ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2019 A, RN Comprehensive Predictor 2019 Form B and C (790 Questions & Answers).

Document Content and Description Below

ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2019 A, RN Comprehensive Predictor 2019 Form B and C (790 Questions & Answers) What is a nurses priority action when a patient is experienc... ing anaphylactic shock while receiving IV medications? - ✔✔Priority action: stop the medication infusion The nurse can also: Administer epinephrine; infuse .9% sodium chloride, and elevate the lower extremities to help maintain adequate blood pressure A nurse is caring for a group of clients in a long-term facility. One of the clients is walking in the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first? - ✔✔Accompany the client back to his room. What medication is contra indicated while taking St. John's wort? And why? - ✔✔Sertraline Taking concurrently puts the patient at risk for serotonin syndrome Both of these are used for Tx of depression Persistent otitis media - ✔✔An infection of the middle ear Passive smoking promote adherence of respiratory pathogen's to the lining of the middle ear space which prolongs inflammation and impedes drainage from the ear Exposure to cold weather does not cause otitis mediaAcarbose (Precose) adverse effects - ✔✔Sleepiness, headaches, anemia; the most common adverse effects are gastrointestinal - diarrhea, abdominal distention, cramping, flatulence presbyopia - ✔✔impaired vision as a result of aging Can affect one's ability to read the newspaper, the lens is unable to change shape to focus on close up objects Myelomeningocele - ✔✔Most severe form of spina bifida in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac and protrude through the spine Neural tube defect pts are at Rx for latex allergy Most common complication of this disorder is UTI Prevention of the development of amblyopia - ✔✔A disorder of the eye and which unilateral central blindness occurs as a result of another problem, such as strabismus Parents should patch the unaffected I Strabismus - ✔✔Cross eyed Without treatment by 6 years of age this can lead to central blindness (amblyopia) Ethambutol (Myambutol) - ✔✔Med for TB, report vision changes immediately Adverse effects: loss of red/green color discrimination due to optic neuritis; d/c if this occurs Isoniazid (INH) - ✔✔AntitubercularAdverse effects: hepatotoxicity, peripheral neuropathy, yellowing of the sclera is an indication of jaundice that accompanies liver failure Rifampin (Rifadin) - ✔✔Anti TB and Antibiotic Adverse effects: changes in color of bodily secretions to red-orange What is a patient at risk for when they're platelet count is below the reference range? - ✔✔Indicates thrombocytopenia, which puts the patient at increased risk for bleeding What should a nurse anticipate with bladder distention in the fourth stage of labor? - ✔✔Bladder will fluctuate with palpation Bladder is dull to percussion Uterus will be displaced to the right, is boggy, well above the umbilicus cystitis - ✔✔inflammation of the bladder lining, Commonly occurs with UTI Prevention methods: Stay well hydrated, urinate before and after sex, wipe front to back, avoid tub baths Intrauterine device (IUD) - ✔✔Small, T-shaped device inserted by a physician inside the uterus to prevent pregnancy Increased risk for a topic pregnancy Does not protect from STI's or HIVManifestations of retinal detachment - ✔✔sudden onset of decreased peripheral or central vision, dark floaters, flashes of light. curtain vision over part of visual field Manifestations of cataract - ✔✔Decreased color perception, blurry vision,clouding of the lens of the eye Without treatment leads to blindness Manifestations of Angle-closure glaucoma - ✔✔Rapid onset of e severe pain around the eyes and face, reduced vision, colored halos, headaches, sudden onset of elevated IOP Manifestations of macular degeneration - ✔✔Gradual, mild to moderate reduction of central vision Nursing actions for a patient in Balanced skeletal traction - ✔✔Patient who is in mobile is at risk for constipation, nurse should encourage a high fiber diet and increased fluid intake Active range of motion of the affected limb is not feasible due to limited mobility with the traction apparatus The nurse should not remove the weights after they're in place Nurse should inspect the pin site at least every 8 to 12 hours due to risk of infection Priority assessment for infant experiencing dehydration - ✔✔Measure the patient's weight daily; critical for infants and children because fluid accounts for a greater portion of their body weight What is included in an infant Hydration assessment what does it determine? - ✔✔Checking for absence of tears, palpating the fontanelles excess skin turgor Assessing these factors determines degree or severity of an infants dehydrationPriority action for a patient who had a seizure and is unconscious - ✔✔Priority action: CHECK AIRWAY PATENCY (airway always first) A nurse can then assess the patient for injuries perform a neurological exam and measure the patient's vital signs once an airway is established Vaginal yeast infections during pregnancy - ✔✔Hormonal changes of pregnancy change the acidity of the vagina, making used infections more common Clozapine (Clozaril) - ✔✔Atypical Antipsychotic Tx of schizophrenia Adverse effects: urinary retention, orthostatic hypotension, agranulocytosis Fever is an early indication of possible