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NSG 4060 ATI Comprehensive Predictor 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 clie... nt appears to be anxious & agitated. What action should the nurse take? 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 for a 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 - 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 infection or 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. 10. 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 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. 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 radiation therapy 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 nurse consider when using this pain scale? ANS: Level Of Activity - The nurse should consider the infants level of activity when using FLACC pain scale. 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 terrors rather 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 ff surgery. The child weighs 21.8 kg (48 lb) & has a chest tube applied to suction. 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. 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 been receiving betaxolol to treat glaucoma. Which findings is an A/E if this medication? 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 the nurse 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 to follow 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? 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 understanding of 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. 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.” 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 client is 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 should assure 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! 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. The nurse 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. 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 ATI comprehensive: 1. 4hr postpartum, boggy uterus with heavy lochia. Which of the following actions should the nurse take? • Massage the uterus to expel clots • Rationale: ABC approach, priority is to massage uterus to expel clots and increase uterine firmness, resulting in decreased bleeding 2. Deficit in Cranial nerve 2: results in visual impairment and lead to falls • clear objects from the walking area 3. indicate the progression of labor and are a benign finding -nurse should continue to monitor FHR 4. Review ABGs 5. A nurse is interviewing a client who has just lost her home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? • Determine the client's perception of the personal impact of the crisis • First thing in the nursing process is assessment so assess client’s feelings and understanding of the natural disaster and its personal impact 6. An assistive personnel (AP) and a nurse are turning a client on to her right side. Which of the following actions by the AP requires the nurse to intervene? • Places a pillow under the client's right arm 7. A nurse in a community center is providing an educational session to a group of women about ovarian cancer. For which of the following manifestations should the nurse instruct the women to contact their providers? • Abd bloating • The nurse should include the presence of abdominal bloating as an early indication of ovarian cancer as well as other manifestations which include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency. 8. Hypokalemia • signs and symptoms: muscle weakness and decreased deep tendon reflexes 9. Hypocalcemia • numbness and tingling of the extremities and around the mouth 10. Car safety, d/c teaching • secure the retainer clip at the level of your baby’s armpits • The nurse should instruct the client to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs. 11. Nurse in ED is admitting a client who has cardiac tamponade, which assessment finding should the nurse expect? • pulsus paradoxus • The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension. 12. Allowable foods for a client who has a hx of uric-acid based urinary calculi formation. Which of the following foods should the nurse recommend that the client include in his diet? • Citrus fruits such as oranges • Avoid animal-based proteins and alcohol 13. A nurse is caring for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse take to provide comfort to this client? • Allow for frequent rest periods throughout the day • To maintain muscle strength, joint function and ROM • Warm shower instead of warm TUB baths 14. first trimester with an acupressure on wrist, indicates that this therapy is having desired effects? • I have not vomited for the past two weeks • Using an acupressure band on the wrists is a type of complementary and alternative therapy that applies pressure to a specific part of the body the client can use to alleviate nausea and vomiting. 15. Risk of development of a pressure ulcer? • Recent weight loss 16. 4hr post op following a total vaginal hysterectomy, actions to take first? • Measure client’s VS • The first action the nurse should take when using the nursing process is to assess the client. The nurse should measure the client's vital signs to assess for respiratory depression and hypotension resulting from anesthesia. 17. A nurse in an emergency department is reviewing the prescriptions of an older adult client who has type 1 DM. reports of severe ankle pain after falling from a stepstool at home. Which order should the nurse verify with the provider? • Apply a cold pack to the edematous area on the client’s ankle for 30mins every other hour • The nurse should verify a prescription for a cold pack because type 1 diabetes mellitus is a contraindication for receiving cold therapy. A client who has type 1 diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. 