacemaker battery pack. Take care when moving the client, and ensure that there is enough wire slack. ☐For a permanent pacemaker Provide the client with a pacemaker identification card including the manufacturer's name, model number, mode of function, rate parameters, and expected battery life. Insulate pacemaker terminals and leads with nonconductive materialwhen not in use (rubber gloves). Keep spare generator, leads, and batteries at the client's bedside. Permanent pacemaker teaching: Prevent wire dislodgement (wear sling when out of bed, do not raise arm above shoulder for 1 to 2 weeks). Take pulse daily at the same time. Notify the provider if heart rate is less than five beats below the pacemaker rate. Permanent pacemaker teaching: Report signs of dizziness, fainting, fatigue, weakness, chest pain, hiccupping, or palpitations. For clients with pacemaker-defibrillators, a) 450 of 640 when the device delivers a shock, anyone touching the client will feel a slight electrical impulse, but the impulse will not harm the person. Permanent pacemaker teaching: Follow activity restrictions as prescribed, including no contact sports or heavy lifting for 2 months. Avoid direct blows or injury to the generator site. Resume sexual activity as desired, avoiding positions that put stress onthe incision site. Permanent pacemaker teaching: Never place items that generate a magnetic field directly over the pacemaker generator. These items can affect function and settings. This includes garage door openers, burglar alarms, strong magnets, generators and other power transmitters, and large stereo speakers. Permanent pacemaker teaching: Inform other providers and dentists about the pacemaker. Some tests, such as magnetic resonance imaging and therapeutic diathermy (heat therapy), may be contraindicated. Pacemakers will set off airport security detectors, and officials should be notified. The airport security device should not affect pacemaker functioning. Airport security personnel should not place wand detection devices directly over the pacemaker. Macular degeneration, often called age-related macular degeneration (AMD), is the central loss of vision that affects the macula of the eye. There is no cure Risk Factors: Dry macular degeneration: Female Short body stature Diet lacking carotene and vitamin A a) 451 of 640 Loss of central vision: Blindness: Consume foods high in antioxidants, carotene, vitamin E, and B12. Provider may prescribe daily supplement high in carotene + vitamin E. An ophthalmoscope is used to examine the back part of the eyeball (fundus), including the retina, optic disc, macula, and blood vessels. A cataract is an opacity in the lens of an eye that impairs vision. There are three types of cataracts: A subcapsular cataract - back of the lens. A nuclear cataract - center (nucleus) of the lens. A cortical cataract - lens cortex and extends from the outside of the lensto the center. CataractsTeach clients to wear sunglasses while outside. Educate clients to wear protective eyewear while performing hazardous activities, such as welding and yard work. Encourage annual eye examinations and good eye health, in adults > 40 yr. Assessment: Decreased visual acuity (prescription changes, reduced night vision) Blurred vision; Diplopia - double vision Glare and light sensitivity - photo sensitivity;Halo around lights Cycloplegic mydriatic (Atropine 1% ophthalmic solution) This medication prevents pupil constriction for prolonged periods of time and relaxes muscles in the eye. a) 452 of 640 Dilates the eye preoperatively and for visualization of the eye's internal structures. Surgical Interventions: Surgical removal of the lens; A small incision is made, and the lens is either removed in one piece, or in several pieces, after being broken up using sound waves. The posterior capsule is retained. A replacement; or intraocular lens is inserted. Replacement lenses can correct refractive errors, resulting in improved vision. Postoperative - Client Education: Wear sunglasses while outside or in brightly lit areas. Report signs of infection: Client should report include yellow or green drainage, increased redness or pain, reduction in visual acuity, increased tear production, and photophobia. Avoid activities that increase IOP.Bending over at the waist Sneezing; Coughing ; Straining; Head hyperflexion; Restrictive clothing, such as tight shirt a) 453 of 640 collars;Sexual intercourse a) 454 of 640 Limit activities. Avoid tilting the head back to wash hair. Limit cooking and housekeeping. Avoid rapid, jerky movements, such as vacuuming.Avoid driving and operating machinery. Avoid sports. Complications: Infection; Bleeding: Bleeding is a potential risk several days following surgery. Client Education Clients should immediately report any sudden change in visual acuity or an increase in pain. Open-angle glaucoma - most common form of glaucoma. Open-angle refers to the angle between the iris and sclera. The aqueous humor outflow is decreased due to blockages in the eye's drainage system (Canal of Schlemm and trabecular meshwork), causing a rise in IOP. Open-angle glaucoma ■ Headache ■ Mild eye pain ■ Loss of peripheral vision ■ Decreased accommodation ■ Elevated IOP (greater than 21 mm Hg) Angle-closure glaucoma - less common form of glaucoma. IOP rises suddenly. With angle-closure glaucoma, the angle between the iris a) 455 of 640 and the sclera suddenly closes, causing a corresponding increase in IOP. Angle-closure glaucoma ■ Rapid onset of elevated IOP; ■ Decreased or blurred vision; ■ Seeing halos around lights; ■ Pupils are nonreactive to light ■ Severe pain and nausea; ■ Photophobia; Medications The priority intervention for treating glaucoma is drug therapy. Client teaching should include the following: Prescribed eye medication is beneficial if used every 12 hr. Instill one drop in each eye twice daily. Wait 10 to 15 min in between eye drops if more than one is prescribed bythe provider. Avoid touching the tip of the application bottle to the eye. ■ Always wash hands before and after use. ■ Once eyedrop is instilled, apply pressure using the punctal occlusiontechnique (placing pressure on the inner corner of the eye). Pilocarpine (Isopto Carpine - ophthalmic solution) Pilocarpine is a miotic, which constricts the pupil and allows for better circulation of the aqueous humor. Miotics can cause blurred vision. Prednisolone acetate (Pred Forte ophthalmic solution) ■ Prednisolone acetate is an ocular steroid used to decrease inflammation. a) 456 of 640 Timolol (Timoptic - ophthalmic solution) and acetazolamide (Diamox - oral medication) Beta-blockers (timolol) and carbonic anhydrase inhibitors (acetazolamide) decrease IOP by reducing aqueous humor production. IV mannitol (Osmitrol) ■ IV mannitol is an osmotic Diuretic used in the emergency treatment for angle-closure glaucoma to quickly decrease IOP. Acetazolamide (Diamox - oral medication) Acetazolamide is administered preoperatively to reduce IOP, to dilatepupils, and to create eye paralysis to prevent lens movement. Gonioscopy ☐Gonioscopy is used to determine the drainage angle of the anteriorchamber of the eyes. Laser trabeculectomy, iridotomy, or the placement of a shunt are procedures used to improve the flow of the aqueous humor by opening a channel out of the anterior chamber of the eye. Diagnostic Procedures ■ Visual assessments ☐Decrease in visual acuity and peripheral vision Tonometry Toetry is used to measure IOP. IOP, expected reference range is 10 to 21 mm Hg) is elevated with glaucoma w/ angle-closure. Nursing Considerations ☐Always ask clients whether they are allergic to sulfa. Acetazolamide is a sulfa-based medication a) 457 of 640 Laser trabeculectomy - Post OP Clients should not lie on the operative side and should report severe painor nausea , possible hemorrhage. Clients should report if any changes occur, such as lid swelling, decreased vision, bleeding or discharge, a sharp, sudden pain in the eye and/or flashes of light or floating shapes. Limit activities. Avoid tilting head back to wash hair. Limit cooking and housekeeping. Avoid rapid, jerky movements, such as vacuuming.Avoid driving and operating machinery. Avoid sports. Report pain with nausea/vomiting - indications of increased IOP or hemorrhage. ☐Final best vision is not expected until 4 to 6 weeks after surgery Blindness is a potential consequence of undiagnosed and untreatedglaucoma. Encourage adults 40 or older to have an annual examination, including a measurement of IOP. Care after Discharge: Set up services such as community outreach programs, meals on wheels,and services for the blind. Retinal Detachment : Painless change in vision (floaters caused by blood cells in the vitreous and flashes of light as the vitreous humor pulls on the retina). Photopsia( recurrent flashes of light). Blurred vision worsening as detachment increases. a) 458 of 640 With progression of detachment, painless vision loss that may be described as veil, curtain or cobweb that eliminates part of the visualfield. Cervical Tongs Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with cervical tongs is placed on a Stryker frame or Roto-Rest bed. The nurse ensures that weights hang freely, and the amount of weightmatches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys.The nurse does not remove the weights to administer care. Blood donation: universal donor and universal recipient? -O negative universal donor. -AB universal recipient. Profile of the patient with polycythemia Vera: nature of the condition, how the patient appears? Bone marrow abnormality, excessive production of RBC, WBC and platelets Looks erythemic. Characteristics of the patient with agranulocytosis, including primary risk for the patient? Infection a) 459 of 640 Risks for the patient with leukemia. Why is there a risk for hemorrhage for some leukemia patients? -Risk for infection. -ineffective coping, related to diagnosis and disease process. -Thrombocytopenia induced hemorrhage. Characteristics of DIC (disseminated intravascular coagulation)? Overstimulation of clotting in anticlotting process. Characteristics and functions of hemoglobin with reference to oxygenand carbon dioxide? Carries oxygen from the lungs to the cells and Carbon Dioxide carries away from the cells to the lungs. Characteristics of the spleen including its location in the body? Found in the left upper quadrant. Serves a reservoir for blood (up to 500cc), forms lymphocytes monocytes and plasma cells, destroys worn out RBC, removes bacteria from phagocytosis. Priority nursing a concern for the patient with immuno suppression related to chemotherapy? Prevent infection, hand-washing. Priority nursing concern for the patient with severely decreased plateletcount? Hemorrhage Therapeutic communication between the nurse and the spouse of a dyingpatient? OPEN ENDED QUESTIONS, LISTEN The relationship between cancer and heredity? There can be a predisposition in family for specific types of cancer (ex: other family members have history of cancer, go get checked out. Do not wait until it hits you) a) 460 of 640 Characteristics of ultrasound as a diagnostic tool. What does it do and how does it work? Transducer emits hundreds of thousand sound wavesat high frequency wherever there is a density, it converts the sound waves back and creates an image. Cancer antigen important in the diagnosis of gynecologic cancer? CA-125 Nursing diagnosis for the patient who has experienced surgery for cancer involving the removal of breast, limb, or surgery that results in an ileostomy or a colostomy. How best to address this concern? Disturbed body image related to surgical removals Nursing care for a patient with a radioactive implant? Keep distance as much as possible, minimize time in room (implant doesnot make urine or stool radioactive) An accessory organ of digestion, the largest glandular organ in the body? Liver Therapeutic communication to reassure a patient who is about to undergo surgery? Educate them about nursing care postoperatively. Monitor closely, give pain medications Teaching a patient about lifestyle changes to assist the patient with the management of GRED (Gastroesophageal Reflux Disease). Do not each 3 hours before bed, sit two hours after meals, small frequent meals, reduce intake of caffeine and alcohol preferably to zero Risk for the patient with peptic ulcer disease? Perforation (peritonitis, death) Treatment for an ulcer caused by Heliobacter Pylori? a) 461 of 640 Antibiotic therapy Characteristics of Crohn's Disease? Inflammation of segments of the GI tract, malabsorption, diarrheafrequently Characteristics of Jaundice? Yellow, discoloration of the skin, mucous membranes, and sclerae of the eyes, caused by bilirubin. Look at liver and bilirubin test Nursing assessment prior to the administration of contrast medium? Allergies to iodine, shellfish Characteristics of the 4 major types of cirrhosis? Alcoholic, postnecrotic, biliary, lanex Medications that are contraindicated for the patient with Cirrhosis? Tylenol Most common types of hepatitis in the united states? Hepatitis A Appropriate foods for the patient newly recovered from acute pancreatitis? Low fat, high complex carbs Characteristics of the electromyogram? Needle electrode into the skeletal muscles so that electrical activity canbe heard Teaching a patient about her newly diagnosed rheumatoid arthritis?Rest and exercise, autoimmune disease for the rest of your life Teaching a patient about her newly diagnosed osteoarthritis? a) 462 of 640 Degenerative disorder, exercise must be joint sparing (swimming) Favored alternative supplement for patient with a chronic musculoskeletal disorder? Glucosamine Characteristics of pain? Subjective (whatever and wherever the patient says it is), pain often occurs when there is tissue damage. Chronic: long last pain over six months acute: less than six months What are the five vital signs? BP, Temp, Resp., Pulse, Pain pain scale to be used with children? Wong baker faces scale Appropriate nursing measures to prevent/treat constipation? Fluids, high fiber, DSS (Colace), stool softeners Appropriate nursing response to the patient's complaint of pain? Believe what the patient says Describe the process of withdrawal form an opiate agonist? Pain medications (opioid direct), takes about 2 days for symptoms topeak and about 5-7 days to disappear Restrictions on the use of digoxin? Hold if the apical pulse is less than 60 bpm Medication to reverse the effects of an opiate? Narcan a) 463 of 640 Compare and contrast the use of acetaminophen and aspirin for the patient with arthritis? Aspirin-upsides:anti inflammatory downside: GI upset Tylenol- upside: analgesic downside: non anti inflammatory, less irritating to the stomach but in high doses is hepatotoxic If it is a autoimmune, think about NSAIDS because there is no inflammation process Patient teaching about how a patient who has been receiving opioids fora few months should discontinue the medication. Gradually drop the dose so the patient does not go through withdrawals Characteristics of patient controlled analgesia? Allows patient to control, inject whenever pain comes, it locks you out what is the difference between objective symptoms and subjectivesymptoms? -Objective is what you observe -Subjective is what the patient tells you Characteristics of Transcutaneous Electric Nerve Stimulation? Electrical current that is attached to your body that stimulates a nerve locally that blocks transmission of pain sensation using gate theory Possible effects of unrelieved pain? Anxiety, slows recovery, reduces trust Preferred route of administration of different types of pain relievers for different types of pain? IV (opioid agonist), PO Characteristics of orthopnea? Sit or stand to breath deeply (place on chair facing back or lean overtable) a) 464 of 640 Characteristics of tuberculosis including it mode of transmission and infective potential? Droplet nuclei, isolation, negative pressure, spores forming phase, not highly contagious but you should take appropriate precautions Characteristics of empyema? Pus in the pleural space of the thoracic cavity Signs and symptoms of the sudden development of a pneumothorax? Decreased breath sounds, air hunger (gasping), unequal rise and fall ofthe chest Characteristics of informed consent? The physician informs the patient about the procedure being done Best time to teach the patient about the use of a PCA (Patient Controlled Analgesia.) Prior to surgery (this is when you informs hat there will be additional medication if needed) Uses and characteristics of conscious sedation? It decompressed the central nervous system. Sedated sufficiently so thatthere is no anxiety, no apprehension of fear, and little or no pain Teaching for a patient who will do daily dressing changes at home? Clean from least sterile to most sterile, hand hygiene, keep sterile technique, teach signs of infection (pus, dead skin cells, erythema, inflammation, heat Frequency of nursing assessments for new post-operative patients? Every 15 minutes x4 Every 30 minutes x4Every hour x4 who has the authority to sign the informed consent for surgery? a) 465 of 640 Patient, advanced directive (designated person), if no one is available and is emergent to do surgery the physicians can sign Counseling the patient who is afraid of pain associated with an upcoming surgery? Talk to them preoperatively and explain that we're going to observe you and do our utmost to keep you safe and make sure that any pain is treated quickly, do not be afraid to ask Patient teaching about the use of the incentive spirometer? Prior to surgery, inhale slowly and keep it between the parameters toinflate your lungs fully to prevent complications especially pneumonia Why does the nurse take a complete medication history, including the use of supplements, when admitting a patient for surgery? To know what can cause adverse reactions and what may interfere with postoperative medications First priority for the nurse in admitting the patient to a med-surg bed after transfer from the PACU ? ABC's Circumstances that could prevent from validly signing his informed consent document? If the patient is sedated, major tranquilizers, major pain medication The four types of anesthesia. When and how are they administered? General(IV immediately before surgery), regional(epidural or spinal) conscious sedation(30 minutes prior to procedure) local(immediately before procedure) Measures to encouraging peristalsis in a post-operative patient? Early ambulation a) 466 of 640 First signs and symptoms of hemorrhage? Increase pulse, increase respiration, decrease BP, pallor to ashy grey skin, decreased urine output, bright red blood, upper GI coffee ground emesis, lower GI black tarry stool Nursing intervention after a wound evisceration? Wound opens and intestines come out, cover with warm normal saline Routine of offering post-operative analgesia to a patient in her second post-op day? Continue with every 4 hours around the clock Administration of IM analgesia to a patient before controlled deep breathing and coughing? Must correctly demonstrate it back to you, giveanalgesia attest 30 minutes before exercises postoperatively Abnormal early post-operative signs? Respiratory distress, urinary retention, bright red bleeding or emesis,signs of shock Signs of a pulmonary embolus? Sense of impending dume, extremely restless, sudden sharp pain in chest, respiratory distress, petechiae in upper part of chest How to splint a patient for deep breathing and coughing who has an incision in his lower left abdomen? Hug a pillow over the whole low abdomen Teaching of controlled beep breathing and coughing? 2-3 deep breaths then cough from as deep down as possible Ideal time to do pre-op teaching if possible? 1-2 days before surgery Priority nursing problems for a patient with a new ileostomy? Excoriation of skin (impaired skin integrity) , disturbed body image a) 467 of 640 Patient teaching for a patient who is about to undergo an esophagogastroduedenoscopy? NPO after midnight, down the esophagus into stomach and into duodenum. No pain during procedure. Will carefully monitor before food or drinks. Make sure gagreflexes are active Special assessment required for a patient after a gastrectom? Concerned about pernicious anemia (vitamin B12 taken in form of abilityto metabolize which is injection or sublingual) and dumping syndrome (rapid gastric emptying) A nursing measure to prevent or minimized dumping syndrome? Six small meals First priority for the patient after completing barium swallow examination? Immediate access to restroom Nursing education for a patient who is undergoing a stool test for ova and parasites? Once a day for three consecutive days The most serious complication of a hernia? Strangulation it occluded blood supply and obstructs intestinal flow Therapeutic communication between a nurse and a patient who is expressing that he does not think he will ever adjust to his new colostomy? Listen, open needed questions, encourage to express feelings What is the importance of bowel sound assessment for a patient who hashad an abdominal surgery? Peristalsis has returned in ALL four quadrants Signs of an anaphylactic reaction? a) 468 of 640 Respiratory distress, hives, swelling around eyes, swelling of lips, swelling of tongue Primary nursing goal for a patient with an immunodeficiency disease? Prevent infection A critical nursing goal for a post-operative liver transplant patient who is receiving Imuran? Prevent infection Nursing procedure after giving a clinic patient an injection of penicillin? Wait 20-30 minutes to see if there is an allergic reaction The purpose of giving cyclosporine to a patient after a kidney transplant? To prevent tissue rejection Emergency medication for a patient experiencing an anaphylactic reaction? Epinephrine The first evidence in a patient's history of a possible immunodeficiency disease? Recent history of repeated infections Priority nursing action before administering a blood transfusion to apatient? Two lisenced nurses check the blood and the chart, then check onceentered the room What is the average length of time between infection with HIV (the Human Immunodeficiency Virus) and the onset of AIDS (Acquired Immune Deficiency Syndrome)? 