depletion of WBCs or agranulocytosis; WBC count should be checked tympanostomy tube placement - ✔✔placement of a tube in the tympanic membrane to relieve symptoms caused by fluid buildup Most children do not need tubes from more than one year; usually fall out on their own between 6 to 12 months after insertion Should wear air plugs to prevent contaminated or soapy water from entering the ears Hearing impairment common with otitis media and can continue after tubes are in place Thrombocytopenia precautions - ✔✔Thrombocytopenia is a low platelet count, common after bone marrow transplant'sPatients are at increased risk for bleeding Prevention: avoid hard foods No fresh flowers because patient is in protective isolation Use of an electric shaver Do not blow nose or insert objects into nares Lactose free calcium sources - ✔✔One cup of collard greens provides about the same amount of calcium equivalent to 8 ounces of milk Ventriculoperitoneal shunt placement discharge teaching - ✔✔Patient at increased risk for infection especially 1 to 2 months after placement; parents should report fever, vomiting, seizure activity, decreases in responsiveness which all are indications of infection A minimal amount of fluid is redirected from the ventricles to the abdomen by the shunt and is absorbed readily into the peritoneum Older children should wear a helmet during physical activity to decrease risk for injury, Helmet is not necessary for infants Chronic use of oral glucocorticoids high doses by children can result in what? - ✔✔Slowed linear growth Children should be prescribed inhaler glucocorticoids in order to deliver the anti-inflammatory agent directly to the local target area resulting in a decrease risk of adrenal suppression (which leads to slowed linear growth) Abdominal aortic aneurysm (AAA) - ✔✔aorta that becomes abnormally large, ballooning outward*triple A= triple the size* Indications of a rupturing AAA: Sudden and increasing lower abdominal and back pain (indication that the aneurysm is extending down word and pressing on the lumbar sacral nerve roots) Indications of Shock including decreased BP and increased pulse Right sided heart failure - ✔✔*RIGHT= EVERYTHING ELSE BUT LUNGS Fluid backs up into heart Manifestations: S3 gallop, peripheral edema, jugular vein distention Left sided heart failure - ✔✔*LEFT =LUNGS Fluid backs up into lungs Manifestations: crackles in lungs, dyspnea, pulmonary edema (d/t blood cannot get out of pulmonary circulation) Nurse should expect to see oliguria during the day because of decreased blood flow to the kidneys Varenicline (Chantix) - ✔✔Smoking cessation Adverse effects: changes in mood, n/v, altered sense of taste, skin rash Rx factors: ↑risk depression/suicide; priority nursing action is to monitor for any mood changes Colorectal cancer primary, secondary, tertiary prevention methods - ✔✔Primary prevention:Smoking secession, there is an association between ling-term smoking in colorectal cancer Dietary teaching on the benefits of a diet high in cruciferous vegetables, which helps prevent the development of the disease Secondary prevention: Screening exams starting at age 50 promotes early detection of the disease Tertiary prevention: information about ostomy appliances and care, an action to minimize the effects of long-term disease or disability Patient education for EEG therapy - ✔✔EEG electrodes only monitor brain activity, they do not stimulate Patient should not drink any beverages that contain caffeine the day of the test, patient should not fast because hypoglycemia can affect diagnostic results Patient should shampoo their hair before the procedure and refrain from putting any styling products on it afterwards to promote adherence of the electrodes to the scalp Short term memory loss does not occur after an EEG (common after electroconclusive therapy) Doxycycline (Vibramycin, Doryx) - ✔✔Tetracycline antibiotic Adverse effects: photosensitivity, diarrhea, interference with color vision Avoid direct exposure to sunlight or UV light, wearing protective clothing outdoors and using sunscreen Precipitous labor - ✔✔Labor that lasts 3 hours or less from onset of contractions to time of delivery occurs between 20 and 37 wks gestation, uterine contractions and cervical changesPriority nursing action: Regardless of the cause of rapid delivery, uterine atony can result, causing PP hemorrhage; nurse should palpate the fundus and massage as needed to monitor and reduce risk of hemorrhage What oxygen-delivery method should a nurse plan to use for a patient with history of COPD? - ✔✔Nasal cannula- delivers precise concentrations of 02 which is required in a COPD patient Simple face masks and nonrebreather mask can reduce the respiratory drive in a patient with COPD; do not use Patient education on how to use an albuterol metered dose inhaler - ✔✔1. Remove the cap 2. Shake the canister 3. Hold the mouthpiece 2 to 4 cm or 1 to 2 inches from the mouth 4. Tilt your head back slightly and open your mouth wide 5. Depress the medication canister I'll taking a slow deep breath to facilitate delivery of the medication through the airway 6. Hold your breath for 10 seconds, then resume usual breathing pattern What protective equipment is necessary when entering a patient's room who has MRSA infection? - ✔✔Contact precautions- gown, gloves, mask/goggles (if secretions from the infected individual could spray into the personnels face), use of hand sanitizer when entering