18. Discharge teaching for a client who has colorectal cancer and is post op following a new colostomy • Arrange for a referral to social services is correct. Arranging for a referral to social services is appropriate for a client who faces challenges with self-care, as well as with paying for medical equipment and supplies. Initiate a consult with an enterostomal therapist is correct. Initiating a consult with an enterostomal therapist can assist the client in learning to care for the colostomy. Provide the client with information about the American Cancer Society is correct. The client can learn about helpful resources from the American Cancer Society. Postpone the client's discharge is incorrect. There is no indication that the client should remain in the facility. Give the client information about local support groups is correct. A client who has cancer and a new colostomy can get help with coping from a support group. 19. Alprazolam/Xanax • Initiate fall precautions • Can cause orthostatic hypotension, dizziness, drowsiness and fainting upon arising 20. Celiac dx diet teaching • Gluten free diet 1. An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client 1. in semi-Fowler's position. 2. prone, with the head turned to the side. 3. with the head of the bed elevated 45° and the neck extended. 4. supine, with the head in the midline position.: 1 2. A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness.: 4 3. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says she feels pressure against her diaphragm when the baby moves.: 1 4. A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy set-up. 4. Suction equipment.: 1 5. A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge." 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication.": 3 6. A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter.: 3 7. The ABC framework identifies, in order, the three basic needs for sustaining life: Airway Breathing Circulation 8. An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse? 1. "Take the medication on a full stomach, or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for two weeks.": 2 9. Adverse effect of Verapamil: Avoid grapefruit juice 10. Adverse effects of ferrous sulfate: constipation; upset stomach; black or dark-colored stools; or. temporary staining of the teeth. 11. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube.: 2 12. After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes: 2 13. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.: 2 14. After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver: C 15. Alcohol Use Manifestations of Withdrawal: Body burns 0.5 oz of alcohol per hour * Withdrawal appears within 4-12 hours * Irritability + Tremors + Anxiety * Nausea + Vomiting + HA * Diaphoresis * Sleep Disturbances * TACHYCARDIA + HTN Use Benzodiazepines = tx Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) 16. alcohol withdrawal heroin withdrawal nicotine withdrawal alcohol abstinence opioid over dose: chlordiazeproxide( Librium) methadone( dolophine) bupropion ( wellbutrin) disulfiram ( antabuse) naloxone (narcan) 17. At what age does bone loss begin with osteoporotis what are normal Calcium levels?: at age 35 (women) 8.6-10 mg/dL 18. Baclofen (Lioresal) therapeutic outcome:: Decrease the frequency and severity of muscle spasms (MS). 19. Bladder retraining for the treatment of urge incontinence:: • Use timed voidings to increase intervals between voidings/decrease voiding frequency. • Perform pelvic floor (Kegel) exercises. • Perform relaxation techniques. • Offer undergarments while the client is retraining. • Teach the client not to ignore the urge to void. • Provide positive reinforcement as client maintains continence. • Eliminate or decrease caffeine drinks. • Take diuretics in the morning. 20. Bowel elimination how to get a specimen collection: Collect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine. 21. Case Management nursing involves:: *Decreasing cost by improving client outcomes * Providing education to optimize health participation * Advocating for services + client's rights 22. A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting: D 23. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation.: 2 24. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4. Magnesium.: 1 25. a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider: serum potassium 5.2 26. a client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medication: thrombocytes, amylase count and liver function test 27. A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant: D 28. A client is being discharged with sublingual nitroglycerin (Nitrostat ). The client should be cautioned by the nurse to 1. take the medication five minutes after the pain has started. 2. stop taking the medication if a stinging sensation is absent. 3. take the medication on an empty stomach. 4. avoid abrupt changes in posture.: 4 29. The client is exhibiting symptoms of myxedema. The nursing assessment should reveal 1. increased pulse rate. 2. decreased temperature. 3. fine tremors. 4. increased radioactive iodine uptake level.: 2 30. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via facemask or nasal prongs. 