10-14 years Contaminated blood transfusion or dirty needle 1-2 years Laboratory finding that indicates progression for HIV infection to the onset of AIDS? CD4 count less than or equal to 200 a) 469 of 640 Patient education regarding the use of condoms in the prevention ofsexually acquired diseases? Demonstrate how to use and give them information Signs of a Kaposi's sarcoma lesion? Purple, irregular borders, not ulcerated lesions, all over the body Is the HIV positive patient contagious before acquiring full-blown AIDS? Yes Nursing measures to assist the patient with comfort and pain control?Lift patient, reposition patient, use other methods for pain before medication Nursing measures to assist a patient to prevent post-operative pulmonary complications? Deep breathing, coughing, incentive spirometer Fontella Closing on Newborn (Anterior and Posterior)Anterior: 12-18 months Posterior: 1-2 months Best time to perform bladder scan. Immediate after void Cholecystitis (inflammation of gallbladder) Diet -Increase fruits, vegetables, whole grains. Ex: Melon -Avoid greasy/fatty foods Moro Reflex (one of many reflexes present at birth) -Startled (arms out sideways, palms up, thumb flexed). Ex: strike surface next to newborn. a) 470 of 640 Position for suppository or enema administration. -Sim's/left lateral/Rt. knee to chest Varicella contraindication Corticosteroids DTAP contraindication Hx of inconsolable crying Newborn Car Seat Safety Snug harness across axillary. Not across abdomen or neck. Ileostomy what pt expect on appearance. -Initial drainage: dark green, odorless. -Some initial bleeding normal -Pink or red stoma color normal -Initial swelling; decreases 2-3 weeks later Ileostomy care and education *-Empty pouch: 1/3 to 1/2 full. -Clean pouch 1-2 times daily. -Pouch change every 4-6 weeks. -Wafer size 1/8 to 1/4 larger than stoma -Avoid high fiber foods to prevent blockage. Delirium (occurs quickly) Simple orientation and low stimuli environment Hep B contraindication Baker's yeast MMR contraindication -Pregnancy, recent blood transfusion.... a) 471 of 640 Anorexia Nervosa Electrolytes increasing: Sodium, Potassium, Chloride, BUN, Liver function, Cholesterol. Bulimia Therapeutic Nursing Careoffer small and frequent meals 89% oxygen postoperative: what to do... Change oxygen to another finger Non-Rebreather Mask Ensure two "flaps" open during exhalation/close during inhalation. Venturi Mask Ensure reservoir bag 2/3 full during inspiration and expiration. Thoracentesis position sitting position, arms raised and resting overbed table. Chlorpromazine (med for psychoses) -Adverse Effects and given treatment -Severe Spasms/Tremors Tx: benzotropine (Cogentin), diphenhydramine (Benadryl). Contraction Stress Test (CST). Description, Purpose, normal range. -Brush palm across nipple for 2-3min to release natural oxytocin that produce contractions. -Determine how fetus will tolerate stress of labor. -3 contractions, 10 min period, duration 40-60 secs. What is most likely to happen during variable deceleration? Cord compression a) 472 of 640 What is most likely to happen during early deceleration? Fetal Head Compression Cystic Fibrosis (Respiratory Disorder) -Diagnostic Test -Possible Medication Administration -DNA mutant geneidentification. -Open capsule sprinkle on food (Enzyme: Pancrease). Levothyroxine (Synthroid) -What is it? -What patients should use this medication with caution? -Best way to take? -Thyroid hormone; treats hypothyroidism. -Cardiac pts; aggrevates tachy and anxiety -Take in the morning, on empty stomach Levothyroxine (Synthroid) -Signs of Toxicity *Cardiac: anxiety, chest pain, tachy, htn. Buck's Traction -Goal -Following conservative measurements -Skin integrity/Neuro -Immobilization -Follow RX orders: type of traction, weights, whether it can be removed. -Reposition every 2 hrs, provide pin care, neuro checks Amputation -Patient education Apply prosthetic before ambulating. Ferrous Sulfate (Feosol) a) 473 of 640 -Purpose -Reporting symptoms -Administration -How to monitor effectiveness -Treats iron deficiency -GI distress: nausea, constipation, heartburn. -Take on empty stomach, drink with straw and rinse to prevent staining. - Increase Hgb of 2g/dL, Hct Orientation Phase Introduce, Discuss confidentiality, Set goals Working Phase Problem Solve Terminal Phase Evaluation (evaluate goals, experience, feelings) Chadwick's Sign Purplish vulva during pregnancy Patient is having a hysterectomy and states, "I can possibly plan a pregnancy". What needs to be reinforced? Outcome Vaginal Flush Complications Preterm Labor: Ruptured membranes, signs of infection Sucralfate for PUD coats stomach to prevent formation of ulcer and aids with healing existing ulcers 17 year old having an emergency surgery. What type of consent is best to intervene? Verbal a) 474 of 640 Insulins not to mix garglarine and determis Malfunctioning IV machine mark as defected and get new one What is the best recommendation for a newly diagnosed diabetic 2 patients that lives independently? Refer to support group Circumcision post op care: cleaning -Change diaper every 4 hrs. -Clean penis with each change. -Apply petroleum jelly for at least 24 hrs after circumcision (preventadhering). -Fan fold diaper (prevent pressure). -Avoid wrapping penis (impairs circulation) -Washing: trickle warm water over penis. -Do not clean yellowish mucus that appears by day 2. -Do not use moistened towelettes. -Healing: a couple of weeks. TB precautions and care -private room/negative pressure -N95 masks -pt wear mask when transported out of room or in any public place. -Medications: may be taking up to 4 meds at a time; up to 6-12 months -Test exposed family members -Sputum culture every 2-3 weeks; 3 negatives results in noninfectious. Vaginal discharge during early pregnancy Leukorrhea MRSA Contact Precautions a) 475 of 640 -keep distance within 3 ft of client -Private room or share with someone with similar infection (wound infection, herpes simplex) -double bag dressing gauze. -PPE: Gloves and Gowns. Metformin most common side effect Renal (kidney) failure Drawing up Insulin? Regular vs. NPH First Regular (clear), then NPH (cloudy) Interaction between SSRI (e.g. fluoxetine) and St. John's Worts Hypertension and Increased HR; may be life-threatening. Diabetic Foot Care -Nailcare: Podiatrist, cut nail straight across. -Wear Clean Cotton Socks/Closed Shoes -Do not soak feet or wear ointments Used Opioid overdose Naloxone (Narcan) Contraindication During Alcohol Withdrawal Delirium, accompanied by hallucinations. Patient education for Amniocentesis. -Position: supine or rolled towel under right hip -Continue breathing normally when inserting needle -Rest 30 mins after procedure. -Increase fluids for next 24 hrs. Indications of Fluid Volume Depletion (Hypovolemia) a) 476 of 640 -Thready pulse/Hypotensive -Tachy -Increased Respiration -Cool, Clammy, Diaphoretic -Decreased Urine Output -Thirst Type Stomas: Appearance -Single -Loop -Divided -Double-Barrel -Single (one stoma); brought through onto anterior abd wall. -Loop (two openings); proximal (active) and distal (inactive). -Divided (two separate stomas); proximal (digestive) and distal (secretes mucus). -Double-Barrel (distal and proximal sutured together are both brought uponto abd wall). Documentation for Ostomy Care (Stool) Amount Consistency Color Priority for Panic DisorderBreathing Technique Education on meds for Kidney Disease1.Digoxin (Lanoxin) 2.Sodium plystyrene (Kayexalate)3.Epoetin alfa (Epogen) 4.Ferrous sulfate (Feosol) 5.Aluminum hydroxide gel (Amphojel) 6.Furosemide (Lasix) a) 477 of 640 1. Take within 2 hrs of meal, monitor signs of toxicity, apical pulse for 1 min. 2. Monitor hypokalemia, restrict sodium intake. 3. blood twice a week, monitor HTN. 4. administer following dialysis with stool softner, take with food. 5. avoid pts with GI disorders, take 2 hrs before or after Digoxin. 6. Monitor I&O, bp, weight. Report thirst, cough. Newborn Water and Room Temp Water: 120F or lower Room: 97.9-99 F Bathing Newborn technique Bathe from cleanest to dirtiest -Eyes -Face -Head -Chest -Arms -Legs -Groin (last) Newborn reflex shown on day 1 hear voice Immunization is recommended for postexposure protection Hep A (fecal route) a) 478 of 640 Arthroplasty pt education -How to avoid contractures, dislocations; prevent DVT's. -Non-pharmalogical treatment -Do not bend at waist. -Use abductor pillow in between legs. -Perform Continuous Passive Motion -Ice pack COPD -conservative measurements -Rapid relief med -High Fowler position -Increase fluids to liquify mucous -Albuterol Dementia Living Coordination Home health Agency>Assisted Living>Nursing Home Need for Sterile GlovesInserting Catheter Discomforts During Pregnancy -Nausea -Fatigue -Backache -Constipation -Varicose Veins -Hemoroids -Heartburn -Nasal stuffiness -Dyspnea -Leg Cramps -Edema lower extremities a) 479 of 640 Acute Mania Interventions -Decrease stimuli and one to one observation if necessary. Bulimia Plan of Care when meal planning closely monitor the client during and after meals to prevent purging Reinforcing Teaching About Oppositional Defiant Disorder Set clear limits on unacceptable behaviors and be consistent. Rewardsystem for acceptable behavior. Osteoarthritis Alternate: Heat Therapy for Pain and Cold Therapy for Inflammation -Use assistive devices (raised toilet to help not straining) What to do before bolus feeding or administration of medication Check for residuals (60 mL syringe) What to do when pt complains of cramping during tube feeding? Decrease infusion rate Ideal location for drainage bag of catheters Hang on bedframe below level of the bladder. Ventilator Alarms -Low Pressure -High Pressure -Low: disconnection -High: suction for possible secretions, kinks. Glasgow Coma Scale (head injuries)(eyes, verbal, motor) highest number 15, a) 480 of 640 good. lowest number 3, severe. Pressure Ulcer Strategies -Reposition time (bed/chair) -Incontinent Pt. -Bed every 2hr, chair every hour. -Apply barrier cream and moisture absorbing pad. Immunization: booster every 10 years DTP HPV vaccination doses3 doses How to measure Fundal Height top of symphysis pubis to top of fundus How to calculate due date: LMP 8/2/15 -subtract 8-3=5 -add 7 + 2= 9 May 9, 2016 Contraindicated Immunizations During Pregnancy -Varicella -Zoster -MMR True Labor vs False Labor AbdominalDiscomfort true: low back and abdominal false: abd and groin Types of Decelerations: <120 fhr -early -late a) 481 of 640 -variable -early: head compression -late: uteroplacental insufficiency -variable: cord compression Nursing Interventions during late or variable deceleration left lateral position, oxygen, c-section Normal Fetal HR120-160 Nursing Care for Boggy Uterus Ask pt to void; if still boggy massage top of fundus with fingers and reassess every 15 mins. Nursing Care for Engorgement Apply moist heat for 5 min before breastfeeding. Ice compresses after feeding to reduce discomfort and swelling. Nursing Care for Mastitis Continue breastfeeding and take antibiotics as prescribed. Narcotic antidote Naloxone (narcan) What is wrong with the script? gentamicin 50 mg po every 4 hours #30 Drug name: Gentamicin (capital G) Anemia lab RBC 4.20- 4.87 BUN/Creatinine normal values(for kidney function) a) 482 of 640 7-20/0.8-1.4 WBC normal values(for infection) 4,000- 10,000 Sodium 136-144 Potassium 3.5-5.5 Chlorid e96-106 Be ready to administer for Magnesium sulfate toxicity Calcium gluconate Sign of mag sulfate toxicity (4) 1. Absent deep tendon reflexes 2.Resp rate < 12 3. Urine output < 30 4.Mag levels above 8 Understanding Rh. Administration of antibody and time. Mother Rh negative. Fetus Rh positive. Rhogam at 28 weeks, then 72 hrs after birth. Stroke eating precautions -check gag reflex -thickened fluids/puree -Sit upright/flexed neck forward a) 483 of 640 Dehydration S&S (hypovolemia) -pulse; weak and thready. hypotension -tachy -confused -decreased urine output -skin and mucous membranes dry Urine Specificity increased Urine Specific Normal Values and Significance Decreased hypervolemia.Increased hypovolemia. 1.001-1.029 JVD. What side of heart?Right Adverse effect of ACE inhibitor (pril's) ACE inhibitors, such as captopril, increase potassium levels (hyperkalemia) VERSION 9 RN COMPREHENSIVE PREDICTOR 2019 a) 484 of 640 a) 485 of 640 a) 486 of 640 a) 487 of 640 a) 488 of 640 a) 489 of 640 a) 490 of 640 a) 491 of 640 a) 492 of 640 a) 493 of 640 a) 494 of 640 a) 495 of 640 a) 496 of 640 a) 497 of 640 a) 498 of 640 a) 499 of 640 a) 500 of 640 a) 501 of 640 a) 502 of 640 a) 503 of 640 a) 504 of 640 a) 505 of 640 a) 506 of 640 a) 507 of 640 a) 508 of 640 a) 509 of 640 a) 51 0 of 640 a) 511 of 640 a) 512 of 640 a) 513 of 640 a) 498 of 640 a) 499 of 640 a) 500 of 640 a) 501 of 640 a) 502 of 640 a) 503 of 640 a) 504 of 640 a) 505 of 640 a) 506 of 640 a) 507 of 640 a) 508 of 640 a) 509 of 640 a) 510 of 640 a) 511 of 640 a) 512 of 640 a) 513 of 640 a) 514 of 640 a) 515 of 640 a) 516 of 640 a) 517 of 640 a) 518 of 640 a) 519 of 640 a) 520 of 640 a) 521 of 640 a) 522 of 640 VERSION 10 RN COMPREHENSIVE PREDICTOR 2019 FORM B 1. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration. 2. A nurse is administering digoxin 0.125 mg Po to an adultclient. For which of the following findings should the nursereport to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D. Constipation for 2 days. a) 523 of 640 3. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of the following action should the nurse take? A. Arrange for an ethics committee meeting to address the family’s concerns. B. Support the family’s decision and initiate life-sustaining measures. C. Complete an incident report. D. Encourage the family to contact an attorney. 4. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 5. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? A. Remove the protective gown after the client’s room. a) 524 of 640 B. Place the client in a room with negative pressure. C. Wear gloves when providing care to the client. D. Wear a mask when changing the linens in the client’s room. 6.A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the clientin a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation. 7. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is acontradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. a) 525 of 640 Hypocalcemia. 8 A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? A. Schedule a meeting between the hospital ethics committee and the client. B. Evaluate the client’s understanding of life-sustaining measures. C. Determine the client’s preferences about post mortem care. D. Request a conference with the client’s family. 9.A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reportedto the provider? A. Substernal retractions. B. Hematuria. C. Temperature 37.9 C (100.2 F). D. Sneezing. 10.A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the .following action should the nurse take? A. Instill 500 ml of solution through the NG tube. B. Insert a large-bore NG tube. C. Use a cold irrigation solution. D. a) 526 of 640 D. Instruct the client to lie on his right side. 11. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals isthe nurse’s priority? A.Psychologist. B. Social worker. C. Occupational therapist. D. Speech-language pathologist. 12.A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. D. Erythrocyte sedimentation rate 75 mm/hr a) 527 of 640 13. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level. C. Creatine clearance. D. Prealbumin. 14. A nurse is caring for a client following application of a cast.Which of the following actions should the nurse take first? A. Place an ice pack over the cast. B. Palpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow. 15. A nurse is caring for a client who has vision loss. Which ofthe following actions should the nurse take? (Select all that apply) A. Keep objects in the client’s room in the same place. B. Ensure there is high-wattage lighting in the client’s room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. a) 528 of 640 16. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. 17. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen. 18. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? a) 529 of 640 A.Place food on the left side of the client’s mouth when he is ready to eat. B. Provide total care in performing the client’s ADLs. C. Maintain the client on bed rest. D. Place the client’s left arm on a pillow while he is sitting. 19. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions shouldthe nurse take? A. Confront the client about this behavior. B. Express sympathy for the client’s situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. 20. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client’s room. B. Limit the client’s visitors to 30 min per day. a) 530 of 640 C. Discard the client’s linens in a double bag. Discard the radioactive source in a biohazard bag 21. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D..Bradypnea 22. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin. A. Diabetes mellitus. B. Shoulder presentation. C. Postterm with oligohydramnios. (I think Maternal Newborn Chapter 15 page 100) D. Chorioamnionitis 23. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy,pink sputum. D. Jugular vein distention. a) 531 of 640 E. Weight gain. D.Bradypnea 24. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing” 25. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” a) 532 of 640 D. “Taking furosemide can cause you to be overhydrated” 26. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors. 27. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. S e r o t o n i n s y n a) 533 of 640 B. Tardivedyskinesdrome a) 534 of 640 iaC.Pseudoparkinso a) 535 of 640 n i s m . D. Acute dystonia. 28. A nurse is assessing a client who is receiving packed RBCs.Which of the following findings indicate fluid overload? A. Low back pain. B. Dyspnea. C. Hypotension. D. Thready pulse. 29. A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began on April . Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? (Use mmdd format.) 0119 date a) 536 of 640 30. A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. (Mental Health Chapter 8 Page 42) C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. 31. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching. UNSURE IF ON THE REPORT A. “OOB with assistance for breakfast” B. “Given 2 mg MSO4 IM for report of pain” C. “Dressing changed qd” D. “Administered 8 u regular insulin sq.” 32. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a) 537 of 640 1. Apply pressure to the lacrimal punctum. 2. Ask the child to look upward. 3. Pull the lower eyelid downward. 4. Instill the drops of medication. 5. Place the child in a sitting position. 5 2 3 4 1 33. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter. 34. A nurse is caring for a client who is in labor and is receivingoxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? a) 538 of 640 ON THE REPORT needs double checking A. Urine output 20ml/hr. B. Montevideo units constantly 300 mm Hg. C. FHR pattern with absent variability. D. Contractions every 5 min that last 30 seconds. 35.A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. B. Conducting mental health screenings at the local community center. C. Referring client whohave obesity to community exercise programs. D. Providing crisis intervention through a mobile counselingunit. a) 539 of 640 36. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client’s blood type with the type and cross match specimens. B. Confirm the provider’s prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client’s identification band matches the number on the blood unit. 37. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy? A. “I have been experiencing more tremors in my left arm than before” B. “I noticed that I am having a harder time holding on to my toothbrush” C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground” a) 540 of 640 D. “Sometimes, I feel I am making a chewing motion when I’mnot eating” 38. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B.Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium. 39. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? A. “Did the doctor discuss with you that there was a change in this medication?” B. “I recommend that you take this medication as prescribed” C. “Do you know why this medication is being prescribed to you?” D. “I will call the pharmacist now to check on this medication” 40 A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. a) 541 of 640 Use three pronged grounded plugs. B. Cover extensioncords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 41. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the followingshould the nurse recommend for discharge? A. A 42-year-old client who has preeclampsia and a BP of166/110 mm Hg. B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for apostpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. 42. A nurse in a provider’s office is reviewing the laboratoryresults of a group of clients. Which to report? A. Herpes simplex. a) 542 of 640 B. Human papillomavirus C. Candidiasis D. Chlamydia 43. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 44. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. a) 543 of 640 45. A nurse in a pediatric clinic is teaching a newly hired nurseabout the varicella rooster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 46.A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. 47. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? a) 544 of 640 A. Pregabalin Lorazepam Colchicine Codeine. 48. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. Use a 24-gauge IV catheter Obtain filter less IV tubing. Place blood in the warmer for 1 hr. 49. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. B. C. D. B. C. D. a) 545 of 640 50. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. 51. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 52. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an a) 546 of 640 indwelling urinarycatheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 53. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. 54. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B . P a t i e a) 547 of 640 nt(Unabletorea d) C. Evid a) 548 of 640 e n c e b a s e d p r a c t i c e . D. Informatics. a) 549 of 640 55. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. 56. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. 66. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. “Staff will apply identification band after first bath” B. “I will not publish public announcement about my baby’s birth” a) 550 of 640 C. “I can remove my baby’s identification band as long as she is in my room” D. “I can leave my baby in my room while I walk in thehallway” 57. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. “Morphine 3 mg SQ every 4 hr. PRN for pain.” B. “Morphine 3 mg Subcutaneous (Unable to read) C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” D. “Morphine 3 mg SC q 4 hr. PRN for pain.” 58. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Reportthe incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. 59. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? a) 551 of 640 A. “Dehydration is treated with calcium supplements” B. “Dehydration can increase the risk of preterm labor” C. “Dehydration associated gastroesophageal reflux” D. “Dehydration is caused by a decreased hemoglobin and hematocrit” 60. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) 61. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client’s children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client’s translation services for a nominal fee. D. Evaluate the clients’ understanding at regular intervals. a) 552 of 640 62 C 63 A 64. C a) 553 of 640 65. D 66.C D. . 67.A a) 554 of 640 68.B 69.A 70.C a) 555 of 640 71.D 72.C 73.D 74.C a) 556 of 640 75.A 76.C 77.C 78.B a) 557 of 640 79. C a) 558 of 640 a) 559 of 640 80. D 81. A a) 560 of 640 82. B 83. A 84. A a) 561 of 640 85. A 86. C 87. A 88. C a) 562 of 640 89. D 90. C 91. A a) 563 of 640 92. A 93. A 94. A 95. C a) 564 of 640 96. C 97. D 98. D a) 565 of 640 99. D 100. D 101. A a) 566 of 640 102. B 103. B 104. D 105. A 106. A a) 567 of 640 107. D 108. B 109. C 110. B a) 568 of 640 111. D 112. C 113. B 114. C a) 569 of 640 115. A 116. D 117. B 118. D a) 570 of 640 119. D 120. A 121. C a) 571 of 640 122. A 123. A 124. C a) 572 of 640 125. D 126. D 127. Intradermal Injection areas A. Buttocks. B. Upper back. C. Hamstring area. a) 573 of 640 128.A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply.) a. Impulse control difficulty b. Left hemiplegia c. Loss of depth perception d.Aphasia e.Lack of situational awareness 128.A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? f. Teach the client to scan the right to see objects on the right side of her body. g.Place the bedside table on the right side of the bed. h.Orient the client to the food on her plate using the clock method. a) 574 of 640 i. Place the wheelchair on the client’s left side. 129.A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) j. Have suction equipment available for use. k. Feed the client thickened liquids. l. Place food on the unaffected side of the client’s mouth. m. Assign an assistive personnel to feed the client slowly. n.Teach the client to swallow with her neck flexed. 