and exiting patient room When in direct contact with the patient a personnel must wear a gown When not in direct contact with the patient but still in contact with the patients environment, personnel should don gloves and use hand sanitizer when entering and exiting pancreatitis - ✔✔Lab results: Elevated amylase within 12 to 24 hours and remains elevated for 2 to 3 days Hypomagnesia HypocalcemiaIncreased WBC count, indication of inflammation Nursing interventions: first pain relief, second cough and deep breathe Discharge teaching on performance of intermittent urinary self catheterization at home - ✔✔Might initially require self-catheterization every 2 to 3 hours, with the frequency eventually going to every 4 to 6 hours; longer interval between catheterization can result in bladder distention and increased risk of UTI Should empty bladder completely with each catheterization, to decrease risk of UTI No need for sterile technique; Home use of clean technique shows no greater risk for infection due to acclamation to the bacterial environment of the home Drink at least 2 to 2.5 L of fluid daily Hypovolemic shock lab values and S&S - ✔✔Decreased BUN (<10) Elevated hematocrit (>47% in F; >52% in M) Increased urine specific gravity (>1.030) Other indications of hypervolemia: weak pulse, tachycardia, orthostatic hypotension, tackypnea, decreased urinary output, slow capillary refill Phenelzine (Nardil) - ✔✔MAOIs Restrict foods containing tyramine: processed meats,lunch meats, aged cheeses, sourdough, alcoholic beverages, overripe fruits, fava beans or fermented soybeansPossible food options: chicken salad, whole wheat enriched bread or crackers, cereals, fish or poultry, sweet potato or white potato, fresh or frozen fruits and vegetables, eggs Nursing actions prior to initiating feeding via gastrostomy tube for a patient who had a stroke - ✔✔Priority action: Elevate the head of the bed because of increased risk of aspiration Formula should be at room temperature Nurse should flush the tube with water before initiating to ensure patency of the tube Verify the gastric pH is within proper range for placement in the stomach (1.5-3.5) Zidovudine (Retrovir) - ✔✔Antiretroviral, AIDS Early Adverse effects: Gi upset, fatigue headache, fever, rash. Late adverse effects: anemia, neutropenia, neuropathy, myopathy Other adverse effects: decreased appetite, anxiety, decreased hemoglobin* (anemia and neutropenia can occur d/t bone marrow suppression) Priority nursing action: monitor hemoglobin levels Tolvaptan (Samsca) - ✔✔Tx SIADH Promotes excretion of water which helps correct the flute in balance and patient to have SIADH Vasopressin (ADH) - ✔✔Exogenous form of antidiuretic hormone secreted by the pituitary gland Stimulates water reabsorption in the kidneysTx Diabetes Insipidus Contraindicated: pts w/ SIADH because it worsens manifestations Desmopressin acetate (DDAVP) - ✔✔Synthetic form of antidiuretic hormone Medicine used to treat hyposecretion of ADH Contraindicated: patients with SIADH because it worsens manifestations Chlorpropamide (Diabinese) - ✔✔(Used less often today) Antidiabetic agents that also has antidiuretic affects Tx of Diabetes Inipidus Contraindicated: patient with SIADH because it worsens manifestations Adverse effects: Gastrointestinal, Cutaneous reactions, Hypoglycemia, Dermatitis, eczema Skin lesions that indicate Malignant melanoma - ✔✔Irregularly shaped lesions w/ hues of blue, white and red tones Commonly start an exposed skin areas like the back, scale, face, neck and metastasizes readily to other areas Pharmacological treatment of chronic phantom limb pain - ✔✔Amitriptyline: tricyclic antidepressant Gabapentin: anti-epilepticPropranolol and other beta blockers: can reduce the persistent doll, burning sensations of chronic phantom limo pain Preoperative teaching for a patient who is to undergo LASIK eye surgery - ✔✔Type of we Factive laser eye surgery to correct myopia, hyperopia, astigmatism, which are most common causes of nearsightedness Overcorrection or under correction can occur so some patients will need prescription eyeglasses after the surgery Patient might receive sedation prior to the procedure and may have blurry vision, tearing, and hyper sensitivity to light postoperatively; should not drive afterwards Should not wear soft contact lenses for 2 to 3 weeks or hard contact lenses for four weeks prior to surgery because it limits oxygenation to the cornea which can slow post-op healing Some patients will have clear vision an hour after surgery but it can take up to four weeks for complete healing in optimal vision to occur Nursing interventions for a patient receiving a transfusion of packed RBCs that is exhibiting manifestations of a hypervolemic reaction - ✔✔Hypervolemic rxn due to circulatory overload If the blood transfusion is to rapid for the patient size/status this will occur Priority nursing action: use a transfusion pump to regulate and maintain the transfusion at a slower rate Administration of insulin glargine (Lantus ) and NPH insulin - ✔✔Do not mix insulin glargine with any other insulin- use separate syringes for administering both types of insulin Lantus (insulin glargine) - ✔✔Long-acting T1DM, T2DMCan administer at anytime of the day, administered only once in a 24 hour period Clear solution Pharmacological treatment of residual limb pain - ✔✔Meperidine (Demerol) Opioid More effective for residual limb pain rather than phantom limb pain NPH (Humulin