3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside.: 3 31. A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess for which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 cc per hour.: 4 32. A client is scheduled for a left lower lobectomy. The physician has ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure.: 3 33. A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side.: 1 34. a client should receive a dose of flumazenil ( romazicon) to treat symptoms of: benzodiazepine overdose 35. a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for which of the following should the nurse monitor this client: orthostatic hypotension 36. a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid ibuprofen. why or why not ?: what , if any is the appropriate action for the nurse to take NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should notify the provider of client headache and ibuprofen us 41. discrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual loss: anticipatory grief 42. During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.: 2 3 4 43. An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client 1. eat a high-protein, low-residue diet. 2. lie on her unoperated side. 3. exercise her arms and legs. 4. cough and deep breathe.: 4 44. An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to 1. monitor vital signs, especially blood pressure, every 30 minutes. 2. remain at the client's side to provide reassurance. 3. tell the client the name of the medication and its effects. 4. monitor the anticholinergic effects of the medication.: 1 45. Fill in the blank: 1. is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. , which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone.: 1 & 2 = collaboration 37. A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids.: 4 38. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200- calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be 1. confused with cold, clammy skin and a pulse of 110. 2. lethargic with hot, dry skin and rapid, deep respirations. 3. alert and cooperative with a BP of 130/80 and respirations of 12. 4. short of breath, with distended neck veins and a bounding pulse of 96.: 1 39. The clinic nurse is performing diet teaching with a 67-year- old client with acute gout. The nurse should teach the client to limit his intake of 1. red meat and shellfish. 2. cottage cheese and ice cream. 3. fruit juices and milk. 4. fresh fruits and uncooked vegetables.: 1 40. Describe pre-albumin: this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks) 46. A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.: 2 47. health promotion (injury prevention-suffocation): infant (birth-1 yr): -avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing 48. The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for a duration of 6-9 months.: 4 49. How should you respond when client wants to discontinue dialysis: "What has changed to make you decide this?" = Seek clarification from client to establish mutual understanding while staying therapeutic 50. How to prevent adverse effects of oxycodone: can cause respiratory depression. What is the nursing intervention and/or client education ? Monitor vital signs. › Stop opioids for respiratory rate less than 12/min, and notify the provider. › Have naloxone and resuscitation equipment available. › Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines, consumption of alcohol). 51. hypotension is classified with a reading below normal;: systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation 52. Identifying manifestations of transient ischemic attacks: symptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke. 53. . If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe 1. increasing respiratory difficulty seen with exertion. 2. cough productive of a large amount of thick, yellow mucus. 3. peripheral edema and anorexia. 4. twitching of extremities.: 3 54. If a patient has anorexia nervosa and works out constantly: Allow them to workout and continue their regimen 55. includes the group when decisions are made Motivates by supporting star achievements Communication occurs up and down the chain of command Work output by staff is usually of good quality-good when cooperation and collaboration is necessary: Democratic 56. Interaction of diuretics and ACE inhibitors: excessive reduction in blood pressure and symptomatic hypotension or hyperkalemia 57. involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of time: dysfunctional grief 58. Levothyroxine effects: Used to restore client's metabolic rate * Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension 59. Long term effects of NSAIDS (Ibuprofen): Gastric Ulcerations, perforations, hemorrhage, hypertension 60. makes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings: Authoritative 61. makes very few decisions and does little planning motivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situation: Laissez faire 62. Malnourished COPD patients: (1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soup 63. Most managers can be categorized as: authoritative, democratic, and laissez faire 64. Multiple Sclerosis Patient: Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug) * Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone) * Vomiting = causes dehydration * Hair Loss = emotional distress * Amenorrhea = emotional distress 65. Musculoskeletal congenital disorders: Monitor skin for breakdown areas and prevent pressure sores. 66. A nonstress test is scheduled for a client at 34-weeks gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 1. Start an intravenous line for an oxytocin infusion. 2. Obtain a signed consent prior to the procedure. 3. Instruct client to push a button when she feels fetal movement. 4. Attach a spiral electrode to the fetal head.: 3 67. The nurse caring for a child in Buck's skin traction will keep the:: Child pulled up in bed 68. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea: A 69. The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? 