130.A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client’s plan of care? (Select all that apply.) o. Speak to the client at aslower rate. p. Assist the client to use flash cards with pictures. q.Speak to the client in a loud voice. r.Complete sentences that the client cannot finish. s.Give instructions one step at a time. 131.A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? t. Impulse control difficulty u.Poor judgement v.Inability to recognize familiar objects a) 575 of 640 w. Loss of depth perception 132.A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? a.Position the client in an upright position, leaning over the bedside table. b. Explain the procedure. c.Obtain ABG’s. d. Administer benzocaine spray. 133.A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? e.Respiratory acidosis f.Respiratory alkalosisg.Metabolic acidosis h.Metabolic alkalosis 134.A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider? i. Blood-tinged sputum j. Dry, nonproductive cough k.Sore throat l. Bronchospasms 135.A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client’s room? (Select all that apply.) m. Oxygen equipment a) 576 of 640 n. Incentive spirometer o. Pulse oximeter p. Sterile dressing q.Suture removal kit 136.A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) r. Dyspnea s.Localized bloody drainage on the dressing t. Fever u.Hypotension v.Report of pain at the puncture site 137.A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client’s room? (Select all that apply.) a. Oxygen b. Sterile water c. Enclosed hemostat clamps d.Indwelling urinary catheter a) 577 of 640 j.C m ontinuous bubbling in the water seal cham . E x p o e.Occlusive dressing 138.A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? f.Obtain a chest x-ray g.Apply sterile gauze to the insertion site. h.Place tape around the insertion site. i. Assess respiratory status. 139.A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) s ed sutu res with out dres sing n.Drai nag e syst em upri k. Gentle constant bubbling in the suctionber control chamber l. Rise and fall in the level of water in the water seal chamber wit inspiration and expiration a) 578 of 640 ght at ches t leve l 140.A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? o.Lie on it left side. p.Use the incentive spirometer. q.Cough at regular intervals. r.Perform the Valsalva maneuver. 141.A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) s. Encourage the client to cough every 2 hours. t. Check the continuous bubbling in the suction chamber. u.Strip the drainage tubing every 4 hours. v.Clamp the tube once a day. w. Obtain a chest x-ray. 142.A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? a) 579 of 640 a.“It keeps the alveoli open and prevents atelectasis.” b.“It allows preset pressure delivered during spontaneous ventilation.” c.“It guarantees minimal minute ventilator.” d.“It delivers a preset ventilatory rate and tidal volume to the client.” 143.A nurse is caring for a client who is experiencingrespiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) e. Confusion f. Pale skin g.Bradycardia h. Hypotension i. Elevation blood pressure. 144.A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? j. Apply a vest restraint if self-extubation is attempted. k.Monitor ventilator settings ever 8 hours. l. Document tube placement in centimeters at the angle of jaw. m. Assess breath sounds every 1 to 2 hours. 145.A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? n. Nonrebreather mask o. Venturi mask p. Nasal cannula a) 580 of 640 q. Simple face mask 146.A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client’s respiratory muscles should the nurse include in the planof care? (Select all that apply.) r.Assist-control v.Independent lung ventilation 146.A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) a. Client who has dysphagia b. Client who has AIDS c.Client who was vaccinated for pneumococcus and influenza 6 months ago d.Client who is postoperative and received local anesthesia. e. Client who has a closed head injury and is s. Synchronized intermittent mandatory ventilation t. Continuous positive airway pressure u. Pressure support ventilation a) 581 of 640 148.A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority? g.Obtain baseline vital signs and oxygen saturation. h. Obtain a sputum culture. i. Obtain a complete history from the client. j. Provide a pneumococcal vaccine. 149.A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. k.Administer antibiotics. (3 ) l. Administer oxygen therapy. (1 ) m. Perform a sputum culture. (2 ) n.Administer an antipyretic medication to promote client comfort. (4 ) 150.A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? o.Percussion of posterior lobes of lungs p.Auscultation of the trachea q.Inspection of the conjunctiva r. Palpation of the orbital areas 151.A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? receiving ventilation f. Client who has myasthenia gravis a) 582 of 640 s. “I should wash my hands after blowing my nose to prevent spreading the virus.” t. “I need to avoid drinking fluids if I developsymptoms.” u.“I need a flu shot every 2 years because of the different flu strains.” v.“I should cover my mouth with my hand when I sneeze.” 152.A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.) a.SaO2 95% b. Wheezing c. Retraction of sternal muscles d.Pink mucous membranes e.Premature ventricular complexes (PVC’s) 153.A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer? f. Antibiotic g.Beta-blocker h.Antiviral i. Beta2 agonist 154.A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching? a) 583 of 640 j. “I will decrease my fluid intake while taking thismedication.” k.“I will expected to have black, tarry stools.” l. “I will take my medication with meals.” m. “I will monitor for weight loss while on thismedication.” 155.A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? n.Gender o.Environmental allergiesp.Alcohol use q.Race 156.A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? r. “This medication can decrease my immune response.” s. “I take this medication to prevent asthma attacks.” t. “I need to take this medication with food.” u.“This medication has a slow onset to treat my symptoms.” 157.A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates and understanding of the teaching? a.“This medication can increase my blood sugar levels.” b.“This medication can decrease my immune response.” a) 584 of 640 c.“I can have an increase in my heart rate while taking this medication.” d.“I can have mouth sores while taking this medication.” 158.A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.) a.Hypokalemia b. Tachycardia c.Fluid retention d. Nausea e.Black, tarry stools 159.A nurse is discharging a client who has COPD. Upondischarge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? a. “There are portable oxygen delivery systems that you can take with you.” b. “When you go out, you can remove the oxygen and then reapply it when you get home.” c. “You probably will not be able to go out at much as you used to.” d. “Home health services will come to see you so you will not need to get out.” 160.A nurse is instructing a client on the use of an incentive spirometer. Which of the following a) 585 of 640 statements by the client indicates an understanding of the teaching? a. “I will place the adapter on my finger to read my blood oxygen saturation level.” b. “I will lie on my back with my knees bent.” c. “I will rest my hand over my abdomen to create resistance.” d. “I will take in a deep breath and hold it before exhaling.” 161.A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? a. Take quick breaths upon inhalation. b. Place you hand over your stomach. c. Take a deep breath in through your nose. d. Puff your cheeks upon exhalation. 162.A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mgPO daily, and ethambutol 1 mg PO daily. Which of thefollowing client statements indicate the client understands the teaching? (Select all that apply.) a. “I can substitute one medication for another if I run out because that all fight infection.” b. “I will wash my hands each time I cough.” c. “I will wear a mask when I am in apublic area.” a) 586 of 640 d. “I am glad I don’t have to have any more sputum specimens.” e. “I don’t need to worry where I go once I start taking my medications.” 163.A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? a. “You will need to continue to take the multi-medication regimen for 4 months.” b. “You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.” c. “You will need to remain hospitalized fortreatment.” d. “You will need to wear a mask at all times.” 164.A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client relatedto ethambutol? a. “Your urine can turn a dark orange.” b. “Watch for a change in the sclera of your eyes.” c. “Watch for any changes in vision.” d. “Take vitamin B6 daily.” 165.A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? a. “You might notice yellowing of your skin.” b. “You might experience pain in your joints.” a) 587 of 640 c. “You might notice tingling of your hands.” d. “You might experience loss of appetite.” 166.A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum 167.A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? (Select all that apply.) a.A client who has a BMI of 30 b. A female client who is postmenopausal c.A client who has a fractured femur d. A client who is a marathon runner e.A client who has chronic atrial fibrillation 168.A nurse is assessing a client who has a pulmonary embolism. Which of the following information should the nurse expect to find? (Select all that apply.) f. Bradypnea g.Pleural friction rub h.Hypertension a) 588 of 640 i . Petechiae j . Tachycardi a 169.A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? k.Notify the provider. l. Administer heparin via IV infusion. m. Administer oxygen therapy. n.Obtain a spiral CT scan. 170.A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse? o. “I am allergic to morphine.” p. “I take antacids several times a day.” q. “I had a blood clot in my leg several years ago.” r. “It hurts to take a deep breath.” 171.A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? a. Hip arthroplasty 2 weeks ago b. Elevated sedimentation rate c. Incident of exercise-induced asthma 1 week ago d. Elevated platelet count a) 589 of 640 172.A nurse is assessing a client following a gunshotwound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) a. Tachypnea b. Deviation of the trachea c. Bradycardia d. Decreased use of accessory muscles e. Pleuritic pain 173.A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? a. Assess the client’s pain. b. Obtain a large-bore IV needle for decompression. c. Administer lorazepam. d. Prepare for chest tube insertion. 174.A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client? a. “Notify the provider if you experience weakness.” b. “You should be able to return to work in 1 week.” a) 590 of 640 c. “You need to wear a mask when in crowded areas.” d. “Notify your provider if you experience a productive cough.” 175.A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) a.Bradycardia b. Cyanosis c. Hypotension d. Dyspnea e. Paradoxic chest movement 176.A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first? a.Obtain a chest ex-ray. b.Prepare for chest tube insertion. c.Administer oxygen via high-flow mask. d.Initiate IV access. 177.A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of a) 591 of 640 the following statements by the newly licensed nurse indicates understanding of the teaching? e. “This medication is given to treat infection.” f. “This medication is given to facilitate ventilation.” g.“This medication is given to decrease inflammation.” h.“This medication is given to reduce anxiety.” 177.A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) a. A client who experienced a near-drowning incident b. A client following coronary artery bypass graft surgery c.A client who has a hemoglobin of 15.1 mg/dL d. A client who has dysphagia e. A client who experienced a drug overdose 178.A nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.) a. Administer antibiotics. b. Provide supplemental oxygen. c. Administer antiviral medications. d. Administer bronchodilators. e. Maintain ventilatory support. 179.A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. a) 592 of 640 Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) a. Fentanyl b. Furosemide c. Midazolam d. Famotidine e. Dexamethasone 180.A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? a. “Air should be instilled into the monitoring system prior to the procedure.” b. “The client should be positioned on the left side during the procedure.” c. “The transducer should be level with the second intercostal spaced after the line is placed.” d. “A chest x-ray is needed to verify placement after the procedure.” ATI PN Comprehensive 2017 A VERSION 11 1. A nurse in a long term care facility notices a client who has alzheimers disease standing at the exit doors at the end of the hallway. The clients appears to be anxious and agitated. Which of the following actions should the nurse take? Escort the client to a quiet area on the nursing unit 2. A nurse is assisting with the plan of care for a client who has a continent urinary division. Which of the following interventions should the nurse plan to implement to facilitate urinary elimination? Use intermittent urinary catheterization for a client at regular intervals 3. A nurse is assisting with a educational program about car restraint safety for a group of parents. Which of the following statements by a parent indicates an understanding of the instructions? a) 593 of 640 My 12 year old child should place the shoulder lap belt low across his hips 4. A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which of the following instructions should the nurse include in the teaching? Drink high protein and high calorie nutritional supplements 5. A nurse is supervising an assistive personnel who is preparing to remove her personal protective equipment after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the procedure when she removes which of the following PPE first? Gloves 6. A nurse is caring for a client who is crying and states that his provider informed him that he has a tumor and will need a biopsy. Which of the following responses should the nurse make? What have you done in the past to help yourself get through stressful situations before? 7. A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to the provider Generalized petechiae 8. A nurse is contributing to a teaching plan for a group of male adolescents about the adverse effects of anabolic steroid use. Which of the following manifestations should the nurse include Reduced height potential 9. A nurse is reinforcing teaching with an older adult client who has a severe left sided heart failure. Which of the following statements should the nurse make Rest 15 minutes between activities 10. A nurse in a long term care facility is documenting the care of an older client. Which of the following information should the nurse include in the weekly nursing care summary Hydration status 11. A nurse is caring for a client who has a head injury. Using the gasgow coma scale collection data, the nurse should obtain which of the following information Motor response 12. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which of the following instructions should the nurse include? Apply stockings in the morning 13. A nurse in a providers office is obtaining a health history from a client who is scheduled to undergo a cardiac catheterization in 2 days. Which of the following questions is the Do you know if your allergic to iodine 14. A nurse is planning to administer nystatin oral suspension to a client who has oral candiasis. Which of the following instructions should the nurse give to the client Hold the medication in your mouth for several minutes prior to swallowing 15. A nurse is preparing to care for the assigned clients on her upcoming shift. Which of the following time management strategies should the nurse plan to use? Prepare a priority list of client needs for the shift 16. A nurse is preparing to witness a client who is scheduled for surgery sign a informed consent. Which of the following actions should the nurse take? Ask the client if he understands the procedure 17. A nurse in an inpatient mental health clinic is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about alcoholics anonymous. Which of the following responses should the nurse make? What is your current understanding about the purpose of AA 18. A nurse is assisting with the care of a client who is 2 days postop following a total knee arthroplasty. Which of the following tasks should the nurse assign to an assistive personnel? Reapply antiembolic stockings to the client following a shower 19. A client in a mental health facility unjustly accuses a nurse of stealing money from his room. Which of the following therapeutic responses should the nurse make? Tell me how you decided who took your money 20. A nurse isreinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates understanding of the teaching? I will wear a soft scarf around my neck when I am outside a) 594 of 640 21. A nurse is using the FLACC scale to determine the level of pain for an 11 month old infant who ispostop. Which of the following factors should the nurse consider when using this pain scale Level of activity 22. A nurse is reviewing the techniques for transferring a client from bed to chair with a group of assistive personnel. Which of the following instructions should the nurse include Use lower body strength 23. A nurse is reinforcing taching with a client who is to self administer epoetin alfa. Which of the following instructions should the nurse include Administer the medication subcutaneously 24. A nurse is collecting data from a 5 year old child at a well child visit. The parents reports that the child is having frequent nightmares. Which of the following statements by the parent indicates to the nurse that the child is experiencing sleep terrors rather than nightmares My child goes back to sleep right away 25. A nurse assisting with the care of a school age child immediately following surgery. The child weighs 21.8kg and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider 250ml of sanguineous drainage over the last 3hr 26. A nurse is reinforcing teaching about advanced directives with a client. Which of the following statements by the client indicates an understanding of the teaching I can change my health care decisions even if I have advanced directives 27. A nurse is assisting with the admission of a client who has rubeola. Which of the following transmission-based precautions should the nurse plan to initiate for this client Airbourne 28. A nurse is administering morning medications to clients on the unit. A client questions the nurse regarding a medication that she does not recognize. Which of the following actions should the nurse take first Verify the prescription in the clients medical record 29. A nurse in an urgent care clinic is collecting data from four clients. Which of the following clientsshould the nurse recommend for treatment A client who is experiencing shortness of breath after taking amoxicillin 30. A nurse enters a clients room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse take first Assist the client to a nearby waiting area 31. A nurse is caring for a client who is in the final stages of cancer. Which of the following situationsshould the nurse identify as an ethical dilemma The client asks the nurse to help her die peacefully in her sleep 32. A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which of the following instructions should the nurse includes Apply capsaicin cream 4 times daily 33. A nurse in a urgent care clinic is caring for a child who has a minor burn on his palm after touching the burner on a hot stove. Which of the following actions should the nurse take? 1. clean the burn with soap and tepid water 2. Remove any embedded debris 3. Apply an antimicrobial ointment 4. Wrap the hand in a gauze dressing 5. Inform the parent of dressing change schedule 34. A nurse on a medical unit is reviewing a clients medical record. Which of the following procedures should the nurse identify requires the client to sign a separate informed consent Lumbar puncture 35. A nurse isreinforcing teaching about managing manifestations of anxiety with a client who has generalized anxiety disorder. Which of the following information should the nurse include Say the word stop when upsetting thoughts occur 36. A nurse is performing a dressing change for a client who is 3 days postop. Which of the following findings should the nurse report to the provider Yellow green drainage at the incision line 37. A nurse ina long term care facility is collecting data from a client who has been receiving betaxolol to treat glaucoma. Which of the following findings in an adverse effect of this medication Bradycardia a) 595 of 640 38. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching? Strain the urine to collect stone fragments 39. A nurse is caring for a client who is scheduled for a peritoneal dialysis. Which of the followingactions should the nurse take first Ensure the dialysate solution is at room temperature 40. A nurse in a providers office is reinforcing teaching with a client who is to follow a 2000mg sodiumrestricted diet. Which of the following client food selections indicates an understanding of the teaching Canned peaches 41. A nurse enters the room of an adolescent client and finds him on the floor experiencing a tonic clonic seizure. Which of the following actions should the nurse take when the seizure subsides Keep the client in a side lying position 42. A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take? Tell the client she should not experience any discomfort 43. A nurse is assisting with the admission of an older adult client. Which of the following actions should the nurse take first Complete a fall risk assessment on the client 44. A nurse is contributing to the plan of care for a client who has a prescription for range of motion exercises of the shoulder. Which of the following exercises should the nurse recommend to promote shoulder hyper-extension Move her arm behind her body with her elbow straight 45. A nurse isreceiving change of shift report for four clients. The nurse should plan to collect data from which of the following clients first A client who has asthma and had frequently exacerbation on the previous shift 46. A nurse in a providers office is caring for a client who is at 34 weeks of geststion. Which of thefollowing instructions should the nurse anticipate providing to the client? Monitor your blood pressure using your right are daily 47. A nurse is collecting data from an older adult client who has a gastric ulcer. Which of the findings should the nurse identify as a complication to report to the provider? Hematemesis 48. A nurse is assisting with planning palliative care for a client who has stage IV cancer and is in the active stage of dying. Which of the following interventions should the nurse include in the plan of care Administer atropine to reduce the clients respiratory secretions 49. A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this method of pain control? I should report leaking at the insertion site to the anesthesiologist 50. A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation immediately following a transurethral resection of the prostate. Which of the following interventions should the nurse include Maintain a drainage flow rate to keep the urine diluted to a reddish pink color 51. A nurse is caring for a client who is scheduled for a mastectomy the following day. The client is tearful and tells the nurse that she is not ready to have this procedure done at this time. Which of the following responses should the nirse make? Would you like for me to talk to the surgeon with you 52. A nurse is collecting data from a school age child who has hypoglycemia. Which of the followingclinical manifestations should the nurse expect? Sweating 53. A nurse is assisting with a community education program for parents of preschoolers about recommend activities to promote physical development. Which of the following statements should the nurse make? You should provide unorganized play activities for your child each day a) 596 of 640 54. A nurse monitoring a school age child who has anemia and is receiving a transfusion of packed RBCs. Which of the following statements by the child indicates a possible hemolytic transfusion reaction that the nurse should report to the charge nurse and the provider? I an really cold. May I have another warm blanket 55. A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes. The nurse should report which of the following findings as an indication of hyperglycemia Polyuria 56. A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which of the following indicates the client is experiencing a therapeutic response to the medication Reports decrease in number of stools 57. A nurse is caring for a client who is 12hr postop following a total hip arthroplasty. Which of the following actions should the nurse take? Place an abduction wedge between the clients legs when he is in bed 58. A nurse in a providers office is caring for four clients. Which of the following clients should thenurse see first? A client who is 36 weeks of gestation and reports a painless vaginal bleeding 59. A nurse is reinforcing teaching with a client about how to replace her 2 piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest Hold the skin taut while removing the barrier 60. A nurse is instructing an assistive personnel about caring for a client who has hepatitis A and is incontinent of stool. Which of the following infection control precautions should the nurse instruct the ap to use Contact 61. A nurse is assisting in the plan of care for a client who has a viral meningitis. Which of thefollowing interventions should the nurse include in the plan of care? Place the client in a private room 62. A nurse is reinforcing teaching regarding puberty with a group of prepubescent female clients. Which of the following information should the nurse include in the teaching You will likely gain weight before you start to get taller 63. A nurse in a providers office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use? Coronary artery disease 64. A nurse is caring for a client who has just been diagnosed with a terminal illness. The client states,I have nothing to live for. I just cannot go on. Which of the following responses should the nurse make? It sounds like you feel there is no hope. Are you thinking about harming yourself? 65. A nurse is contributing to the plan of care for a client who has a nasogastric tube and is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan Measure the pH of gastric tube aspirate prior to administering nutrition 66. A nurse is caring for a client who is at 34 weeks of gestation and has mild preeclampsia. Which of the following findings indicates a progression from mild to severe preeclampsia‘ Client reports blurred vision 67. A nurse is collecting data from a client who has chronic hepatitis. In which of the following locations should the nurse expect the client to point to indicate hepatic tenderness? The client with chronic hepatitis will experience hepatic tenderness in the upper right quadrant, which is where the nurse should palpate. This is the area where the liver is located 68. A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural effusion. In which of the following positions should the nurse place the client for the provider? Upright with arms resting on the overbed table 69. A nurse is reinforcing teaching with a client who has asthma and has a prescription for thophylline which of the following statements should the nurse make Discontinue drinking caffeinated beverages a) 597 of 640 70. A nurse isreinforcing teaching with a client who has a new prescription for metrondiazole. The nurse should instruct the client to expert which of the following adverse effects while taking this medication Reddish-brown urine 71. A nurse is reinforcing preop teaching with a client who will receive morphine through a PCA pumpafter surgery. Which of the following information should the nurse include You should increase your fluid intake while receiving this medication through the PCA pump 72. A home health nurse is collecting data from an older adult client who has generalized anxiety disorder. The client lives at home with her partner and a sibling. Which of the following responses by the clients partner is the priority for the nurse to address Her prescription isn’t generic so we cant afford it anymore 73. A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations A visitor who develops a bruise on her head following a syncopal episode 74. A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty usingeating utensils. The nurse should identify the need for a referral to which of the following interprofessional team members Occupational therapist 75. A nurse is caring for a client who is being discharged home after experiencing a cerebrovascular accident. Which of the following documents should the nurse plan to include with discharge instructions List of symptoms to report 76. A nurse in a pediatric clinic receives a phone call from a parent whose child has just ingested the contents of a full bottle of acetaminophen. Which of the following responses should the nurse make Take your child to the emergency department 77. A client is requesting information from a nurse about creating a health care proxy. Which of the following statements should the nurse make The person you appoint will make health care decisions when the client is no longer able to make decisions herself 78. A nurse is preparing to perform venipuncture to obtain a blood sample from a client. Which of the following actions should the nurse take Select a site in the antecubital fossa 79. A nurse is reviewing the laboratory reports for a client who is 2 days postop following thoracic surgery. Which of the following results should the nurse report to the provider WBC 25000 80. A nurse is assisting with the transfer of a client to a long term care facility. The nurse should review which of the following sections of the electronic medical record to locate information about the clients personal health insurance Admission sheet 81. A nurse is caring for a client who is in an inpatient mental health unit and has dependent personality disorder. Which of the following client behaviors should the nurse expect The client calls her partner to ask what she should wear each day 82. A nurse is monitoring a client who is receiving IV fluids. For which of the following findingsshould the nurse stop the infusion Edema above the catheter insertion site 83. A nurse is using an interpreter to reinforce discharge teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse take Observe the clients facial expressions during communication 84. A nurse is assisting with the development of an in service for newly licensed nurses about seclusion. The nurse should identify the need to request a prescription for seclusion for which of the following situations A client hits another client because she thought he was talking about her 85. A nurse is caring for a client who has a phobia of elevators. Which of the following should the nurse recognize as indicative of a positive client response to a systemic desensitization The client remains relaxed when thinking of the phobia a) 598 of 640 86. A nurse is assisting with the care of a client who is postpartum and has deep vein thrombosis. The client has been receiving heparin via IV infusion. Which of the following medications should the nurse ensure is readily available Protamine sulfate 87. A nurse is contributing to the plan of care for a client who has pneumonia. Which of the following entries should the nurse include in the plan Client prefers bathing in the evening 88. A nurse in a providers office is reviewing pediculosis capitis management and prevention strategies with the parent of a school aged child. Which of the following should the nurse include Store the childs clothing in a separate cubicle when at school. Boil brushes and combs in water for 10min. Dry bed lines and clothing in a hot dryer for atleast 20min 89. A nurse is caring for a client who has a gastrostomy tube. Which of the following actions should the nurse plan to take Flush the tume with 60ml of water if the tube becomes clogged 90. A nurse is preparing to insert an indwelling catheter for a female adult client. Cleanse the clients labia and meatus using a front to back motion Use the nondominant hand to expose the clients urinary meatus Advance the cathter 5-7in into the clients urinary meatus Ask the client to bear down while inserting the catheter 91. A nurse is caring for a client who is 4hr postop following gastrointestinal surgery and has an NG tube for gastric decompression. Which of the following actions should the nurse take Keep the plugged tube above the level of the stomach when the client is ambulating 92. A nurse is monitoring a client who is receiving lactated ringers 500ml iv over 4hr. The drop factorof the manual iv tubing is 10gtt/ml. The nurse should check that the manual iv infusion is delivering how many gtt/min? 21 93. A nurse is assisting a client who is postop to sit on the side of the bed. Which of the following actions should the nurse take Elevate the head of the clients bed 94. A nurse is reinforcing teaching about a therapeutic diet with a client who has iron deficiency anemia. Which of the following food items should the nurse recommend that the client consume Red meats 95. A nurse is caring for a 3 year old toddler at a well child visit. The parent states that the child will not eat a full meal. Which of the following responses should the nurse make? Offer healthy snacks more frequently rather than expecting him to eat full meals 96. A nurse is reinforcing teaching with a client who is scheduled for an exercise ECG stress test.Which of the following actions should the nurse make? Recommend the client wear comfortable shoes during the test 97. A nurse is assisting with the care of a client who has a terminal illness. The client practices orthodox Judaism. Which of the following actions should the nurse take. Assure the client that a family member will stay with his body after death 98. A nurse is working in an acute care facility when a natural disaster occurs. The facility must discharge clients to provide room for new admissions. Which of the following clients should the nurse recommend to the charge nurse for discharge A client who has pneumonia and is currently receiving oral antibiotics 99. A nurse is caring for a newborn who is 1hr old. The mother received fentanyl 30 min before delivery. For which of the following adverse effects should the nurse monitor the newborn Respiratory depression 100. A nurse isreinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include Apply a water based lubricant around the nostrils to prevent irritation 101. A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril. Which of the following over the counter medications should the nurse instruct the client to avoid Ibuprofen a) 599 of 640 102. A nurse is assisting with the care of a client who has a terminal cancer. Which of the following statements by the clients family should indicate to the nurse that they are coping with their situation Dad, I remember the time we all went fishing at the lake 103. A nurse observes a client in labor. Which of the following interventions should the nurse recommend for this client Squatting using a birth ball counterpressure to the sacral area leaning forward while kneeling 104. A nurse in a providers office is collecting growth and development data from a 7 month old infant during a well child visit. Which of the following images should the nurse identify indicates expected gross motor skills for the infant Sitting and leaning forward using both hands for support is an expected finding for a 7 month old infant 105. A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following client statements indicates an understanding of teaching the client I will dispose of my needles in a plastic laundry detergent container 106. A nurse is preparing to admin amoxicillin 875mg po every 12hr. The amount available is amoxicillin oral suspension 400mg/5ml. How many ml should the nurse administer per dose 11ml 107. A nurse is preparing to perform blood glucose monitoring for a client who has type 2 diabetes mellitus. Which of the following actions should the nurse take first Hold the finger for testing in a dependent position 108. A nurse is reinforcing discharge teaching with the parents of a school age child who has severe hemophilia A. Which of the following statements by the parents indicates an understanding of the teaching I will soak my sons toothbrush in warm water to soften it for him before he uses it 109. A nurse is caring for an older adult client who is experiencing difficulty sleeping. Which of thefollowing actions should the nurse take Offer the client a snack of whole grain crackers before bedtime 110. A nurse is reinforcing teaching on self admin of enoxaparin. Which of the following instructionsshould the nurse give the client Admin by subq injection 111. A nurse is talking with a client who says the provider agreed to initiate a DNR prescription. Afterleaving the clients room, which of the following actions should the nurse take first Check for documentation that the provider spoke with the client about the DNR 112. A nurse caring for a client who has hiv and lost 15% of his body weight in the last 3 months. The nurse should offer a serving of which of the following foods to add the most protein to the clients diet Peanut butter 113. A nurse is collecting data from an older adult client who has a hip fracture. Which of the following findings should the nurse expect External rotation 114. A nurse is observing an assistive personnel apply antiembolic stockings for a client who is at risk for deep vein thrombosis. Which of the following actions indicates the AP is applying the stockings correctly The AP applies the stockings before getting the client out of bed 115. A nurse is preparing to admin an IM immunization to a preschooler. Which of the following statements should the nurse plan to make prior to performing the injection Lets give the medicine to your doll first 116. A nurse is caring for a client who is recovering from a motor vehicle crash. The clients employer calls to ask if the clients injuries will prevent him from returning to work. Which of the following responses should the nurse make I cannot give you this information you will need to speak with your employee 117. A nurse is caring for a newborn who is 12hr old. Which of the following stools should the nurse instruct the parents to expect during the first 24hr after birth Dark green and viscous 118. A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new prescription for atorvastatin. The nurse should instruct the client that which of the following findings is an adverse effect of this medication and should be reported to the provider a) 600 of 640 Muscle pain 119. A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client Walking outside with a staff member 120. A nurse is assisting with a discussion about STI’s with a group of adolescents at a health fair.Which of the following statements should the nurse make? An infection with gonorrhea may result in infertility 121. A nurse is instructing an assistive personnel about caring for an older adult client who has herpes zoster. Which of the following information should the nurse include The infection is contagious until blisters heal 122. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first Open steril packages 123. A nurse in a long term care facility is reviewing standard precaution guidelines with an assistive personnel. The nurse should instruct the AP that which of the following should be used to clean up a blood spill Chlorine bleach solution 124. A nurse in a pediatric clinic is collecting data from a toddler. Which of the following findingsshould the nurse identify as possible physical neglect The toddler is inadequately dressed for the weather 125. A nurse is reviewing a clients medication record. He recognizes that a double dose of oral digoxin was given 1hr ago. Which of the following actions should the nurse take first Obtain a set of the clients vitals 126. When preparing a client for an enteral feeding a nurse notices that the pump at the clients bedside is warm to touch. Which of the following actions should the nurse take Unplug the equipment and remove it from the room 127. A nurse is working at a inpatient mental health facility is contributing to plan of care for a newly admitted patient who has anorexia nervosa. Which of the following actions should the nurse includein the plan of care Record the amount of food the client consumes 128. A nurse is documenting client care in the medical record. Which of the following entries should the nurse make Client remains NPO until xray is complete’ 129. A nurse is checking reflexes of a newborn. Which of the following techniques should the nurse use to elicit babinski reflex Stroke the sole of the infants foot upward toward the great toe 130. A nurse is caring for a client who is receiving telemetry. Which of the following ECG findingsshould the nurse report to the charge nurse PR interval 0.24 seconds 131. A nurse is reviewing various defense mechanisms with newly licensed nurse. Which of the following client statements should the nurse use as an example of rationalization I didn’t get a good grade because my teacher does not like me 132. A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting along with fever and chills. Which of the following diagnostic test should the nurse expect the provider to prescribe Cerebrospinal fluid analysis 133. A nurse is reinforcing teaching with a client who is scheduled for a lumbar puncture. Which of the following statements should the nurse make You should increase your fluid intake after this procedure 134. A nurse is caring for a client who has asthma and has been taking montelukast for 1 month which of the following findings should indicate to the nurse the client is complying with this regimen? The client takes the medication once daily at bedtime 135. A nurse is reinforcing teaching with a client who has a prescription for phenytoin. Which of the following instructions should the nurse include as a measure to assist with the possible adverse effects of this medication Perform gum massage a) 601 of 640 136. A nurse in an urgent care clinic is completing a client examination. After listening to the clients lungs, which of the following adventitious sounds should the nurse document Wheeze 137. A nurse is monitoring a client who is 12hr postop following a cholecystectomy and received morphine 30 min ago for pain. The nurse should identify which of the following findings as an adverse effect of the medication Respiratory rate 10/min 138. A nurse is reviewing the critical pathway of a client who is 4 days postop following a total knee arthroplasty. The clients vital signs are oral temp 102.4 heart rate 116/min respiratory rate 24 and blood pressure 152/92. Which of the following actions should the nurse take? Document the findings as a variance 139. A nurse is reviewing laboratory results for a client who is receiving mechanical ventilation. Whichof the following findings should the nurse recognize as a potential complication of mechanical ventilation Ph 7.5 140. A nurse is assisting with an educational session for a newly licensed nurses about intimate partner violence. Which of the following characteristics should the nurse include as placing a vulnerable person at risk for intimate partner violence Recent confirmation of pregnancy 141. A nurse is collecting data from a client who has schizophrenia which of the following statements by the client should the nurse identify as delusional My doctors glasses have lasers that will burn holes in my brain if I look at him 142. A LPN is reviewing her client assignments for the upcoming shift. Which of the following clientsshould the LNP ask the charge nurse reassign to a registered nurse A client who has a new colostomy and requires the development of a teaching plan 143. A nurse is caring for a client who is expressing sadness about amputation of her leg 72 hr ago due to trauma. The nurse must leave the room but promises to return as soon as possible. Which of the following ethical principles is the nurse demonstrating when he returns as promised Fidelity 144. A nurse is caring for a client who practices orthodox judaism and adheres to a kosher diet. Which of the following food selections should the nurse expect to see on the clients meal tray Spaghetti noodles with red meat sauce 145. A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take Flush the feeding tube with water before and after administering the medication 146. A nurse is collecting a urine specimen from a female client who has iabetes insipidus. The nurse should expect which of the following findings Urine specific gravity of 1.002 147. A nurse is working on a unit with an assistive personnel. Which of the following actions by the APshould the nurse recognize and report as assault The ap threatens a client with insertion of an NG tube if she does not eat breakfast 148. A nurse is reinforcing teaching with a female client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates understanding of the teachingI will use condoms in addition to birth control pills to decrease my risk of becoming pregnant 149. A nurse is reinforcing teaching with a client who has alcohol use disorder and is to begin disulfiram therapy. Which of the following statements should the nurse make You will need to sign an informed consent before starting this medication 150. A nurse is caring for a client who reports twelve liquid stools in the past 8hr. Which of the following findings should indicate to the nurse that the client is experiencing dehydration Potassium level of 2.5 PN COMPREHENSIVE 2014 A a) 602 of 640 VERSION 12 1. A client begins treatment with phenytoin (Dilantin). Which following should the nurse reinforce as a measure to help minimize possible adverse effects of this medication? A. Performing daily gum massage 2. A nurse who is facilitating a support group notices that one client in the group is extremely talkative, to the point where others in the group have difficulty sharing their own ideas. Which of the ff. strategies should the nurse use to facilitate the group process with this client? A. Speak privately to the client about this behavior. 