N) - ✔✔Intermediate-acting insulin. Tx DM2 Onset: 1-2 hours. Peak: 4-12 hours. Duration: 18-24 hours. Cloudy solution Roll the valve between the palms, do not shake before administration When administering the patient should rotate injection sites in the same anatomical area to prevent lipodystrophy Developmental skills established by 18 months old - ✔✔Acquired at 8 months: sitting unsupported, stranger anxietyAcquired at 9 months: drinking well from a cup Acquired at 12 mo: Presence of six teeth, ability to say two words or speak in 2-word phrases Acquired at 18 mo: closure of anterior fontanel Treatment for systemic manifestations of SLE (systemic lupus erythematosus) - ✔✔Corticosteroids, such as prednisone, treatment of choice for SLE because of rapid anti-inflammatory action Expected lab values for a patient w/ SLE (lupus) - ✔✔Pancytopenia (decreased platelets, RBCs, HCT) increased ESR systemic lupus erythematosus (SLE) - ✔✔Autoimmune disorder a more severe form of lupus involving the skin, joints, and often vital organs- such as heart, lungs, kidneys Inflammation of these organs Indications of thyrotoxicosis - ✔✔Occurs if too much levothyroxine is taken Manifestations: chest pain, tachycardia, insomnia, tremors, hyperthermia, heat intolerance, diaphoresis Notify provider is these occur Levothyroxine (Synthroid) - ✔✔Tx for Hypothyroidism Manifestations of hypothyroidism such as constipation should subside during therapyPts taking this often lose weight and revert to an average basal metabolic rate Symptoms of fatigue can persist until the patient reaches therapeutic levels Patient education for the first 48 hrs following placement of a fiberglass cast on a lower extremity - ✔✔Do not insert any objects between the cast and skin, scratches/abrasions can lead to infection Reston avoid strenuous activities but use the muscles of the leg and joints above and below the cast Keep the affected limb above the level of the heart to prevent edema and pain and promote venous return Keep cast dry Nonpharmacological approaches to relieve osteoarthritis pain - ✔✔Warm packs or compresses well balanced diet to maintain healthy weight Rest joints in functional position, do not place pillows under knees to avoid flexion contractures sleep for 8 to 10 hours per night and rest for 1 to 2 hours when awake Bleomycin (Blenoxane) - ✔✔Antibiotic Antineoplastic Adverse effects/ Rx factors: thrombocytopenia, decreased kidney function which leads to peripheralperipheral edema and weight gain Complications: severe lung injury, including pneumonitis and pulmonary fibrosis -->Priority nursing assessment: pulmonary function *REMEMBER: mycin drugs = mon pulmonary function Prednisone (Deltasone) - ✔✔Glucocorticoid, corticosteroid, anti-inflammatory Tx of arthritis; high doses required At Rx for delayed wound healing Nifedipine (Procardia) - ✔✔Ca channel blocker Tocolytic that is given to stop preterm labor Adverse effects: dermatitis, urticaria hemothroax - ✔✔blood in the pleural cavity (chest) Treatment: chest tube insertion to drain blood accumulated in chest cavity Rubeola (measles) - ✔✔Airborne infection, opportunistic infection Manifestations: Koplik spots/oral lesions that are small, irregular spots w/ blue/white center appearing on bucks mucosa opposite to molars (prodromal stage of measles) Candidiasis (thrush) - ✔✔Opportunistic fungus that develops and oral cavity of patients who have amateur/compromised immune system's Manifestations: cheesy white plaque that looks like milk curds on the bugle mucosa and tongueOften initial opportunistic infection and HIV-positive child who is developing AIDS Transient ischemic attack (TIA) - ✔✔Temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurological function Most common causes: atherosclerotic plaque in the carotid arteries and hypertension Monitor: BP regularly to promote hypertension management and reduce risk of another TIA or cerebrovascular accident D/C teaching: Limit Na intake to help control HTN and prevent future TIAs Increase K intake to manage HTN Increase fiber intake Limit alcohol intake to no > 2 serving for men and 1 serving for women per day What does it mean when the low-pressure alarm on a mechanical ventilator sounds? - ✔✔There is either a leak or the tubing has come apart or detached from the patient What equipment should be available at the bedside of a patient following a subtotal thyroidectomy? - ✔✔Tracheostomy Tray Laryngeal edema common post-thyroidectomy can lead to respiratory distress and airway obstruction which makes emergency intubatuon difficult and increases risk for hemorrhaging because it increases tension in incision during insertion Metropolol d/c teaching - ✔✔Do not stop taking abruptly because it increases patient risk for angina, HTN, MI; reduce the dosage gradually over 1 to 2 weeks Count your radio pulse dailyChange positions slowly d/t Rx of orthostatic hypotension Expected findings of celiac disease - ✔✔Foul, fatty, frothy stools known as steatorrhea Indications of an acute intravascular hemolytic reaction for a patient who is receiving a transfusion of packed RBCs - ✔✔This type of transfusion reaction causes acute kidney injury (leading to oliguria and hemoglobinuria) Manifestations: oliguria and hemoglobinuria, tachypnea, fever, hypotension Indications that can make a hearing aid whistle include- - ✔✔Poor seal with the earmold, air infection, excessive wax in the canal, and proper fit, malfunction hyperthyroidism - ✔✔excessive