1. The client advances the cane 18 inches in front of her foot with each step. 2. The client holds the cane in her left hand. 3. The client advances her right leg, then her left leg, and then the cane. 4. The client holds the cane with her elbow flexed 60°.: 2 70. The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Green color and texture b) Black and tarry appearance c) Clay-like quality d) Bright red blood in stool: B 71. A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0mg/dL. 4. The patient's hemoglobin is 8.5g/dL.: 3 72. A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self- care tasks d) ask the client if a family member is available to assist with his care: C 73. A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter: A 74. A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. Nonmalificience: A 75. A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chloride: C 76. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the wound: C 77. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room: A 78. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene: A B E 79. A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take? a) assess for bladder distention after 6 hr b) encourage the client to use a bed pan in the supine position c) restrict the clients intake of oral fluids d) pour warm water over the clients perineum: D 80. A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? a) "I had a bowel movement, but I was able to save the urine" b) "I have a specimen in the bathroom from about 30 minutes ago" c) "I flushed what I urinated at 7 am and have saved the rest since" d) "I drink a lot, so I will fill up the bottle and complete the test quickly": C 81. a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at risk: Toxic level of digoxin 82. A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: a) restrict fluid intake to 1 qt (1,000 ml)/day. b) drink liquids only between meals. c) don't drink liquids 2 hours before meals. d) drink liquids only with meals.: B 83. A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a) Skim milk b) Nothing by mouth c) Regular diet d) Clear liquids: B 84. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room.: 4 85. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client.: 2 86. A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity?: * Verapamil (Calan) 87. The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply: 1 88. The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient 1. with his neck in a midline position and the head of the bed elevated 30°. 2. side-lying with his head extended and the bed flat. 3. in high Fowler's position with his head maintained in a neutral position. 4. in semi-Fowler's position with his head turned to the side.: 1 89. The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization.: 1 90. 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 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: B C D 91. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside: A 92. A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmaleficence: C 93. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.: 1 94. The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.: 3 95. a nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin) . which of the following over the counter medication should the nurse instruct the client to avoid: Aspirin 96. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL.: 2 97. 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: B C E 98. a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV) . for what adverse effect should the nurse monitor this client: the nurse should monitor the client respiratory depression 99. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.: B C E 100. A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. Passive smoking Carbon monoxide poisoning Food poisoning A. Have water heaters inspected on an annual basis. B. Cook all meat at an appropriate temperature. C. Avoid enclosed areas with others who may be smoking.: C A B 101. A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale c) black coffee d) orange sherbet: D 102. a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching: i should decrease the amount of calcium in my diet while taking the medication 103. A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step: C 104. a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teaching: I will tell my doctor before I stop taking the medication 105. a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include: 1. change position slowly to minimize dizziness 2. chewing sugarless gum to prevent dry mouth 106. A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? a) serum albumin level of 3 g/dL b) HDL level of 90 mg/dL c) Norton scale score of 18 d) Braden scale score of 20: A 107. The nurse is supervising the staff providing care for an 18- month-old 108. hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions.: 1 The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to perform intermittent self- catheterization at home. The nurse should instruct the client to 1. use a new sterile catheter each time he performs a catheterization. 2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization. 3. perform the catheterization procedure every 8 hours. 4. limit his fluid intake to reduce the number of times a catheterization is needed.: 2 109. A nurse manager of a med surge unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client? A. Charge nurse B. RN C. LVN D. AP: B 110. A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficience: D 111. A nurse on a med surge 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: C 112. A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmalificence: D 113. A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. reestablishes a trusting relationship with his/her other parent. 