3. The partner of a client who died from leukemia tells a nurse, “It’s so unfair that God took him from me. I just can’t live without him.”. Which of the following actions by the nurse is the priority? A. Ask the client she has had suicidal thoughts. 4. A nurse is preparing to remove a client’s peripheral IV catheter. Which of the following actions should the nurse plan to take? A. Maintain the catheter parallel to the vein when withdrawing the catheter. 5. A nurse is reinforcing teaching to the parents of a newborn who has a new prescription for nystatin (Mycostatin) for oral candidiasis. Which of the following should the nurse include in the teaching? A. Instill the medication 1 hr. after feeding. 6. A nurse is reinforcing teaching about an IV urography (IVP) with the parent of a 3yr. old child. Which of the ff. statements indicates the parent understands the teaching? A. My child will need to have a soapsuds enema before this procedure. 7. A nurse is reinforcing teaching with the parent of a school-age child who has nephrotic syndrome with peripheral edema. Which of the ff. statements by the parent indicates understanding of the teaching? A. I will provide a low-sodium diet for my child. 8. A nurse is caring for a client who is on complete bed rest and is unable to change positon in bed without assistance. The nurse delegates the task of repositioning the client every 2 hr. to an assistive personnel(AP). Which of the ff. is an appropriate method to ensure that the AP has performed the task correctly? A. Check that the client is in a new position every 2hr. 9. A newly hired nurse discovers that some medication doses provided on a client’s medication record have not been updated since yesterday. Coworkers admit that new changes in the medication orders have not been processed yet, but they advise the nurse to administer the new prescriptions anyway. The nurse should notify which of the ff.? A. The nurse manager. 10. A registered nurse and a licensed practice nurse (LPN) on a medical–surgical unit are collaborating to provide care for a group of clients. The LPN should recognize that which of the ff. tasks are not within the LPN scope of practice? a) 603 of 640 A. Develop a plan of care for a client who requires bladder training. a) 604 of 640 11. Which of the ff. should a nurse recognize as indicative of a positive client response to systematic desensitization for treatment of a phobia? A. The client remains relaxed when thinking of the phobia. 12. A nurse in a long-term care facility is reviewing standard precaution guidelines with an assistive personnel(AP). The nurse should instruct the AP that which of the ff. should be used to clean up a blood spill? A. Chlorine bleach solution. 13. A nurse is caring for a client who is 3 days postoperative ff. a transurethral resection of the prostate and has an indwelling urinary catheter. Which of the ff. findings should the nurse expect? A. Yellow urine with red sediment. 14. A nurse is preparing to administer cephalexin (Keflex) to a client when he states, “ I just remembered that I have an allergy to penicillin. “Which of the ff. actions should the nurse take? A. Call the provider who prescribed the medication. 15. A nurse is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the ff. solutions to clean the inner cannula? A. Hydrogen peroxide. 16. A nurse is working with an interpreter to explain a diagnostic procedure to a client who does not speak English. Which of the ff. actions should the nurse take? A. Ensure the interpreter is culturally compatible with the client. 17. A client 12 hr. postoperative cholecystectomy was given morphine 10mg intravenously at 0700. The nurse marking rounds at 0720 should recognize which of the ff. as an adverse effect of the medication? A. Respiratory rate 10/min 18. A nurse is inserting an indwelling catheter into a female client who has urinary retention. After urine is seen in the tubing, which of the ff. actions should the nurse take next? A. Advance the catheter 2.5 to 5 cm. 19. A nurse is administering morning medication to clients on the unit. A client questions the nurse regarding a medication that she does not recognize. Which of the ff. nursing interventions should the nurse take first? A. Verify the prescription in the client’s medical record. 20. A nurse is reinforcing teaching regarding prenatal discomfort to a client who is at 20 weeks of gestation. Which of the ff. statements made by the client indicates an understanding of the teaching? A. I will wear a supportive bra overnight. 21. A nurse is caring for a client who has leukemia and is experiencing stomatitis ff. treatment. Which of the ff. is an appropriate diet selection by the nurse? A. Oatmeal and apple sauce 22. A nurse is reinforcing teaching for a client who has coronary artery disease and is taking low-dose aspirin daily. The nurse should reinforce that this medication regimen has which of the ff. therapeutic effects? A. Antiplatelet a) 605 of 640 23. A nurse is discussing STIs with a group of adolescents at a health fair. Which of the ff. is an appropriate statement? A. An infection with Neisseria gonorrhoeae may result in infertility. 24. A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depressive disorder. After the procedure, which of the ff. actions should the nurse take? A. Orient the client frequently. 25. A nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. Which of the ff. should the nurse include in the client’s diet plan? A. Dried beans 26. A nurse working in a long-term care facility discovers a client has fallen and appears to have injured his neck. After calling for help, which of the ff. actions should the nurse take? A. Place a rolled blanket on each side of the client’s head. 27. A nurse is reinforcing client teaching on relaxation techniques during labor. Which of the ff. indicates a need for further client teaching? A. I will wait until I go into labor to decide if I will use hypnosis as a relaxation technique. 28. A nurse is caring for a client experiencing hypovolemic shock. Which of the ff. actions should the nurse take? A. Elevate the clients leg. 29. A nurse in a provider’s office is auscultating the lung sounds of an older adult client and notices small, circular burn marks on her back and trunk. Which of the ff. actions is appropriate for the nurse to take? A. Interview the client privately about the burn marks. 30. A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping. Which of the ff. instructions should the nurse include? A. Preform range of motion exercises 31. A nurse is contributing to the plan for care for a client who has a nasogastric tube and is receiving continuous enteral feedings. Which of the ff. should the nurse include in the plan? A. Measure the pH of gastric tube aspirate prior to administering nutrition. 32. When preparing a client for an enteral feeding, a nurse notices that the pump at the client’s bedside is very hot to the touch. Which of the ff. actions should the nurse take? A. Unplug the equipment and remove it from the room. 33. A nurse is reinforcing teaching for a client who is taking spironolactone (Aldactone). Which of the ff. dietary choices should the client limit? A. Cantaloupe 34. A nurse is caring for a client who has been prescribed amitriptyline. After 1 week, the client calls the provider’s office and states, “I’m not taking these pills anymore. They are not doing anything”. Which of the ff. response by the nurse is appropriate? A. It may take up to 4 weeks before you feel a difference when taking this medication. 35. A nurse is caring for an older adult client who had surgery for a ruptured appendix 3 days ago the client has a tube in place. Which of the ff. should the nurse do to determine whether or not peristalsis is restored? A. Auscultate for bowel sounds. a) 606 of 640 36. A nurse is working in a long-term care facility. Which of the ff. actions should the nurse take when using computer-based client records? A. Shred printouts of client care information when they are no longer needed. 37. A nurse working in a community clinic is caring for an adolescent who has infectious mononucleosis. The client the nurse to explain how the disease was acquired. The nurse explains that an individual acquires this disease which of the ff. A. Sharing eating utensils with an infected person. 38. A nurse is reinforcing discharge teaching for a client who has a new colostomy. Which of the ff. statements made by the client indicates an understanding of the teaching? A. “I will open the bottom of the pouch to empty the contents before I remove it.” 39. A nurse is preparing the administer NPH (Novolin N) insulin to a client who has diabetes mellitus before breakfast at 0700. At which of the ff. times should the nurse plan to check the client for hypoglycemia? A. 1100 40. A nurse in a clinic is obtaining a health history from a client scheduled to undergo a cardiac catheterization in 2 days. Which of the ff. questions is the most important for the nurse to ask? A. “Do you know if you’re allergic to iodine?” 41. A nurse in an urgent-care facility is collecting data from a client who is scheduled for a procedure. Which of the ff. clinical manifestations indicates a possible latex allergy? A. Rhinorrhea 42. A nurse in a provider’s office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the ff. statements by the client demonstrates understanding of the teaching? A. “I will rinse my mouth after taking this medication.” 43. A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client who is at risk for a deep thrombosis. Which of the following actions the AP is applying the stockings correctly? A. The AP applies the stockings before getting the client out of bed. 44. A nurse working in a provider’s office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the ff. responses by the nurse is correct? A. “When all the blisters are scabbed over.” 45. A nurse is caring for a client who just had blood drawn for an arterial blood gas analysis. Which of the ff. values should the nurse expect if the client is in respiratory acidosis? A. PaCO2 51 mm Hg 46. A nurse is reinforcing teaching with a client who has a new prosthesis for an above the knee amputation of the right leg. Which of the ff. instructions should the nurse reinforce to the client? A. Apply the prosthesis immediately upon waking each day. 47. A nurse is preparing a client for the insertion of an NG tube. Which of the ff. actions should the nurse take? A. Determine if the client has a deviated septum. a) 607 of 640 48. A nurse is caring for a client who has a fractured radius and has a short arm cast applied yesterday. Which of the ff. findings should the nurse report to the provider? A. Client report of decreased sensation in the finger. 49. A nurse is contributing to the plan of care for a client who is on suicide precautions. Which of the ff. interventions is appropriate for the nurse to recommend? A. Encourage the client to sign a no-harm contract. 50. A nurse is preparing to administer haloperidol (Haldol) 4 mg IM start to a client. Available is haloperidol for injection mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.) A. 0.8 mL 51. A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting, and fever with chills. Which of the following diagnostics tests should the nurse expect to be prescribed? A.Cerebrospinal fluid analysis 52. A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements is appropriate for the nurse to make? A.If you’d like to wear a wig, you should select it before hair loss occurs 53. A change nurse in a long-term care facility observes an assistive personnel (AP) who appears to be under the influence of alcohol. Which of the following actions should the nurse take first? A.Confront the AP about suspected impairment 54. A nurse is caring a client who has asthma and has a prescription for theophylline (theochron) 200mg PO BID. Which of the following should the nurse include in the teaching? A.Discontinue drinking caffeinated beverages 55. While a nurse is assisting a client to ambulate, the client reports lightheadedness and begins to fall. Which of the following nursing actions demonstrates a correct understanding by the nurse about ergonomic principles? A. Spread feet apart and extend one leg for the client to slide down while lowering the client to the floor 56. A nurse is caring for an older adult client who appears lethargic and somnolent. The nurse reviews the client’s medications prior to contacting the provider. Which of the following medication is the likely cause of the increased sedation? A.Lorazepam (Ativan) 57. A nurse is caring for a client who had a bronchoscopy and just arrived to the medical surgical unit. Which of the following actions should the nurse perform first? A.Check for a gag reflex 58. A client is requesting information form a nurse regarding the appointment of a health care proxy. Which of the following responses by the nurse is appropriate? A.The person you appoint will make health care decision for you if you cannot do so yourself. 59. A nurse enters client’s room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse first? A.Assist the client to a nearby waiting area a) 608 of 640 60. A nurse is interviewing clients as part of a skin cancer screening program. Which of the following statement made by a client indicates that he may have a premalignant lesion? A.I have this flat, scaly area with red edge on neck 61. A nurse is caring for a client who reports 12 liquid stools in the past 8hr. Which of the following findings indicates that the client is experience dehydration? A.Potassium level 2.5 mg/L 62. A nurse is talking with a client whose son died in a motor vehicle crash 2 weeks. The client states, “I really thought I’d be back to my usual routines by now, but I can’t think of anything else except that my son is gone.” Which of the following is an appropriate response? A. Grieving for your son is hard work, It will take as much time as you need to come to terms with your loss. 63. A nurse in a long-term care facility is providing postmortem care for a client. Which of the following actions should the nurse take first? A.Check with the family about religious practices 64. A nurse is delegating the administration of an enema to an assistive personnel (AP). Which of the following actions should the nurse take? A.Explain the expected outcome to the AP 65. A nurse is reinforcing teach with the parent of a toddler who has acute otitis media. Which of the following instructions should the nurse give the parent? A.Give acetaminophen (Tylenol) for discomfort 66. A nurse is reinforcing teaching with a client who is reeving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates understand of the instructions? A.I will wear a soft scarf around my neck when I am outside 67. A nurse is reviving a client’s medication record. He recognizes that a double does of oral digoxin (lanoxin) was administered 1 hr. ago. Which of the following actions should the nurse take first? A.Obtain a set of vital signs 68. A nurse enters a client’s room with a prescribed IM medication. The client refuses the injection, but the nurse administers it anyway. This action by the nurse is an example of which of the following? A.Battery 69. A nurse is caring for a client who is postpartum and has deep-vein thrombosis. The client has be receiving heparin via IV infusion. Which of the following medications should the nurse ensure is readily available? A.Protamine sulfate 70. A nurse is preparing to administer a client’s morning medications. Which of the following actions should the nurse take to verify the client’s identity? A.Scan the facility identification band 71. A newborn passes her first stool within 24 hr. after deliver. The nurse recognize that the newborn’s stool is normal because it is A. dark green and viscous 72. A nurse is caring for a client who has hepatitis A. The nurse should recognize that this type of hepatitis can be transmitted through A. contaminated food a) 609 of 640 73. A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol (Haldol) 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question? A.Dosage 74. A nurse is collecting data from a client who has a head injury and has a Glasgow Coma Scale score of 15. Which of the following finding should the nurse expect? A.Oriented and obeys commands 75. A nurse is collecting data from a client in the diagnostic center who is scheduled to undergo a colonoscopy. Based on the information provided in the clients’ chart, which of the following places this client at risk for colorectal cancer A.IBM 76. A nurse is having a discussion with a group of parents regarding prevention of sudden infant death syndrome (SIDS). Which of the following informant should the nurse include in the discussion? A.Use a firm mattress to the crib 77. A client in a mental health facility unjustly accuses a nurse of the stealing money from his hospital room. Which of the following is an appropriate therapeutic response by the nurse? A.Tell me how you decide who took your money 78. A nurse receives a telephone call from a client who has type 2 diabetes mellitus and reports having influence for the past 24 hr. Which of the following instructions should the nurse include? A.Drink 240 mL (8oz) of sugar-free liquid every hour 79. A client is In the end stage of AIDS. She tells the nurse “I knew this day would come, but I’m still soscared.” Which of the following is the appropriate response by the nurse? A.Share your thoughts with me 80. A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? (Select all that apply.) A. Determine the facts related to the dilemma Identify possible solutions Consider the client’s wishes 81. A nurse is receiving change-of shift report on four clients. The nurse should plan to collect data on which of the following clients first? A.A client who has asthma who had frequent exacerbations on the previous shift 82. A long-term care nurse notices notices a client who has Alzheimer’s disease standing at the exit doors at the end of the hallway. The client appears to be anxious and agitated. Which of the following actions would the nurse take? A.Escort the client to a quiet area on the nursing unit. 83. A nurse is collecting date from a client who has left sided heart failure. Which of the following findings should the nurse expect? A. Due to decrease peripheral perfusion, dizziness is an expected finding in left-sided heart failure. 84. A nurse is assisting a provider who is performing an amniotomy to augment a client’s labor. Following the procedure, which is the priority action by the nurse? A. obtain fetal heart tones a) 610 of 640 85. A charge nurse is observing a newly hired nurse apply sterile gloves to perform a sterile dressing change. Which the following actions by the newly hired nurse maintains stile technique? A.Puts a glove on her dominate hand first 86. A nurse is reinforcing teaching regarding puberty to a group of prepubescent female clients. Which for the following should the nurse include the teaching? A.You will likely gain weight before you start to get taller 87. A nurse is preparing to administer prednisone 1mg/kg PO to a preschooler who weights 44lb. Available is prednisone oral solution 5mg/1mL. How many mL should the nurse administer? ( round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero). A. 4 88. A nurse is making assignments at the start of a shift. Which of the following task may be delegated to assistive personnel (AP)? A.Assisting a client who is 2 days postoperative with bathing 89. A nurse is reinforcing teaching with a client who is newly diagnosed with gastroesophageal reflux. Which of the following instructions should the nurse include in the teaching? A.Elevate the head of the bed 15 cm (6in) when sleeping 90. A nurse is caring for a client who is in an impatient mental health unit and has a diagnosis of depend personality disorder. Which of the following is an expected behavior for this client? The client calls her partner to ask what she should wear each day 91. An adolescent client is in the emergency department after a motor vehicle crash. The nurse notes that he is experiencing sever anxiety. Which of the following actions should the nurse take a decrease the clients anxiety? A.Speak to the client using simple sentences 92. A nurse is caring for a client who has COPD and is receiving oxygen at 2 L/min via a nasal cannula.The client is experience respiratory difficulties. Which of the following actions should the nurse take first? A.Place the client in an orthopnea position 93. A nurse is reinforcing teaching to a client who has tuberculosis (TB). The nurse recognizes that the teaching has been effective when the client makes which of the following statements? A.my family members will need to be tested for TB 94. A nurse in a provider’s office is collecting data from a client who has type 2 diabetes mellitus. Which of the following findings is an expected finding? Infection 95. A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations? A visitor who develops a bruise on her head following a syncopal episode 96. A nurse is preparing to administer timolol (Timoptic) eye drops to a client who has glaucoma. The nurse should monitor the client for which of the following adverse effects? Decreased blood pressure 97. A nurse instructs an assistive personnel (AP) to thicken all liquid offered to a client who has impaired swallowing. Which of the following indicates that the AP needs further instruction? A.The AP feeds the client ice chips with a spoon. 