activity of the thyroid gland Manifestations: inability to sleep, creased attention span, mild to severe hyperactivity, low-grade fever, diaphoresis, restlessness, increased systolic BP, tachycardia, dysrhythmias, increased protein, lipid, carbohydrate metabolism rate Recommendations for managing this disorder: Frequent rest. periods in a quiet environment Cool environment to decrease discomfort of heat intolerance Increase caloric intake with meals to prevent muscle weakness and wasting from increased metabolism rate Pneumothorax - ✔✔Air in the pleural cavity (chest cavity) Rx after blunt chest trauma Tx: chest tube insertionAddison's disease - ✔✔occurs when the adrenal glands do not produce enough of the hormones cortisol (glucocorticoids) or aldosterone Manifestations: severe fluid and electrolyte imbalances -> Hyponatremia, hyperkalemia Tx: (to Prevent addisonian crisis) nurse should do rapid infusion of IV fluids such as .9 percent sodium chloride and IV administration of high-dose corticosteroid such as hydrocortisone to correct deficiency Treatment for hypoparathyroidism - ✔✔IV Ca+ or phosphate binding drugs An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors?A. The infant's mother is likely HIV positive.B. The infant's ELISA test result is probably a false positive for HIV.C. Antiretroviral medications are inappropriate for infants and children who have HIV.D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations - ✔✔A. The infant's mother is likely HIV positive DKA therapy - ✔✔Initial goal is a blood glucose level below 240 Patient should receive regular insulin via continuous IV infusion and have blood glucose monitored hourly Mantoux skin test - ✔✔Negative result = reddened, flat area with no induration Positive result = injection cite is raised and feels hard to the touch (induration), with redness; determines exposure to TB not Dx of active TB A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates to the nurse that the client is developing dialysis disequilibrium syndrome (DDS)? - ✔✔headachecaused by the rapid removal of urea during hemodialysis; CNS disorder Rx factors: elevated BUN above 175 Manifestations: headache, nausea, vomiting, decreased LOC, seizures, restlessness; when severe, patient progress to confusion, seizures, coma, death A nurse is assessing a child who has acute lymphocytic leukemia and is receiving vincristine sulfate. Which of the following findings is the nurse's priority? - ✔✔parethesia Tx of acute lymphocytic leukemia Greatest Rx factor for the pt: neurotoxicity (adverse effect) Early findings of neurotoxicity: parethesia (numbing of peripheral extremities) which can progress to I don't gnomic and CNS dysfunction if not treated alopecia - ✔✔hair loss Rx for body image alteration chronic kidney disease - ✔✔kidney damage or a decrease in the glomerular filtration rate lasting for 3 or more months Restrict protein intake to preserve kidney function May require calcium, vitamin D, iron supplements Cochlear implants - ✔✔Work by directly stimulating nerve fibers in the cochlea Diaphragm contraceptive - ✔✔Use spermicidal jelly to increase effectiveness Insert up to six hours before intercourse and wait at least six hours after before removing itMultiple sizes Lab value to monitor to determine effective response of warfarin therapy - ✔✔And INR of 3.0 indicates effective therapy Lab value to monitor to determine effective response of heparin therapy - ✔✔aPTT of 30-40 sec Manifestations of an MI - ✔✔Nausea, vomiting, epigastric distress Ginkgo biloba - ✔✔Contraindicated when patient is taking warfarin d/t increased Rx of bleeding Sildenafil Citrate (viagra) - ✔✔Contraindicated: concurrent use w/ nitrates, such as isosorbide and nitroglycerin due to increased risk of life-threatening hypotension Complictaions of GERD - ✔✔Aspiration, nausea, vomiting, weight loss A nurse is providing teaching to the parents of a child who has a new prescription of lamotrigine for a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider? - ✔✔Rash other lamotrogine adverse effects: dizziness, diplopia, headaches Rx: injury from Steven-Johnsons syndrome or toxic epidermal necrolysis; initially manifests as rash in frost 2-8 wks of Tx ECG reading for pt with Hypocalcemia - ✔✔Prolonged QT interval Manifestations: tingling, numbness, technique, seizures, prolonged QT interval, laryngospasm Causes: hypoparathyroidism, CKD, diarrheaECG reading for pt with hypercalcemia - ✔✔Shortened QT interval ECG reading for pt with hyperkalemia - ✔✔Widened QRS complexes ECG reading for pt with hypokalemia - ✔✔Flattened T wave and cardiac dysthymias 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. - ✔✔B. Tell the child they will feel discomfort during the catheter insertion. 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. - ✔✔B. Absence of a bruit. 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" - ✔✔B. "I will wear loose clothing around my ICD" 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. "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?" - ✔✔A. "Describe your feelings to me about being pregnant" 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. - ✔✔D. Administer a rectal suppository 30 minutes prior to scheduled defecation times. 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. - ✔✔B. Place the client in a warm shower. 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 - ✔✔A. Below-the knee amputation a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? 