3. verbalizes that s/he is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse.: 3 114. a nurse responsible for a client receiving a antihypertensive medication is to: teach the client to change position slowly to avoid dizziness or fainting 115. The nurse should consider the hierarchy of human needs when prioritizing interventions, which are?: - Physiological needs first (oxygen, shelter, food) - Safety & security needs (physical safety) - Love and belonging - Self esteem - Self actualization 116. The nurse's INITIAL priority when managing a physically assaultive client is to 1. restrict the client to the room. 2. place the client under one-to-one supervision. 3. restore the client's self-control and prevent further loss of control. 4. clear the immediate area of other clients to prevent harm.: 3 117. Nurses must follow what code of standards in delegating and assigning tasks: ANA codes of standards 118. opioid agonists can cause Constipation What is the nursing intervention and/or client education ?: Advise the client to increase fluid/fiber intake and physical activity. › Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract decreased bowel motility, or a stool softener such as docusate sodium (Colace) to prevent constipation. 119. Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension 120. b) Bradycardia c) Warm moist skin d) Polyuria: A A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Instruct the patient to keep a record of food intake b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake: C 121. The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse should advise the client the BEST time to take this medication is 1. before breakfast. 2. with dinner. 3. with food. 4. at hs.: 4 122. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.: 3 123. A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of: calcium gluconate (because hypocalcemia causes Chvostek's sign) 124. 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: D 125. seclusion and restraints: -must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min 126. Signs for meningococcemia: Vomiting, febrile, petechial rash (unstable) 127. Sources of potassium: beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas 128. Taking Coumadin. Which foods should the client limit?: Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes 129. Teaching points for naltrexone (Vivitrol)?: Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen. 130. . The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for 1. a client with Alzheimer's requiring assistance with feeding. 2. a client with osteoporosis complaining of burning on urination. 3. a client with scleroderma receiving a tube feeding. 4. a client with cancer who has Cheyne-Stokes respirations.: 1 131. what are good sources of folic acid?: Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils. 132. what are normal creatinine levels? what are normal BUN levels?: 0.8-1.4 mg/dL 8-25 mg/dL 133. What are positive actions to help others: Beneficience 134. What are some things to teach about home safety with elderly patients?: - Removing items that could cause the client to trip, such as throw rugs and loose carpets - Placing electrical cords and extension cords that against a wall behind furniture - Making sure that steps and sidewalks are in good repair - Placing grab bars near the toilet and in the tub or shower and installing a stool riser - Using a non-skid mat in the tub or shower - Placing a shower chair in the shower - Ensuring that lighting is adequate both inside and outside of the home 135. What are some ways to identify a patient before giving a medication?: The Joint Commission requires 2 client identifiers be used when administering medications. - clients name - assigned identification number - telephone number - birth date or other personal-specific identifiers. Bar code scanners may be used to identify clients 136. What are the five stages of grief: denial anger bargaining depression acceptance 137. What are the precautions for vancomycin resistant enterococcus: Standard precautions including hand washing and gloving should be followed 138. What are the signs and symptoms of fluid volume deficit: loss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. 139. What are the S/S of lithium toxicity? (depakote for bipolar disorder): fine hand tremors, mild GI upset, slurred speech and muscle weakness 140. What are the therapeutic effects of protamine: Antidote to severe heparin overdose + Reversal of heparin administered during procedures 141. What are the values and beliefs that guide behavior and decision making?: Morals 142. What are total serum protein values (normals): 6-8 g/dL 143. What can prevent MI, stroke, or death in high-risk patients: Ramipril 144. What comorbidities may be observed with a patient who is bipolar?: Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD. 145. What does a newborns poop look like: If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency 146. What do the nurse need to keep in mind about the client when being their advocate?: Client's religion & culture 147. What do you do when a client has a seizure: - lower to bed/floor - protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement 148. what foods should you avoid if you have diverticulitis?: avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber) 149. What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given?: Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should give = TDaP (Tetanus, Diphtheria, Pertussis) 150. What is an agreement to keep promises: Fidelity 151. What is an interdisciplinary team?: A group of health care professionals from different disciplines 152. what is a normal hematocrit level in a female? What are normal Hgb values (female)? what are normal values for WBCs?: 37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uL 153. What is appropriate for an adolescent in the hospital?: Puzzles and books 154. What is avoidance of harm or injury: Non-maleficence 155. What is bipolar disorder?: Bipolar disorder is a mood disorder with recurrent episodes of depression and mania. 