98. A nurse is collecting data from a client who sustained spinal cord damage from fractures to T1 and T2 vertebrae. Which of the following client outcomes should the nurse expect? a) 611 of 640 Flexes and extends the shoulders 99. A nurse is caring for a client who is at 34 weeks of gestation and has mild preeclampsia. Which of the following indicates a progression from mild to severe preeclampsia? A.Client repots of blurred vision 100. A nurse in a telemetry unit is caring for a client who is recovering from a myocardial infarction. The nurse is monitoring for potential dysrhythmias. Which of the following indicates ventricular fibrillation? Irregular rate without P waves, bizarre and variable QRS 101. A nurse is contributing to the plan of care for a client who sites in a wheelchair most of the day. Which of the following instructions should the nurse include? A.Use a gel-filled seat cushion 102. A nurse is planning care for a client who has COPD. Which of the following images indicates theappropriate oxygen delivery method the nurse should prepare to use if the client develops an exacerbation? A. A venture mask delivers a low to moderate controlled concentration of oxygen. Client who have COPD benefit from this delivery system because it provides a consistent level of oxygen regardless of the clients breathing pattern 103. A nurse is caring for child who is in sickle cell crisis. Which of the following is the nurse priorityaction? Promote oxygenation 104. A nurse is preparing to administer a dose of digoxin (Lanoxin) to client receiving continuous tube feedings. Which of the following actions should the nurse take? A.Flush the feeding tube with 30 mL of watering before and after administering the medication 105. A nurse is reinforcing activity limitations with a client who is postoperative following amastectomy. Which of the following should the nurse include in the teaching? A.Avoid raising the elbow above the shoulder until drains are removed 106. Due to client reports of inadequate pain management, the staff has selected pain managementas an area for improvement. Which of the following strategies should the nurse use to collect data regarding the quality of pain control? A.Check each client’s level of pain within 1 hr. of the client reeving an oral analgesic 107. A nurse is reinforcing teaching abuse initial management of acute diverticulitis with a newly admitted client. Which of the following statement by the client indicates an understanding of the teaching? A.I will relive the nutrients I need through my IV fluid 108. A nurse is reinforcing teaching with the parent of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include? A.Use heat therapy prior to the physical activities 109. A nurse is reinforcing teaching for a client who has a new diagnosis of type 2 diabetes mellitus. The client will use an insulin pen for self-administration of insulin. The nurse reinforces psychomotor learning by having the client A.Perform self-injection of the insulin 110. A nurse in provider’s office is caring for four clients. Which of the following client should thenurse see first? A.A client who is at 36 weeks of gestation who reports painless vaginal bleeding a) 612 of 640 111. A nurse is witnessing a client’s signature on a consent form. Which of the following is includedamong the nurse’s legal responsibilities? A.Verifying that the client understands the procedure before signing 112. A nurse is collecting data from a client who is taking digoxin (lanoxin) for heart failure. Which ofthe following findings should the nurse report to the provider as a indication of digoxin toxicity? A.Anorexia 113. A nurse working in a clinic should recognize that which of the following client conditions must bereported to a regulatory agency? A.A client in respiratory distress is diagnosed with tuberculosis. 114. A nurse is preparing to administer an injection of tetanus toxoid to an adolescent client who stepped on a rusty nail. Which of the following statements by the nurse is appropriate? A. another booster will be needed in 10 years 115. A nurse is reviewing discharge instructions with a new mother regarding car seat safety instructions. Which of the following statements by the mother indicates an understanding of the teaching? A.I will secure the car seat in the car by using the seatbelt 116. A nurse on a medical surgical unit is providing care for four clients. The nurse should ensure that informed consent is obtained from the client who is scheduled for which of the following diagnostic procedures? A.Lumbar puncture 117. A nurse isreviewing a client’s chart and finds that an assistive personnel (AP) recorded the client’s temperature as 35.3C (95.5F) 2 hr. earlier. Which of the following actions should the nurse take first? A.Check the clients’ temperature 118. A nurse is assisting a client who is to undergo a nonstress test (NST). Which of the followingactions should the nurse take? A.Administer 120 mL (4oz) of orange juice prior to the test. 119. A nurse is reinforcing teaching with a client who has left-sided weakness and is learning how to ambulate with a cane. The nurse knows that the client understands the teaching when she places the cane in which of the following positions when advancing forward? The cane is held in the hand of the stronger side of the body; in this scenario, it would be the right hand. When ambulating forward, the can is moved forward first (in front of right foot) and the weaker leg is oved forward next, so that the clients body weight is evenly distributed between the cane and the stronger leg. 120. A nurse working at an inpatient mental health facility is contributing to the plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? A.Record the amount of food the client consumes 121. A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following statements indicates an understand of the teaching? A.I will dispose of my needles in a plastic laundry detergent container 122. A nurse is visiting the home of a client who recently had a total hip arthroplasty. During Observation of the clients’ home, which of the following findings places the client at risk for falls? (select all that apply.) A.Medication stored on the top shelf of the cupboard a) 613 of 640 Client walks barefoot in the house 123. A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin (nitrostat) sublingual tablets for treatment of angina. Which of the following instructions should the nurse include? A.Take up to three tablets during a single angina episode 124. A nurse is caring for a client who has right-sided heart failure. The client’s partner expresses concern that the client will die. Which of the following is an appropriate response by the nurse? A. “It is difficult to see someone so sick. What have you have been told about your partner’s prognosis” 125. A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increase fatigue. Listen to the audio clip. Which of the following lung sounds should the nurse report to the provider? A.Fine crackles 126. A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa (Epogen). Which of the following instructions should the nurse include. A.Administer the medication subcutaneously 127. A nurse is caring for a client who has a Salem Sump tube connected to intermittent wall suction. Which of the following nursing interventions should the nurse perform? Reposition the client every 2 hrs. 128. A nurse is provider’s office is reviewing pediculosis capitis management and prevention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (select all that apply) A. Store the child’s clothing in a separate cubicle when at school Boil brushes and combs in water for 10 min Dry bed linens and clothing in a hot dryer for at least 20mins 129. A nurse is contributing to the plan of care for an adolescent who has cystic fibrosis. Which of the following diets should the nurse recommend? A.High-calorie 130. A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the medical record to the locate information about the clients personal health insurance? A. Admission sheet 131. A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison’s disease. Which of the ff. instructions should the nurse include? A. “You will need to schedule a bone density test.” 132. A nurse is assisting in the admission of a client who has diabetic ketoacidosis to a medical unit. Which of the ff. IV solutions the nurse anticipates administering first upon admission? A. 0.9% sodium chloride 133. A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings is the priority? A.Tingling around the mouth 134. A client who has asthma and is started on montelukast (Singular) returns to the clinic 1 month later. Which of the ff. indicates that the client is complying with this medication regimen? A.The client takes the medication once daily at bedtime. 135. A nurse is collecting data from an older adult client who is receiving a unit of packed RBCs.Which of the ff. findings should the nurse report to the provider as an indication of circulatory overload? a) 614 of 640 A.Crackles heard on auscultation 136. A nurse is preparing a client for surgery. The client states, “I’m sure this surgery will not helpme get better.” Which of the ff. responses by the nurse is appropriate? A. “You’re saying that you are doubtful that this procedure will benefit you.” 137. A nurse is preparing to provide suctioning for a toddler who has a tracheostomy. Which of ff. actions should be included in the plan of care? A.Allow the child to rest for 45 seconds between aspirations. 138. A nurse is assisting with the plan of care for a client who has chest tube connected to a disposable chest tube drainage system. Which of the ff. should the nurse include in the plan of care? A.Maintain the drainage system below the level of this client’s chest. 139. A nurse in a long-term care facility is assisting with the admission of a client who requires oropharyngeal suction. Which of the ff. supplies does the nurse need to perform this task? A.Yankauer catheter 140. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions by the nurse is appropriate? A.Wear a surgical mask within 3 feet of the client. 141. A nurse is collecting data from a client who has cholecystitis. In which of the ff. locationsshould the nurse expect the client to report pain? A.Right upper quadrant 142. The parents of a 12-month-old voice their concern that their child is crawling but not pulling herself up to stand like the other children at the day care center. The nurse should recommend to the parents that them. A. have the child evaluated by a pediatrician. 143. A nurse recognizes that nurse-client communication is effective when the client. A. asks the nurses to listen to potential solutions. 144. A nurse is caring for a client who is receiving IV fluids. As the nurse enters the room, the IV pump’s alarm begins beeping. The client tells the nurse, “That happens all the time. Just turn off the alarm.” Which of the ff. actions should the nurse take first? A.Observe the IV site. 145. A nurse is caring for a client who is scheduled for colonoscopy with polyp removal. Which of the following client statements should alert the nurse that the client may be at risk for complications from the procedure? A. “I needed three ibuprofens for my arthritis pain last night.” 146. A nurse is reinforcing teaching with the parents of a newborn about physical assessments. Which of the ff. statements by the parent demonstrates understanding of the newborn hearing screening test? A. “If my baby fails the hearing test, he will need to be rested in 3 months.” 147. A nurse is reviewing instructions with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the client should take after washing his hands. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must used.) a) Expose the glans of the penis b) Cleanse the penis using antiseptic swab c) Begin urination d) Pass the cup into the urine stream e) Move the cup out of the urine stream f) Move the cup out of the urine stream g) Replace the foreskin 148. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the ff. actions should the nurse take? A. Provide step-by-step instructions for performing ADLs. 149. A nurse is reinforcing teaching about breastfeeding with a pregnant client. Which of the ff. statements by the nurse is appropriate? A. ” Breastfeeding reduces the infant’s risk of infection.” a) 615 of 640 150. A nurse is reviewing client positioning for a thoracentesis with a newly licensed nurse. The nurse validates that newly licensed nurse’s understanding when he indicates that the client should be placed in which of the ff. positions for the procedure? A.Leaning forward over pillows. PN Comprehensive Online Practice B Assessment VERSION 13 Above the knee amputation:  Assist patient to prone position every 4 hours  Wrap limb in distal to proximal direction  Do not elevate after 48hrs to prevent flexion contractures Aphasia  Limits ability to communicate  Does not affect swallowing and eating Radiation therapy:  Can wash irradiated area with mild soap and water  Avoid applying lotion to irradiated area  Diarrhea is an expected side effect Oxygen therapy:  Apply a water based lubricant to nares as needed  Wear cotton clothes during oxygen therapy because do not cause static electricity a) 616 of 640  Check oxygen equipment daily for proper functioning Stages of change:  First educate staff members about problem  Develop goals, encourage staff input, and do a trial run of new system or change Severe preeclampsia:  Blurred vision  Facial edema  Proteinuria TB:  Will take medications for 6 months  Diet should consist of good amount of iron, protein, and calories  No mask needed while in public Glomerulonephritis:  Proteinuria  Decreased GFR  Causes increased nitrates in the blood (not urine) Newborn apnea monitoring:  Remove leads when not monitoring  Avoid co-sleeping with baby  Do not adjust monitor  Make sure alarms can be heard throughout the house a) 617 of 640  Keep monitor outside of the crib Newborn cold stress:  Axillary temp under 36.5 (97.5) Uric acid calculi diet:  Oranges and other citric fruits  Avoid chicken and organ meats  Avoid alcohol Opioids:  Can cause urinary retention  Decrease in vision at night due to constriction of pupils (miosis)  Constipation Heparin:  Normal aPTT is 40 seconds  Therapeutic dose can increase aPTT to 60-80 seconds  Elevated aPTT- hold heparin Anemia:  Low hgb  Low hct  Dyspnea on exertion  Decreased exercise tolerance Oxygen toxicity: a) 618 of 640  Bradypnea- RR decreases because body perceives it has enough oxygen Misoprostol:  Reduces gastric acid secretions so ulcers can heal  Take pregnancy test prior to starting med (can cause uterine contractions) Prevention of pressure ulcers:  remind patient to shift weight in chair every 15 mins  place client in 30 degree lateral position to minimize pressure on sacral area  Avoid massaging bony prominences PICC lines:  Use alcohol to cleanse port  Prior to first use, confirm tip placement with a chest x-ray  flush with heparin after administering medications Blood glucose monitoring:  Use side of finger tip  wipe away first drop of blood  wash hands with soap and water prior to testing Newborn signs of effective breastfeeding:  Measuring wet diapers is adequate way of measuring input  6-8 wet diapers a day is adequate  15-3g/day weight gain after day 5 a) 619 of 640 Non-weight bearing  use a 3 point gait  when going up stairs- advance unaffected leg first  wear rubber soled shoes when using crutches Reducing ICP:  raise HOB no more than 30 degrees  Provide quiet environment  spread out nursing activities to minimize fatigue  Only suction as needed Status epilepticus:  treat with diazepam (a benzo)  gabapentin, carbamazepine, and valproic acid are for long-term management Glucose control (low blood sugar):  4 oz. of orange juice or 15 g of carbs  wait 15 min then recheck blood sugar  provide cheese and crackers (high protein snack) A fib:  presents with no P waves and narrow QRS complexes  irregular ventricular response  patient may c/o palpitations N&V:  causes dehydration  will cause urine concentration  will increase urine specific gravity a) 620 of 640 Hemanopsia:  blindness in half of visual field  teach visual scanning when ambulating  secure extension cords along baseboards Total hip arthroplasty:  maintain hip angle less than 90 degrees  use a walker for safety  avoid putting pillows under knees when lying down  installing higher toilet seats will prevent hip flexion and dislocation Enteral feedings:  should run for at least 10 ml/min  side lying after feeding with HOB 30 degrees  aspirate before initiating feeding (less than 25% of feeding is ok to give next feeding) 3 hr. oral glucose test:  fast the night before  follow unrestricted diet for 3 days prior  blood sample taken every hour ATI COMPREHENSIVE PRACTICE A VERSION 14 **A client is postoperative following a lumbar discectomy and is having difficulty voiding. The nurse should recognize that which of the following medications place the client at risk for urinary retention? Ketorolac a) 621 of 640 Hydromorphone (Dilaudid) a) 622 of 640 Bethanechol (Urecholine) Tobramycin (Nebcin) **A nurse is caring for an older adult client in a long-term care facility who is disoriented and continues to get out of bed without assistance. Which of the following images indicates the nurse is using an appropriate intervention to minimize the risk of injury due to a fall? D **A practical nurse (PN) on medical-surgical unit is beginning her shift and is working with a registered nurse (RN) and an assistive personnel (AP). The PN should expect to be assigned which of the following tasks? Teach a client who has a new diagnosis of diabetes mellitus how to self-administer insulin. Create a plan of care for a newly admitted client. Obtain a stool specimen from a client who has ulcerative colitis---- Administer an NG tube feeding to a client who had a stroke **A nurse on an acute mental health unit observes a client who begins to speak loudly in the common room, saying that he can’t hear the TV. Which of the following is an appropriate response by the nurse? You will need to go to your room until you can calm down okay The TV is loud enough for everyone to hear it You are being inconsiderate. Please stop talking so loudly Let’s go to another room to talk about what is upsetting you **A client tells a nurse that he would like to observe kosher dietary laws. The nurse should recognize which of the following? A vegetarian diet is the preferred diet Dairy products are served separately from meat Fasting during daylight is required during a month-long holiday Fish with scales and fins should not be eaten **A nursing unit receives new glucose monitoring equipment from staff development with the promise that in-service education will be given soon. Which of the following instructions should the nurse give to the assistive personnel (AP) who is preforming glucose monitoring on the unit? Contact the staff development department for instructionContinue using the current glucose monitors Check for accuracy and proper functioning of the new monitor Read the instruction manual before attempting to use the new monitor **Which of the following should the nurse document as an indication of the IV infiltration in a client’s forearm? Redness along vein Tissue sloughing at the site Forearm that is warm to the touch Pallor surrounding the infusion site **A client requests information about advanced directives. Which of the following is the appropriate response by the nurse? Advanced directives are written instructions regarding end of life care Advanced directives provide education on palliative care issues Advanced directives require the provider’s approval before changes can be implemented Advanced directives help determine legal competency **A nurse is caring for a client who is on telemetry. Which of the following ECG findings should thenurse report to the charge nurse? One P wave prior to each QRS complex a) 623 of 640 PR interval 0.24 seconds QRS duration 0.06 seconds Ventricular rate 75/min **A nurse is checking the reflexes of a newborn. Which of the following techniques should the nurse use to elicit the Babinski reflex? Startle the infant by clapping hands Stroke the sole of the infant’s foot upward and toward the great toe Hold the infant upright and allow one foot to touch the table’s surfacePlace an object in the palm of the infant’s hand **A charge nurse in a long-term care facility notices an assistive personnel’s (AP) repeated failure to provide oral care for clients. Which of the following actions should the nurse take? Provide oral care for clients after the AP has completed other care Develop an educational session about the importance of oral care for all Aps Discuss the unacceptable behavior with the AP while reinforcing expectations Suspend the AP for 3 days pending disciplinary action **A nurse is caring for a client who has terminal cancer. Which of the following statements by the client’s family should indicate the nurse that they are coping with their situation? Dad I remember the time we all went to the lake fishing Dad I truly believe that it’s not your time to leave us I feel like I don’t know what to do anymore I think we need to concentrate on whose house we plan to meet at for our holiday get-together **A nurse is performing a dressing change for a client who had abdominal surgery 5 days ago. The nurse notes organs protruding from the incision. Which of the following actions should the nurse take? Apply an abdominal binder Have the client lie flat in bed. Cover the exposed area with sterile, saline-soaked dressing Place gentle pressure on the exposed organ with sterile gauze **A nurse in a skilled nursing facility is caring for a client who is receiving warfarin (Coumadin) therapy following a total hip replacement. An assistive personnel reports a positive guaiac. Which of the following laboratory values should the nurse report to the provider? Hematocrit 40% International normalized ratio of 4.5 Hemoglobin 15 g/dL-- Prothrombin time 18 seconds ** A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril (Capoten). Which of the following over-the-counter medications should the nurse instruct the client to avoid? Acetaminophen (Tylenol) Diphenhydramine Ibuprofen (Advil) Guaifenesin (Robitussin) **A nurse is reinforcing teaching for a client who is in her first trimester of pregnancy. Which of the following physiological changes should the nurse instruct the client to expect during the first trimester? Leukorrhea Shortness of breath Pedal edema Perineal pressure a) 624 of 640 ** A nurse is collecting data from a client who has a peptic ulcer disease. Which of the following should the nurse identify as the priority finding? Gnawing epigastric painHeartburn Regurgitation Hematemesis **A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following behavioral indications should the nurse expect? Dependence Euphoria Memory Loss Hypervigilanc e **A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as a delusion? My doctor’s glasses have lasers that will burn holes in my brain if I look at him The movie had an explosion. I once drove a green truck. Where is the ketchupThe voice keeps telling me to go kick the table over. Why won’t it stop I can’t sit here because the purple monkey on the ceiling will jump on me **A nurse is caring for a client who sustained a broken leg while assisting other from a structural fire. The client states I am glad those people were saved but I sure wish I was not hurt. Which of the following is an appropriate response by the nurse? You are a real hero. I am sure that makes your injuries worthwhile It is difficult to experience personal injuries for whatever reason Things will get better before long Let’s talk about this later when we have more time **A nurse is reinforcing teaching for a client who has a new prescription for lithium carbonate (Lithobid). Which of the following instructions should the nurse include? Eliminate all foods containing tyramine Drink 2 to 3 liter of fluid each day Take lithium carbonate on an empty stomach Reduce your daily sodium intake to 1,000 mg **A nurse in a provider’s office is reinforcing teaching with a client who is receiving peritoneal dialysisvia a newly inserted catheter. For which of the following should the nurse instruct the client to contact the provider? Bloody peritoneal fluid Clear peritoneal fluid Cloudy peritoneal fluid Straw-colored peritoneal fluid **A child is brought to the clinic by his parents with injuries inconsistent with the reported cause. A nurse suspects physical abuse. Which of the following actions should the nurse take? Interview the child with the parents in the room Ask the provider to talk to the child and parents Make a note in the chart to check the child during the next visit Report the suspected abuse to the appropriate agency **A nurse is reviewing discharge instructions with a client who has undergone a lumbar laminectomy. Which of the following should the nurse include? Use a soft mattress for sleeping Practice bending from the waist several times daily a) 625 of 640 Sit in a straight backed chair Wear shoes with a slightly raised heel to promote body alignment **A nurse is reinforcing teaching with a client about cancer prevention, the nurse should instruct that frequent consumption of which of the following foods increases the risk of cancer? Tuna Lamb Chicke n Turkey ** A nurse is reinforcing teaching to a client who is scheduled for a lumbar puncture. Which of the following should the nurse include in the teaching? Nausea is common adverse effect after this procedure You should increase your fluid intake after this procedure You will be instructed to remain in an upright position for the first 4 hours after the procedure The provider will apply a pressure bandage to the puncture site **A newborn is scheduled to have a heel stick for blood glucose testing every 4hr. The newborn’s blood glucose on admission was less than 40 mg/dL. Which of to the following additional clinical manifestations should the nurse observe for in this newborn? Jitteriness Bradycardia Inconsolabilit yInsomnia **A nurse is contributing to the plan of care for a client who has a prescription for range of motion exercise of the shoulder. To promote shoulder hyperextension, which of the following exercises should the nurse recommend? Move his arm behind his body with his elbow straight Move his arm in a full circle Raise his arm out to the side and reach it above his head with his palm facing away from his head Raise his arm from his side straight forward and then up above his head. **A nurse is receiving change-of-shit report for four clients. Which of the following clients should the nurse attend to first? A client who requests to be moved to a room closer to the nurse’s station A client who is postoperative and had received morphine twice during the last 8hrsA client whose urinary output was 100 mL for the past 12hr A client who insists on speaking with the provider prior to discharge **A nurse is reinforcing teaching regarding home safety to a client who has diabetes mellitus and is being discharged after an admission for hepatitis B. Which of the following client statements indicates an understanding of the teaching? I will recap my used syringes and throw them away in a plastic bag I will take Tylenol for aches and pains I will use my own eating utensils and dishes at home Houseguest will need to wear masks when they come to visit me **A nurse in a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescription is accurately transcribed by the nurse? Alprazolam (Xanax) 0.5 mg PO QHS for sleepRegular insulin (Humulin R) 10 U SC at 0800 Docusate sodium (Colace) 250 mg PO QOD Potassium chloride (Micro-K) 20mEq PO every morning a) 626 of 640 **A nurse is caring for a client who has altered mental status and has become increasing belligerent. Which of the following medications prescriptions, if written for this client, should the nurse question? Haloperidol (Haldol) Lorazepam (Ativan) Zolpidem (Ambien) Alprazolam (Xanax) **A nurse is caring for a client who is experiencing acute kidney failure. The nurse should monitor the client for which of the following acid-base imbalances? Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis **A nurse in an urgent care clinic is collecting data from four clients. Which of the following clients should the nurse recommend for treatment first? A client who has a fever and abdominal pain in the upper aspect of the right lower quadrantA client who has shortness of breath after taking a dose of amoxicillin (Amoxil) A client who has hemoptysis and has taken medication for tuberculosis (TB) for 2 months A client who has a purple stoma following an open colon resection with a colostomy 2 weeks ago. **A nurse on a medical unit is preforming an audit on his client assisgnment. For which of the following should the client have a separate signed informed consent form. Chest radiography Echocardiogram Indwelling urinary catheter Lumbar puncture ** A nurse in an acute care hospital is planning to discharge an adult client who is immunocompromised. Which of the following immunizations should the nurse plan to administer before discharge. Measles, mumps, and rubella (MMR) immunization Pneumococcal polysaccharide (PPSV) immunizationVaricella immunization Herpes zoster immunization ** A nurse is reinforcing teaching to a client regarding care of her newborn. The nurse determines that the teaching is effective when the client points to which part of the newborn’s head and states it will take 12 to 18 months for the soft stop to close. (top of the head near face) **A parent of a 3yr old child tells the nurse that he cannot get his child to sit at the table to eat a full meal. Which of the following responses by the nurse is appropriate? Provide the child with foods of the same texture rather than a variety of unfamiliar foods Engage the child in conversation during meals to encourage him to eat like the rest of the family Encourage active play prior to meals to increase the child’s appetite Offer the child heathful snacks frequently, rather than expecting him to fully eat at mealtimes **A nurse in a providers office is caring for four clients. Which of the following should the nurse see first. A client who is at 38 weeks gestation and reports urgency and frequency of urinationA client who is at 37 weeks gestation and reports edema of the ankles A client who is at 36 weeks gestation and reports painless vaginal bleeding A client who is at 34 weeks gestation and reports abundant amounts of odorless vaginal mucus **A nurse and an assistive personnel (AP) are caring for four clients in a long-term-care facility. Forwhich of the following situations is it necessary to complete an incident report? a) 627 of 640 A client throws an object across the dinning room A client refuses his morning medications A client who is prescribed full liquid diet receives a clear liquid dietA client who is confused walks into another client’s room ** A nurse working in the clinic receives a phone call from a mother whose child has just ingested the contents of a bottle of acetaminophen (Tylenol). Which of the following is an appropriate response by the nures? Adminster syrup of ipecac to the child to induce vomiting Take the child to the emergency department Give the child a glass of milk to drink Monitor the child’s level of consciousness **A client is scheduled for colon cancer surgery in the morning. The night nurse learns that the client has decided not to have the surgery, even through he has already signed the informed consent form. Which of the following actions should the nurse take? Inform the client that a signed consent form is legally in effect for 24hr Report the situation to the surgeon who obtained the informed consent Reinforce client teaching about the purpose of the procedure Notify the client’s family about the refusal of treatment **A nurse is caring for a newborn who is 1hr old. The mother received fentanyle (Sublimaze) 30 min before delivery. For which of the following should the nurse monitor for in the newborn? Hyperbillrubinemia Hypoglycemia Respiratory depression Increased heart rate **A nurse is reinforcing discharge teaching with the parent of a school-age child who had a tonsillectomy. Which of the following statements by the parent indicates an understandin of the instructions? I will encourage my child to drink 4 ounces of orange juice twice a day I will allow my child to chew gum to prevent throat pain I will ensure my child uses a straw to drink fluidsI will give my child chocolate ice cream ** A nurse is reviewing the laboratory results for an infant receiving gentamicin intermittent IV bolus twice daily and notes the serum creatinine is 0.9 mg/dL. The nurse is aware that this result can indicate an adverse effect on which of the following systems? Hepatic Renal Gastrointestinal Endocrine **A is reinforcing teaching with an adolescent client about a scheduled blood draw of HbA1c. The nurse knows that the client understands the purpose for this test when the client states that this test will measure his average blood glucose level over the past 2 to 3 days 6 weeks 2 to 3 months 6 months **A nurse is caring for a client in Buck’s traction. Which of the following interventions should thenurse perform while the client is in this traction? Allow the weights to hang freely a) 628 of 640 Inspect the skin every 24hr Remove the weights every 24hr Let the client use the bedside commode **A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following? Motor response Vital signs Short-term memory Gait **A nurse is reinforcing teaching to a client who has a new prescription for atorvastatin (Lipitor). For which of the following shold the nurse tell the client to monitor and report to the provider? Anorexia Muscle tenderness Facial flushing Insomnia **A nurse working in a clinic is collecting data on a toddler. Which of the following findings should thenurse identify as suggestive of physical neglect? The toddler is inadequately dressed for the weather The toddler has irriation to the external genitalla The toddler has symmetrical burns to both legs The toddler does not react when the nurse adminsters an injection **A parent of a 2month old infant asks the nurse how she will know if her baby is growing appropriately. Which of the following is an appropriate response by the nurse? Your baby should weigh 2.5 time his height by 6 months Your baby should gain 1 pound per month during the first 6 months Your baby’s weight should be double his birth weight by 4 to 6 months Your baby should grow half an inch per month during the first 6 months **A nurse is contributine to a teaching plan for a group of male adolescents regarding use of anabolic steroids. Which of the following should the nurse include in the teaching as risk of using anabolic steroids? Decreased appetite Reduced height potential Increased dental caries Impaired vision **A client who is 1 day postoperative is unable to ambulate. The nurse should recognize that which of the following will promote venous return? Encouraging the client to cough and deep breathe Maintaining a sequential compression device Elevating the head of the bed Massaging the clients legs **A nurse reinforces the use of a mask prior to a family entering the room of a client who has tuberculosis (TB). Which of the following information should the nurse include? Prior to entering the room, make sure the client puts on a mask If you leave the client’s room for a break, you can reuse your mask upon returning Wearing a mask will help protect you from the client’s illness Masks are part of the hospital protocol, but family members do not have to wear them a) 629 of 640 **A nurse is caring for a client recently diagnosed with adenocarcinoma of the lung. While discussing teatment option with the client, the family asks the nurse about the use of herbal medications for treatment. The nurse should respond by stating, Herbal medicines Are untested for both safety and efficacy Will protect against progression of your cancer Are frequently cheaper than conventional medications Must be prescribed by a provider **A client who is pregnant presents to the emergency department with a broken arm. The client appears anxious and gives conflicting stories about how the injury occurred. The client’s spouse is hovering over her and answering questions for her. What should the nurse do to handle this situation? Disregard the spouse’s remarks while continuing with data collection Request that the spouse go to the waiting room Bring a second nurse into the examination room Ask the client’s spouse to refrain from answering for the client. **A nurse is caring for a client who has a history of long-term alcohol use disorder. The client has a prescription for disulfiram (Antabuse). The nurse should recognize that the use of this medication is a form of which of the following types of therapy? Operant conditioning Systemtic desensitization Aversion therapy Cognitive therapy **A nurse is caring for a client who has impaired vision. Which of the following strategies should the nurse include in the plan of care? Keep the door to the client’s bathroom slightly ajar Hold the client’s arm while standing even with the client’s shoulders while ambulating During ambulation, the nurse should stand just ahead of the client and offer his arm for guidance Place frequently used items on the bedside table **A nurse has administerd lorazepam (Ativan) to a client who is scheduled for surgery within the next hour. Which of the following actions should the nurse take? Instruct the client to remain in bed Ensure that the informed consent form has been signedAssist the client to the bathroom to void Reinforce teaching about deep breathing and coughing exericses **A nurse is preparing to insert a nasogastric tube for a client. Identify the sequence the nurse should follow after performing proper hand hygiene and preparing equipment at the bedside Place the client in high-Fowler’s position Determine which naris has the greatest airflow Measure the distance to insert the tube Lubricate 7.5 to 10 cm (3-4 in) of the end of the tube Instruct the client to hyperextend her neck **A nurse is reinforcing teaching about pancrelipase (Pancreaze) with the parent of a child who has cystic fibrosis. Which of the following instructions should the nurse include in the teaching? Place the medicine under the tongue Take the medication after a meal Sprinkle the contents of the capsule on food Chew each capsule thoroughly **A nurse brings her adolescent son to an urgent care center, stating that “he is high on something and needs help.” The client is exhibiting agitation and paranola, and reports visual hallucinations. The nurse should suspect intoxication with which of the following substances? a) 630 of 640 Methamphetamines Opioids Anbolic steroids Alcohol **A nurse enters the room of a client who had a bone marrow transplant 3 days ago for treatment of leukemia. Which of the following observations warrents intervention? The client’s meal tray contains stewed tomatoes A visitor brought the client a bouquest of flowers The client is using an electric razor to shave An assistive personnel isremoving a bag of biohazardous materials **A nurse is collecting data from a client who is primigravida and at 25 weeks of gestation. The client is tearful and tells the nurse, “I’m sorry, I’m just nervous and emotional today.” Which of the following actions should the nurse take first? Help the client identify a support person to talk to Recoomend the client join a support group for first time mothers Assist the client to schedule childbirth classes Explore the client’s underlying concerns **A nurse is caring for a client who has expressive aphasia following a cerbrovascular accident. Which of the following communication methods is appropriate for the nurse to use with this client? Ask open-ended questions Speak slowly with a raised voiceProvide a picture board Limit the use of gestures **A nurse is caring for a client who is postoperative following an open reduction with internal fixation of the ankle. The client reports pain, and the nurse notes that the affected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical resident, who responds, “It has always been like that.” Which of the following actions should the nurse take first? Notify the nursing supervisor Administer the prescribed pain medication Recheck the client in 30 min Reposition the client to improve anatomical alignment **A nurse is reinforcing teaching to a client about the adverse effects of propranolol (Inderal). For which of the following effects should the nurse instruct the client to observe? Bradycardia Cough Paresthesias Urinary retention **A nurse is caring for a postpartum client who is breastfeeding. Which of the following is appropirate for the nurse to reinforce about breastfeeding? Look for slowed suck/swallow pattern as a sign that the newborn is finished eating Ensure that the newborn has the entire areola in the mouth during feeding Begin feeding the newborn on the same breast each timePush the back of the newborn’s head toward the nipple **A nurse is reinforcing teaching for a client who has a new prescription for metronidazole (Flagyl), The nurses should instruct the client to expect which of the following adverse effects while taking this medication? Reddish brown urine Increased saliva production Photophobia Peripheral edema a) 631 of 640 **A nurse is admitting a client who is at risk for suicide. Which of the following is the nurse’s highest priority? Search the client’s personal belongings. Place the client in a room close to the nurses’ station Ask the client to sign a no-suicide contract Review the client’s SAD PERSONS scale assessment **A nures enters the room of an adolescent client and observes him on the floor experiencing a tonicclonic seizure. Which of the following actions should the nurse take when the seizure subsides?Insert a tongue blade in the client’s mouth Assist the client to an upright posiiton Offer clear fluids through a straw Keep the client in a side-lying position **A nurse is reinforcing discharge teaching for a client who has a new prescription for digoxin (Lanoxin). Which of the following should the nurse include in the instructions as an indication of digoxin toxicity? Visual changesSkin irritation Fever Angina **A female client presents to an outpatient clinic. Which of the following findings place the client at risk for coronary artery disease? The client’s LDL level The client’s daily alcohol consumptionThe client’s weight for her height The client’s blood pressure **A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy? Bulging fontanel Capillary refill 6 seconds Moist mucous membranes Urine specific gravity 1.031 **A nurse is reinforcing teaching for a clientwho has a new prescription for sublinguail nitroglycerin (Nitrostat). Which of the following statements indicates client understanding? I will take half a tablet before I exercise I can take up to four tablets to relieve my pain I will put the tablets in a medication container for easy acessI may develop a headache after taking this medication **A nurse is caring for a client who has a new diagnosis of HIV. The client states, “I don’t want anyone else to know that I have HIV.” Based on the recommendations of the Centers for Disease Control and Prevention, which of the following is an appropriate response by the nurse? Your HIV status will be protected by HIPPA regulations Your HIV status needs to be reported to the state health departmentWe must report your HIV status to your employer Your HIV status is protected under the Patient Care Partnership **A nurse is reinforcing discharge teaching with a client regarding self-administration of epid insulin (Humulin R). Which of the following instructions should the nurse include? Shake the insulin vial before administering Administer insulin at room temperature Administer insulin 15 min prior to each meal a) 632 of 640 Dissolve solid deposits by warming the insulin before administering **A nurse is reinforcing teaching to a client who has schizophrenia and his family regarding treatment options. Which of the following statements by the nurse is appropriate? Family therapy can assist clients and their families to learn effective coping skills Cognitive remediation therapy is used to solve longstanding family problems resulting from the disease Use of medication is considered short-term therapy until symptoms are stabilized Day treatment programs are the desired choice for achieving acute symptom stabilization **A nurse notices an assistive personnel (AP) of the unit taking naps in the break room instead of having a meal or a snack. She appears drowsy while performing routine tasks. Which of the following actions should the nurse take? Keep a record of the AP’s behavior over a period of time Report the observations about the AP to the unit’s nurse manager Ask other unit staff if they have observed the same behavior Determine if the AP is having problems at home **A nurse is assisting with the plan of care for a client following a transurethral resection of the prostate (TURP) surgery. Which of the following is appropriate to include in the plan of care Discontinue the urinary catheter 24hr after surgery Adjust the bladder irrigation to keep the urine a bright yellow color Use 50 mL sterile water to clear the urinary catheter of obstruction Irrigate the bladder using sterile technique **A nurse is collecting a urine specimen from a client with diabetes insipidus. The nurse should expect which of the following findings? Proteinuria Creatinine clearance of 100 mL/min/m Urine specific gravity of 1.002 Hematuria **A nurse is reinforcing teaching with a newborn’s parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions? I will give our baby sponge baths until the cord falls off I will remove the cord clamp after 5 days I will wrap the cord in petroleum jelly gauze I will keep the cord protected by covering it with the diaper **A nurse is preparing to administer a dose of furosemide (Lasix) 30 min past the scheduled time. The nurse notes that there is a new potassium value alert on the client’s electronic record. The nurse should Review the laboratory value prior to preparing the medication Administer the medication, and then review the client’s laboratory values Hold the dose of medication until the provider makes rounds Administer the medication, and notify the provider that new laboratory values are available **A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead electrocardiogram (ECG). Which of the following actions should the nurse include in the plan of care? Place the client in Sims’ position Put chest electrodes on the client’s breast Instruct the client to remain still while the ECG is performed Cleanse the skin with providone-iodine prior to electrode placement a) 633 of 640 **A nurse is caring for an older adult client who is 48hr postoperative following abdominal surgery. The provider writes a prescription to advance the client to a regular diet. After evaluating the client, the nurse should notify the provider about which of the following findings? The client has absent bowel sounds The client is unable to sit for long periodsof time The clients incision is draining serous fluid The client reports loss ofappetite due to pain **A nurse is collecting data from an older client who has a hip fracture. Which of the following findings should the nurse expect? External rotation Muscle flaccidityLeg lengthening Hyperreflexia **A nurse is supevising an assistive personnel (AP) who is preparing to remove his personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse identifies understandingof the procedure when the AP removes which of the following items first? Goggles Gloves Gown Respirator **A nurse is reinforcing newborn care to a client whose newborn underwent clamp circumcision procedure. Which of the following statements made by the client indicates to the nurse a need for further teaching? I should apply petroieum jelly each time I change the diaper I will apply gentle pressure if bleeding occurs I will be sure to wipe off any yellow drainage I should make sure my baby has at least six wet diapers in 24hrs **A client newly diagnosed with diabetes