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 - ✔✔B. Document the client's condition every 15 min 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. - ✔✔A. Acts as an advocate for the nursing unit. A nurse is reviewing the laboratory findings of a client who has and reports that she has been following her 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. - ✔✔C. Hba1c 10 % 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. Chlamydia 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 - ✔✔D. Use modeling to help the clients improve their interpersonal skills A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that its 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. - ✔✔C. Provide unleavened bread. 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. - ✔✔B. The client reports feeling less anxious. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has 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. - ✔✔B. Administer flumazenil to the client. 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 - ✔✔D. Elevated temperature 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. HypertoniaD. Abdominal distention - ✔✔B. Jitteriness 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 - ✔✔D. WBC 14,000/mm3 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." - ✔✔C. "The proxy can make treatment decisions if the client is under anesthesia." A nurse in the PACU is caring for a client who reports nausea. Which of the following 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. - ✔✔A. Turn the client on their side. 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 - ✔✔A. Confirm the client's perception of the event 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 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. - ✔✔d. Document the client's condition every 15 minutes. 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 - ✔✔C. Hypertension A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. 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. - ✔✔C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction. 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 no blanchable 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 - ✔✔B. Teach the client to shift his weight every 15 min while sitting A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following painmanagement is a safe option for the client? E. Naloxone hydrochloride. F. Spinal anesthesia. G. Pudendal block. H. Butorphanol tartrate. - ✔✔G. Pudendal block. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. Teach the client to scan the right to see objects on the right side of her body. b. Place the bedside table on the right side of the bed. c. Orient the client to the food on her plate using the clock method. d. Place the wheelchair on the client's left side. - ✔✔b. Place the bedside table on the right side of the bed.A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the suicidal? 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. D. The client reports giving away personal items. - ✔✔D. The client reports giving away personal items. 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. - ✔✔C. Tetanus diphtheria and acellular pertussis vaccine E. Inactivated influenza vaccine. 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". - ✔✔B. A client who has gout and states, "I can continue to eat anchovies on my pizza."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" - ✔✔A. "I can give you information about respite care if you are interested." 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. - ✔✔A. Methylprednisolone. 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". - ✔✔C. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits". 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. C. Help obtain Medicaid D. Understanding of infant care. - ✔✔C. Help obtain Medicaid A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? A. Critical pathways promote individualized care. B. Critical pathways decrease administrative work time. C. Critical pathways prevent unnecessary expense. D. Critical pathways incorporate provider preferences. - ✔✔C. Critical pathways prevent unnecessary expense. 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 dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. C. Sore throat. D. Blood pressure - ✔✔C. Sore throat.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 - ✔✔D. "An RN evaluates the client needs to determine tasks to delegate A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR C. Temperature 37.4C (99.3) - ✔✔B. FHR baseline 170/min A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of 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. - ✔✔C. Ensure that the client has a referral for physical therapy. 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. C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. - ✔✔C. A client who has depressive disorder and reports feeling hopeless. 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. -down and back 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. Place the tip of the thermometer under the center of the infant's axilla. 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 client in seclusion when he exhibits signs of anxiety - ✔✔C. Encourage the client to take frequent rest periods 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 - ✔✔A. "Does the doctor know you are eating that?"