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Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? Measure the urine output for the next day and immediately notify the health care provider if it should decrease.
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is weekly weight
A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? It is critical to report promptly to your health care provider any findings of peptic ulcers
A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? Have the client turn to the left side
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A cold, pale lower leg
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? Until the health care provider has determined that your ejaculate doesn’t contain
A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? The flow of life is believed to flow through major pathways or nerve clusters in your body.
The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent
A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? Side-lying on the left with the head elevated 10 degrees
A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? minimal drainage into the urinary collection bag
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? Participate with the compressions or breathing
. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? Jugular vein distention
A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication? Can predispose to dysrhythmias
A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? Pupils fixed and dilated
A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis “””I went to the health care provider last week for a cold and I have gotten worse.”””
Which these findings would the nurse more closely associate with anemia in a 10month-old infant? Pale mucosa of the eyelids and lips
The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is Pupil responses
Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A preschooler with intermittent episodes of alertness
The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be Pale, thin arms and legs, uninterested in surroundings
As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? Hair loss
While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today’s temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to Administer acetaminophen as ordered as this is normal at this time
. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse’s priority should be Assess for dyspnea or stridor
Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? I went to the bathroom and my urine looked very red and it didn’t hurt when I went.
A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? Fibroids that cause no problems still need to be taken out.
An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? Stay with client and observe for airway obstruction
A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? FHT 168 beats/min
A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement wouldalert the nurse to a complication? “””I have been coughing up foul-tasting, brown, thick sputum.”””
The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal S3 ventricular gallop
Which of these observations made by the nurse during an excretory urogram indicate a complicaton? The client’s entire body turns a bright red color
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? “””The tube will remove excess air from your chest.”””
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? Serum potassium 6 mEq/L
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? Dyspnea
The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? Pulse oximetry of 88
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? Restlessness
The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to Assist client to turn, deep breathe, and cough
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote Deep breathing and coughing
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? Assist with oral hygiene
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? Assess for post operative arrhythmias
. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? Lower the oxygen rate
A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? Notify the health care provider
The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s first action should be to Reinforce the dressing and elevate the leg
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? Leukopenia
A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriatenursing action? Continue to monitor the rate of drainage
A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? Loss of pulse in the extremity
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? Assist him to stand by the side of the bed to void
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? Perform a quick assessment of the client’s condition
The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? “””I am allergic to shrimp.”””
“The health care provider order reads “”aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate.”” The pH of the aspirate is 10. Which action should the nurse take?” Hold the tube feeding and notify the provider
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must Apply suction for no more than 10 seconds
An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to administer the medication in 2 separate injections
The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to prevent the drug from tissue irritation Skip
A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? improved respiratory status and increased urinary output
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response? “””The medication must be continued so the fluid problem is controlled.”””
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? Change in libido, breast enlargement
A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? No bowel movement for 3 days Skip
A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? Activated PTT
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? Flush adequately with water before and after using the tube Skip
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? “””Our child should brush and floss carefully after every meal.”””
Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? Occult bleeding
The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stressto the client as important? Avoid chocolate and cheese
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? Application of pediculicides
The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? Non-steroidal anti-inflammatory drugs
A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? Potassium
The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? Stop the infusion
Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? Hemoglobin and hematocrit
A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? Protamine
The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? “””I always make sure to shake the NPH bottle hard to mix it well.”””
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? Orthostatic hypotension is a common side effect
The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? Baked potato
An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? Check the client’s gag reflex
The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? Reposition every two hours
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A 79 year-old malnourished client on bed rest
Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse’s priority? Obtain a health and dietary history
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is Abdominal x-ray
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? Perform frequent oral care with a tooth sponge
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to Exercise doing weight bearing activities
The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? Sliced turkey sandwich and canned pineapple
Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? Bed in lowest position, wheels locked, place bed against wall
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula Continuously
The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID Laxatives
A client with diarrhea should avoid which of the following? Orange juice
Which statement best describes the effects of immobility in children? Immobility in children has similar physical effects to those found in adults
A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client’s comfort? Keep conversations short
After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? Decreased sodium and potassium
What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? Oozing liquid stool
A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to accept the client’s report of pain
An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be Assess the severity and location of the pain
A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contactprecautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: Visitors should wash their hands before and after touching the client
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? Place in respiratory/secretion precautions
Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? Altered patterns of urinary elimination related to nocturia
A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? An infant who has been identified to have botulism
A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? Have gloves on while handling bedpans with feces
Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? Contact
The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to includewould be which of these statements? Children are not to share hats, scarves and combs
During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? Wash hands thoroughly before and after client contact
A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? roast beef, mashed potatoes, and green beans
“After an explosion at a factory one of the workers approaches the nurse and says “”I am an unlicensed assistive personnel (UAP) at the local hospital.”” Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers?” Palpate pulses
Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A young adult in the second day of treatment for an overdose of acetometaphen
“The mother of a toddler who is being treated for pesticide poisoning asks: “”Why is activated charcoal used? What does it do?”” What is the nurse’s best response?” “””The charcoal absorbs the poison and forms a compound that doesn’t hurt your child.”””
The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say “””What is your name? What allergies do you have?”” then check the client’s name band and allergy band As the room is entered say”
Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A positive purified protein derivative with an abnormal chest x-ray
A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice.
Which approach is the best way to prevent infections when providing care to clients in the home setting? Hand washing before and after examination of clients
A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to Place the hands or a folded blanket under the head of the child
“A mother calls the hospital hot line and is connected to the triage nurse. The mother proclaims: “”I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.”” Which of thesecomments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance?” Ask the child if the mouth is burning or throat pain is present
The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? Place client in a negative pressure private room and have all who enter the room use masks with shields
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? Irrigate and redress a leg wound
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client’s background because Normal patterns of behavior may be labeled as deviant, immoral, or insane
The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? Supervise a nursing assistant for skin care
The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? Care for a client with discharge orders
“After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, “”I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again.”” The nurse should respond by saying” “””He is scared and taking it out on you. Let’s talk to figure out what to do.”””