mellitus inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? (select all) Local pharmacist Personal tesimonial web sites Package inserts Other clients in a diabetes support group American Diabetes Association **A nurse in an urgent care facility is reinforing teaching to a client about the safe use of crutches. Which of the following statements indicates the client understands the teaching? I will wear leather-soled shoes when walking with my crutches I will ensure the pad of the crutch fits snugly in my armpit I will hold both crutches on the side opposite my injured leg when sittingI will switch to using only one crutch when I regain some strength **A nurse is reinforcing teaching on food selection for a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C? Tomatoes Apricots Avocados Carrots **A nurse is caring for an adolescent who has meningitis. To prevent the adolescent from experiencing increase intracranial pressure, which of the following actions should the nurse take? a) 634 of 640 Keep the head of the bed flat Withhold pain medication until the client is in severe pain Suction the airway when necessary Keep the client’s door open for visual observation **A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis, Which of the following actions should the nurse plan to take? Inject 0.5 mL of medication Insert the needle at a 10degree angle Ensure that the bevel of the needle is pointing down during administration Aspirate the syringe prior to injecting the medication ** A nurse is reinforcing discharge teaching with a client about adverse effects of prescribed medications. The nurse should tell the client that if black, tarry stools are noted, the client should stop taking which oft eh following medications and notify the provider? Acetaminophen (Tylenol)Aspirin (Ecotrin) Guaifenesin (Robitussin) Loratadine (Claritin) **A nurse in a clinic is reinforcing discharge teaching with a client who has a sprained ankle. The nurse should instruct the client to rewrap the compression dressing if she experiences which of the following manifestations? Warm toes Erythema of the ankle Swollen toes Increased ankle stiffness **A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions should the nurse intervene? The AP documents morningcare in the client’s electronic health care record at the bedside The AP writes his own name on the client’s message board in the room The AP instructs the client to void prior to obtaining a daily weight The AP reports client information to the oncoming AP in the hallway **A nurse in the rehabilitation unit is assisting in the development of a plan of care for a client who had a knee arthroplasty. Which of the following should the nurse include first in the plan of care? Discuss with the client the need for family support Assist the client to develop attainable goals Evaluate the clients repsonse to therapy Check the client’s mobility **A providerf prescribes levothyroxine (Synthroid) 0.3 mg PO daily for a client. Available is levothyroxine 150 mcg/tablet. How many tablets does the patient get? 2 tablets **A client is being discharge home after experiencing a cerbrovascular accident. Which of the following documents should the nurse plan to include with the discharge instructions? Physician progress notes Physical therapy record Medication adminstration record List of symptoms to report **Which of the following findings in a client who is postpartum should indicate to a nurse to contact the provider? Temperature of 37.8C (100.2F) after delivery a) 635 of 640 Redness and tenderness of the right calf Breast discomfort on postpartum day 3 Increased lochia after breastfeeding **A nurse is assisting with admitting a client who has colorectal cancer. When collecting data from the client, which of the following clinical manifestations should the nurse expect to find? Abdominal cramps Hematuria Weight gain Epigastfic pain **A client who is crying tells a nurse that his provider informed him that he has a tumor and will needa biopsy. Which of the following is an appropriate response by the nurse? Try to relax as much as possible, because most tumors are benign What have you done to help yourself get through stressful situations before Perhaps you should wait to get your biopsy results before you become overly concernedI will keep you in my thought and check on your results the next time I work **A nurse is reinforcing teaching about defense mechanisms with an adolescent who is angry that her parents won’t let her go to a party. Which of the following statements by the client should the nurse recognize as sublimation? I guess I’ll just go to the mall with friends instead People who go to parties are stupid They’ll probably all get into trouble I’ll just quit cleaning my room and mowing the grass that’ll teach them My parents are just afraid I will get into trouble **A nurse is contributing to the plan of care for a client who is at risk of developing pressure ulcers. Which of the following actions should the nurse recommend to include in the plan of care? Place the client in a 30degree lateral position Limit time spent sitting in a chair to 4hr daily Cleanse the client’s skin twice daily with soap and hot water Massage reddened areas over bony prominences every 2hrs **While making rounds, a nurse smells cigarette smoke in the unit. Upon entering the client’s room, the nurse observes a pack of cigarettes on the bedside table. Which of the following actions should the nurse take first? Provide the client with smoking cessation information Report the finding to the charge nurse Remove the cigarettes from the clients room Notify the provider of the clients behavior **A nurse is caring for a client who reports a sudden onset of an itchy rash after being givenciprofloxacin (Cipro) 1hr ago. Which of the following actions should the nurse take first? Check the client for wheezing Administer diphenhydramine Prepare the client for insertion of an IV catheter Obtain a set of vital signs **A nurse assigns an AP to collect a sputum specimen from a client who has tuberculosis. The nurse should instruct the AP to collect the sputum specimen at which of the following times? Immediately after the client brushes his teeth After the client ambulates When the client reports he is experiencing night sweats As soon as the client wakes up a) 636 of 640 **A nurse is reinforcing discharge teaching with the family of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching? Demonstrate assertiveness Refrain from engaging in power struggles Permit expression of rituals Avoid crowded environments **A nurse is caring for a client who is scheduled to receive hemodialysis through an arteriovenous fistual in the left arm. Which of the following actions should the nurse take prior to the procedure? Ensure the client has fasted for 6hr Obtain the client’s weight Measure the client’s blood pressure about the fistula Draw a blood sample from the fistula **A nurse is reinforcing teaching with a client about how to replace her two-piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest? Break the seal by tugging gently on the bottom of the pouch Hold the skin taut while removing the barrier Pull one corner of the barrier quickly over the stoma Lift both sides of the skin barrier simultaneously **A nurse is caring for a client who has Alzheimer’s disease. Which of the following will help the clientmaintain independence in eating? Allow the client to choose foods from a menu Place the tray of food directly in front of the client Provide music or visula stimulation at mealtimes Maintain a routine for mealtimes **A nurse is caring for a client who has a penrose drain. To ensure proper placement and functioningof the drain, which of the following should the nurse observe? The safety pin is present at the distal end of the drain The suction bulb is fully compressed Wall suction is set at low-intermittent suction The evacuator unit gradulaly expands as it fills with drainage **A nurse is preparing to administer digoxin (Lanoxin) to a client. Which of the following should thenurse check prior to administration? Platelet count Liver enzymes Serum potassium Coagulation studies **A nurse is assisting with the admission of an older adult client. Which of the following actions should the nurse take first? Orient the client to the room Provide the client with nonskid footwear Complete a fall risk assessment on the client Reinforce safe ambulation techniques with the (AP) on the unit **A client who is diagnosed with Parkinson’s disease verbalize frustration due to increase difficulty with ambulation. Which of the following is an appropriate response for the nurse to make? Watch your feet when you walk to maintain balance to prevent fallsWe should monitor your serum blood level of levodopa monthly Perform active range of motion with your arms and legs three times a day You should consider using a wheelchair instead of trying to walk a) 637 of 640 **A nurse is caring for a client and notes the IV fluid rate has slowed. Which of the following actionsshould the nurse take first? Repostion the tip of the catheter Check the tubing for kinks or obstructions Position the IV tubing to avoid tension on the IV catheter Tighten the IV tubin connections **A nurse administers a dose of digoxin (Lanoxin) that was prescribed to be given every other day. She discovers 1hr later that the medication had been given yesterday. Which of the following actions should the nurse take next? Obtain a set of vital signs Document the medication erro on an incident report Report the error to the appropriate hospital personnel** Perform any treatments necessary **A nurse is reinforcing teaching with a client who has a prescription for isoniazid (Laniazid) and rifampin (Rifadin) to treat tuberculosis. Which of the following should the nurse include in the teaching? You may need to take medicatons to treat tuberculosis for as long as two years You can take isoniazid with an antacid if it upsets your stomach You will need to have a tuberculin test in 3 months to determine the effectiveness of the medications You should notify the provider if your urine turns orange while taking the medication **A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following should the nurse plan to include in the teaching? Limit fluid intake to 1 L per day Report the appearance of blood in the urine Strain the urine to collect stone fragments Increase dietary protein intake **A nurse is caring for a client who is expressing sorrow about the amputation of her leg 72hr ago due to trauma. The nurse must leave the room but promises to return as soon as possible. The nurse demonstrates which of the following ethical principles when he returns a promised? Autonomy Nonmaleficence Justice Fidelity **An upper airway x-ray indicates that a toddler has aspirated a bead. A nurse is reinforcing teaching about the need for a bronchoscopy to the parents. Which of the following statements given an accurate description? A bronchoscope is a device that wil help your child breathe This is a scan that will help the doctor see if the bead has done any damage This is a technique that will wash the bead out of the airway A bronchoscope is a tube that allows the doctor to see and remove the bead **A nurse is using the FLACC pain scale to determine the level of pain for an 11-month-old infant whois postoperative. Which of the following factors should the nurse consider when using this pain scale?Quality of feeding Level of activity Respiratory effort Skin color a) 638 of 640 **A nurse is monitoring a client who is receiving lactated Ringer’s 500 mL IV over 4hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should check that the manual IV infusion is delivering how many gtt/min? 21 gtt/min **A nurse is advising a group of AP about lifting clients in prepartion for transfer from the bed to a chair. Which of the following instructions should the nurse include? Stand with feet together Use lower body strength Turn at the waist Raise the bed to a high position **A nurse is reinforcing teaching about conjunctivitis to the parent of a school-aged-child. Which of the following should the nurse reinforce? Maintain a warm compress on the affected eye at bedtime Clean the eye from the outer to the inner canthus Separate the child’s used washcloth from those of others Instill ointment in the child’s affected eye each morning **A nurse at a health fair for college students is reinforcing teaching about skin cancer prevention. Which of the following instructions should the nurse include in her presentation? Reapply sunscreen every 4hr during sun exposure Sunscreen has a shelf life of 5 years Limit sun exposure especially before noon Use sunscreen with a sun protective factor of at least 15 **A home health nurse is caring for an older adult client in his home. Which of the following should the nurse consider as an environmental risk factor? Water heater set at 37.8C (100F) Smooth shower stall floor Carpeted floor Table lamp next to the bed **A nurse is reinforcing teaching about foot care with a client who has a new diagnosis of diabetes mellitus. Which of the following should the nurse include in the teaching? Trim toenails straight across Apply lotion betwene toes daily to prevent drynessWear open-toed footwear Use a heating pad on fee nightly to promote circulation **A nurse is reinforcing teaching with a client who is to undergo a coronary angiography at 0700. Which of the following instrustions should the nurse include? The client will receive general anestheia before the procedure The client may feel a hot flush as the dye is injected The client should report a metallic taste to the provider The client will feel chest pain during the procedure **A nurse is caring for a client who has delirium. Which of the following should the nurse expect? Difficulty using correct words Obsessive behaviors Fluctuating levels of consciousness Reports of hopelessness **A nurse is reinforcing teaching about coughing exercises to a client scheduled for surgery. Which of the following information should the nurse include ine the teaching? Take one deep breath and then cough a) 639 of 640 Repeat coughing exercises twice consecutively Perform coughing exercises every 3hr after surgery Splint the incision with interlocked hands when coughing **A natural diseaster has occurred in a community. Clients who may have safely discharge need to be identified to make room for incoming casualties. Which of the following clients should the nurse recognize could be discharged in this situation? A client who was admitted with diabetic ketoacidosis whose current blood glucose readin is 350 mg/dl A client who was admitted this morning with the onset of fever severe headache and nuchal rigidity A client who has pneumonia who is currently receiving oral antibiotics A client who had a small bowel resection with a loop ileostomy 24hr ago **A nurse is reinforcing teaching with a client who is schedule for modified radical mastectomy with drainage tubes. Which of the following should the nurse include in the teaching? You should avoid exercise of the arm of the affected side Keep your arms at your sides while lying in bed Your drainage tube will be discontinued 24hr following surgery You should avoid measuring your blood pressure on the affected side **A nurse is reinforcing teaching to a client who has cholecystitis. Which of the following foods should the nurse instruct the client to avoid in her diet? Orange juice Eggs Peanut butter Wine **A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural effusion. In which of the following postitons should the nurse place the client? Supine with arms raised over the head Prone with arms at sides Upright with arms resting on the overbed table Left lateral side position **A client who has a chest tube drainage device asks the nurse for assistance in using the bathroom. Which of the following actions should the nurse take? Provide the client with a bedpan until the chest tube is removed Keep the collection device below the level of the client’s chest Strip the chest tube to create negative pressure Clamp the collection device **A nurse has a prescription to perform a bladder scan for a client. Which of the following actions should the nurse take? Ask the client to sign a concent form Use surgical aseptic technique Check for allergies to iodine or shellfish Tell the client she should not experience any discomfort **A nurse is assisting with the plan of care for a client who had a stroke and has dysphagia. Which of the following intervenions should the nurse include in the plan of care? Offer a drink of ice water before meals Maintain the client in an upright position for 10 mins after meals Remind the client to swallow twice with each bite of food Engage the client in conversation during the meal a) 640 of 640 **A nurse is discussing the use of epidural analgesia with a newly licenesed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of this method of pain control? I should instruct the client to administer a dose of medication when he feels painI should monitor the client for hypertension when he is receiving the analgesia I should instruct the client that the medication is administered directly to the nerveI should report leaking at the insertion site to the anesthesiologist **A nurse at a mental health facility is assisting with the development of a an education program for newly licensed nurses. The nurse should include that it is approprite to obtain a prescription to placea client in seclusion in which of the following situations? A client shouts degrading statesments at a family member A client states she is going to leave the facillity in the middle of the night A client refuses to take her medication and throws the pills toward the nurse’s deskA client hits another client because she thought he was talking about her **A nurse is collecting data about health risks from a young adult client. Which of the following questions by the nurse is the priority? How many fruits and vegetables do you include in your diet How much alcohol do you consume on a regular basis What types of physical activity do you engage in Can you describe your peer relationships **A client who is diagnosed with Parkinson’s disease verbalize frustration due to increase difficulty with ambulation. Which of the following is an appropriate response for the nurse to make? Watch your feet when you walk to maintain balance to prevent fallsWe should monitor your serum blood level of levodopa monthly Perform active range of motion with your arms and legs three times a day You should consider using a wheelchair instead of trying to walk **A nurse is caring for a client and notes the IV fluid rate has slowed. Which of the following actionsshould the nurse take first? Repostion the tip of the catheter Check the tubing for kinks or obstructions Position the IV tubing to avoid tension on the IV catheter Tighten the IV tubin connections **A nurse is caring for a client who is NPO and has a NG tube attached to suction for gastric decompression. Which of the following actions is appropriate if the nurse observes abdominal distention? Provide oral hygiene Increase the suction pressure Clamp the tube for 30 min Irrigate the tube with normal saline **A nurse is caring for a client who is on telemetry. Which of the following ECG findings should thenurse report to the charge nurse? One P wave prior to each QRS complexPR interval 0.24 seconds QRS duration 0.06 seconds Ventricular rate 75/min **A nurse on an acute mental health unit observes a client who begins to speak loudly in the common room, saying that he can’t hear the TV. Which of the following is an appropriate response by the nurse? You will need to go to your room until you can calm down okay a) 641 of 640 The TV is loud enough for everyone to hear it You are being inconsiderate. Please stop talking so loudly Let’s go to another room to talk about what is upsetting you **A nurse is caring for a client who is NPO and has a NG tube attached to suction for gastric decompression. Which of the following actions is appropriate if the nurse observes abdominal distention? Provide oral hygiene Increase the suction pressure Clamp the tube for 30 min Irrigate the tube with normal saline **A nurse is caring for a client who delivered a full-term newborn 16hr ago. The nures notes excessive lochia discharge. Which of the following actions should the nurse take first? Obtain a blood specimen for hematocrit Perform fundal massage Have the client empty her bladder Administer carboprost tromethamine (Hemabate) **A nurse is preparing to perform trachostomy care for a client. Which of the following actions should the nurse take first? Don sterile gloves Open sterlie packages Pour sterile solution in a bowl Replace tracheostomy ties Delegation not sure which one I get wrong **A nurse is caring for a client who has COPD. An assistive personnel (AP) reports that the client is having difficulty breathing. The nurse returns to the client’s room with the AP to check the client’sstatus. Which of the following tasks should the nurse delegate to the AP? Perform nasotracheal suctioning Begin low-flow oxygen via nasal cannula Obtain a provider’s prescription for a chest x-ray Place the client in high-fowler’s position **A nurse on a medical unit is deciding what task to delegate to an assistive personnel (AP). Which of the following can the nurse delegate to the AP? Administer a rectal suppository to a client Evaluating a client’s use of an assistive walking deviceObtaining a client’s vital signs prior to discharge Reinforcing teaching to a client on how to perform finger stick blood glucose testing **A nurse is caring for a group of clients who are all scheduled for surgery on the same day. Which of the following nursing actions demonstrates that the nurse possessess effective time management skills? (Select all) Gathers all needed supplies and equipment before entering a client’s room Prepares all preoperative medications early and stores them for later use Completes one task before beginning a new task Documents each client’s preoperative vital signs when they are taken Delegates tasks to the assistive personnel (AP) that are within the scope of practice **A nurse is collecting data from a client who is receiving radiation therapy for throat cancer. Which of the following findings indicates an adverse effect that the nurse should report to the provider immediately? Skin irritation Black, terry stools Chest congestion ---I keep picking this one but I’m not sure if its correct can’t figure it out a) 642 of 640 Fever Keep getting this one wrong **A nurse is involved in developing a security plan for the newborn nursery. Which of the following interventions are appropriate to include? (Select All) Provide a hospital in-service on newborn security policies for personnel Apply a neonatal safety device to each newborn Footprint newborns as soon as they are transferred to the nurseryApply identification braclets to the newborn and parents Require distinctive identification badges for personnel in the newborn nursery Wrong!!! Every time picked a, c **A nurse is preparing to perfom a venipuncture on a client. Which of the following steps by the nurse is appropriate? Shave the excess hair from the skin around the selected site Place the extremity in an elevated position Cleanse the insertion site with the tourniquet in place Select a site in the antecubital fossa [Show More]

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