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 - ✔✔C. Administering potassium via IV bolus 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 - ✔✔A. Establish a toileting schedule for the client 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. - ✔✔B. Thrombophlebitis. 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. "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? - ✔✔D. "What helps you ignore what you are hearing? 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. - ✔✔C. Applying elbow immobilizers of an infant receiving cleft lip injury 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? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis - ✔✔b. Respiratory alkalosis A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following A. Inject air into the NPH insulin vial. B. Inject air into the regular insulin vial C. Withdraw the prescribed dose of regular insulin D. Withdraw the prescribed dose of NPH insulin - ✔✔A. Inject air into the NPH insulin vial.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." - ✔✔B. "We should establish our roles in the initial session." A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster. 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. - ✔✔A. Children who have varicella are contagious until vesicles are crusted. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following requires interventionby 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. - ✔✔A. Waits 2 minutes between suctions. - 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. - ✔✔A. Use three pronged grounded plugs. A nurse is providing care for a group of clients. Which of the following client's should 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. - ✔✔C. A client who has dementia and is incontinent of urine and feces 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 the 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." - ✔✔B. "I will place pressure on the corner of my eye after using the eye drops" 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 - ✔✔C. Swelling of the face 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". - ✔✔B. "I can give you information about making end of life decisions". 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. Keep client's calcium gluconate at the client's bedside B. Monitor blood pressure every 2 hr. C. Remove IV bag from exposure to light. D. Attach tan inline filter to the IV tubing. - ✔✔C. Remove IV bag from exposure to light. 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. Heightened perceptual field C. Rapid speech D. Purposeless activity - ✔✔B. Heightened perceptual field 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 - ✔✔D. Administer the medication 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 - ✔✔D. Eat a light snack before bedtime 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 C. Colchicine D. Codeine - ✔✔A. Pregabalin A nurse is caring for a client following insertion of a chest tube 12 hr. ago. Which 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. - ✔✔C. Report continuous bubbling in the water seal chamber. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects? A. Productive cough.B. Urinary retention. C. Rhinitis D. Fever. - ✔✔B. Urinary retention. 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." - ✔✔A. "Can you talk about what happens with your partner at home?" . 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. "I will put my child on a gluten-free diet". B. "I will administer digestive enzymes with meals and snacks". - CF C. "Provide my child with some high fiber foods." D. "I will give my child whole wheat toast and milk for breakfast" - ✔✔A. "I will put my child on a glutenfree diet". 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 - should be 18g C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. - ✔✔A. Prime IV tubing with 0.9% sodium chloride.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.-long acting D. 0.45% saline. - ✔✔C. Increase exercise activity 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". - ✔✔A. "Drink 2 liters of warm water per day". 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% - ✔✔B. A client who has a hip fracture and a new onset of tachypnea 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.-long acting D. 0.45% saline. - ✔✔A. 0.9% normal saline. 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 - ✔✔A. Consume food high in bran fiber A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? A. the infant 30 ml (1 oz) glucose water every 2 hr. 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. - ✔✔C. Ensure that the newborn wears a diaper. 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. "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." - ✔✔B. "I will intervene if there is conflict between a client and his provider" 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. - ✔✔D. Evaluate the client's ability to help with repositioning. A nurse is orientation a newly licensed nurse who is caring for a client who 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. "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 - ✔✔B. "It allows preset pressure delivered during spontaneous ventilation." 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. Weak femoral pulses A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? - ✔✔- Auscultate Lower Lobes 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. D. A description of the framework the researchers will use to evaluate the data. - ✔✔A. A statement that participants can leave the study at will. 