156. What is fairness in care delivery and use of resources: Justice 157. what is important about the diet of someone taking ACE inhibitors?: can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas) 158. what is normal pre-albumin values? what are normal serum levels of magnesium ? what is a normal potassium serum level?: 17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia) 159. What is the difference between respiratory acidosis and respiratory alkalosis?: Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45. 160. What is the most appropriate method for contraception for an adolescent: IUD or implant 161. What is the nurse's contribution to an interdisciplinary team?: - knowledge of nursing care & its management - a holistic understanding of the client, her/his healthcare needs & healthcare systems. 162. What is the nursing action for dehiscence: Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's . 163. What is the process of taking a telephone order from a provider?: Patient name, drug, dose, route, frequency read back for accuracy 164. What is the proper nutrition during pregnancy: - Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida - green leafy vegetables and brown rice 165. What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest: Autonomy 166. What is the safest way to thaw out frozen foods: In the refrigerator 167. What is the study of conduct and character?: Ethics 168. What kind of medications are indicated for abstinence maintenance of alcohol?: Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral) 169. What medications can be taken to help with smoking cessation: Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a generic. Varenicline (chantix) 170. What position is good to use for a patient who is at high risk for a pressure ulcer: 30 degree lateral position is recommended for clients at risk for pressure ulcers 171. What should be avoided during pregnancy: Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby 172. What should the nurse do when one member of a support group expresses anger repeatedly?: Focus more on the group members who have a positive outlook (Speak to group member privately to uncover source of anger) 173. What temperature should pork be cooked at: 160 degrees 174. What therapy will be useful for patients with bipolar?: Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior. 175. What to monitor for when taking enoxaparin (lovenox): Hyperkalemia Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported 176. What type of infectious diseases are required to be reported to the health department?: - severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA) 177. What values would a nurse possess to be a client advocate?: - caring - autonomy - respect - empowerment 178. When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure.: 3 179. When does Discharge planning begin?: At Admission 180. When performing nasotracheal suctioning what technique should be used?: Sterile asepsis bc the trachea is considered sterile and prevents infections 181. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers: 4 182. When should planning discharge process begin? a. at time of admission b. 2 days after client is admitted c. whenever the nurse has the time to do planning d. when the physician has the discharge order: A 183. When taking MAOI's, limit your consumption of: thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar... 184. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.: 3 185. Where should the cath bag be placed when urinary catheterization: Make sure the catheter bag/system is at a level below the client's bladder to avoid reflux. 186. Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others "I don't deserve to die, this isn't fair": Anger stage 187. Which Grief Process when Client acknowledges the impending loss while remaining hopeful "If I could just make it through this, I'd never smoke again": Bargaining Stage 188. Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep.: 1 189. Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding.: 4 190. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.: 3 191. Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.: 2 192. Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position her on her abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist her with heat application and ROM exercises.: 4 193. Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability b) hypotension c) flushing d) bradycardia: A 194. Which of the following situations can be identified as an ethical dilemma? A. A nurse on a med surge unit demonstrates signs of chemical impairment B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form: C 195. Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing b) apply intermittent suction when withdrawing the catheter c) place the catheter in a location that is clean and dry for later use d) hold the suction catheter with the clean, non-dominant hand: B 196. Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle.: A 197. A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder? 1. "I keep having recurring nightmares." 2. "I have a headache and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am and I don't know where I live.": 4 [Show More]

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