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 - ✔✔Excessive sweating 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. - ✔✔C. The client develops hiccups. 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 - ✔✔D. Food exchange lists for meal planning from the American Diabetes Association. 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." 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." - ✔✔D. "You should push the button before physical activity to allow maximum pain control." 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? E. Glargine insulin. F. Regular insulin. G. NPH insulin. H. Insulin aspart. - ✔✔E. Glargine insulin. 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. Playing with a large plastic truck. A nurse is caring for a client who is receiving intermittent feedings 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. Monitor the rate of the client's feedings. D. Instruct the client to move onto their right side. - ✔✔C. Monitor the rate of the client's feedings. 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. - ✔✔D. Insert an IV line. A nurse is caring for a client who has Raynaud's disease. Which of the following actions 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. - ✔✔A. Provide information about stress management. 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 factor for angina? A. Hyperlipidemia. B. COPD C. Seizure disorder D. Hyponatremia. - ✔✔A. Hyperlipidemia. 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. - ✔✔B. Magnesium hydroxide 30 ml PO. 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. - ✔✔D. Report the incident to the AP's charge nurse. A nurse is planning care for a client who is receiving hemodialysis. Which of the following 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. - ✔✔C. Check the vascular access site for bleeding after dialysis. 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. - ✔✔D. Determine if the client has any injuries.A nurse is caring for a client who is in active labor and note the FHR baseline has 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 - ✔✔C. Maternal hypoglycemia A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? A. Periorbital edema. B. Decreased frequency of urination. C. Enuresis. D. Diarrhea. - ✔✔C. Enuresis. 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 - ✔✔D. A client who is 1 day postoperative following a vertebroplasty 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. Theclient 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 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." 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." - ✔✔A. "This test should be performed after your baby is 24 hours old." 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" - ✔✔C. "I should avoid eating popcorn and fresh pineapple" 98. 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. - ✔✔D. Place the client on NPO status.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" - ✔✔C. "Rise slowly when getting out of bed" 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. 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. - ✔✔C. Determine the client's current pain level. 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. - ✔✔C. Broiled skinless chicken breast with brown rice. 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." - ✔✔C. "Your desire to be an organ donor must be documented in writing." 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. - ✔✔D. The client brushes her teeth twice daily. 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. - ✔✔C. Auscultate the newborn's apical pulse for 60 seconds. 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 - ✔✔C. NephrologistA 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 - ✔✔A. Return unopened equipment to the supply center 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) C. Albumin level 4.0 g/dL. D. WBC count 14,000 mm3 - ✔✔D. WBC count 14,000 mm3 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 7th grade reading level. C. Avoid using cartoons in the teaching material. D. Use words with three or four syllables. - ✔✔A. Emphasize important information using bold lettering. 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" - ✔✔B. "Ice chips" 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 - ✔✔D. Contractions 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. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. - ✔✔B. Apply fetal heart rate monitor. 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) 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" - ✔✔A. "Your baby needs an IV because she is not producing any tears" 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 - ✔✔B. A History of gastroesophageal reflux disease 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 - ✔✔C. Eat 1g/kg of protein per day 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. - ✔✔no answer A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse 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. - ✔✔D. Listens to the client's lung sounds. 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 D. Refer to the hallucinations as if the are real - ✔✔A. Ask the client directly what he is hearing 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 maste [Show More]

Last updated: 1 year ago

Preview 1 out of 204 pages