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response ofthe nurse should be which of these statements? I need to get the client’s written consent before I release any information to you
“A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “”I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.”” The nurse should understand that” The client has a right to know about the prescribed medications
Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? Was minimally responsive to voice and touch
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? Was minimally responsive to voice and touch
“A client tells the nurse, “”I have something very important to tell you if you promise not to tell.”” The best response by the nurse is” “””I can’t make such a promise.”””
Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? Apply and care for a client’s rectal pouch
“A client asks the nurse to call the police and states: “”I need to report that I am being abused by a nurse.”” The nurse should first” Obtain more details of the client’s claim of abuse
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A myocardial infarction that is free from pain and dysrhythmias
An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? “Have you reviewed the list of expected skills you might need on this unit?”””
A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to Discuss the boundaries of the therapeutic relationship with the client
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? Perform nostril and mouth care
The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? Test blood sugar every 2 hours by accu check
A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? A middle-aged client with an obsessive compulsive disorder
The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? Check temperature 15 minutes after hot liquids are taken
A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to Assign 1 of the nursing staff to visit the client regularly
A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? Observation of affect and behavior
A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do? “Pour fluid over the forehead backwards towards the back of the head and say “”I baptize you in the name of the father, the son and the holy spirit. Amen.”””
“An American Indian chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague “”I wonder if he has any idea howridiculous he looks — he’s a grown man!”” The nurse’s response is an example of” Prejudice
A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is client demanded a blanket. “””I see this is frustrating for you. I have a few minutes so let’s talk.”””
An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change incalling the daughter from daily to once a week, and the client’s tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients? A middle aged person who has been on the unit for 72 hours with a dysthymia
“A client diagnosed with anorexia nervosa states after lunch, “”I shouldn’t have eaten all of that sandwich, I don’t know why I ate it, I wasn’t hungry.”” The client’s comments indicate that the client is likely experiencing” Guilt
“A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states “”everyone’s life is in God’s hands.”” The next action for the nurse to take is to” Ask the client if talking with a priest would be desired
A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be “””Tell me about your week prior to being admitted.”””
A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client’s wrist
An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes thatthe student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? Ask the parent to identify the major problem
Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? “””I have powers to get you whatever you wish, no matter the cost.”””
“A client says, “”It’s raining outside and it’s raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I’ve never been to Ireland.”” The nurse would document this behavior as” Flight of ideas
During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurseindicates an attitude of prejudice? “””Doesn’t she know there’s such a thing as birth control?”””
Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? “””You look upset. Would you like to talk about it?”””
A nurse in the emergency department suspects domestic violence as the cause of a client’s injuries. What action should the nurse take first? Interview the client without the persons who came with the client
Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? Recognizes feelings with appropriate expression of feelings
A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice.Which of these actions is the appropriate nursing intervention for the client at this time? Locate a room that has minimal stimulation outside of it for admission process
A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? Disbelief
Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence? “””I have tried leaving, but have always gone back.”””
“A nurse states: “”I dislike caring for African-American clients because they are all so hostile.”” The nurse’s statement is an example of” Stereotyping
Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct? Improvement of the processes in a proactive, preventive mode is paramount.
The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of Autonomy
When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included? Diarrhea, dry mouth, weight loss, reduced libido
The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is Gentle pressure on eye orbit
The nurse is teaching about non steroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? Taking the medication 1 hour before or 2 hours after meals
A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these? Extremity tingling and numbnes
The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child’s parent would be important in determining the etiology of the seizure? “””He has had an ear infection for the past 2 days.”””
A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? Apply a pressure dressing to the site
An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child’s health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understandsthat which of the following is true in regards to giving immunizations to this child? The MMR vaccine should be given now, prior to the transplant
The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastrostomy tube placement, the priority is to Auscultate the abdomen while instilling 10 cc of air into the tube
what do you screen for on a newborn baby? hypothyroidismcheck T4 level (decreased)
what would the potassium level be in a pt with diabetes insipidus? hypokalemia
what is an expected side effect of Solu-Medrol? bleeding, bruising
what does Pilocarpine treat? glaucomaantidote is atropine sulfatemay get a dry mouth
TPN central venous cathetercheck for cloudinessrefrigerate- warm before administrationmonitor electrolytes everydaymonitor for hyperglycemia and infectionchange tubing with each new bagnothing else goes through this line
what drug would you give is extravasation has occurred? phentolamine (Regitine)- it’s a vasodilator and will increase blood flow to the area to prevent necrosis
what diet would be chosen for a pt with CKD? bread & cream of wheat
FIRST action for late decels? give O2
what do you give a premature infant with RDS? surfactantbetamethasone (Celestone) stimulates surfactant production in alveolar space causing less tension when infant breaths- given IM to mother in preterm labor
FIRST action for a newborn choking? aspirate
what would you teach a client about getting pregnant who just received a Rubella vaccine? don’t get pregnant for 3 months
pt receiving a blood transfusion develops fluid volume excess and dyspnea, what do you do? increase O2
a pt returns from TURP surgery, what can the RN delegate? weigh dailyI&O’s- subtract irrigate from outputkegal exercises for temporary incontinence
what can be delegated to a nursing assistant or UAP? can discontinue suction, but cannot turn back ongrooming & hygienefeedingVSROMI&O’sobtain clean urine specimentransport clienttransfer from bed to chair; help with bed to stretcherhelp with turning and repositioningambulate
what can be delegated to a LPN? PO meds and injectionsroutine data collection, dressing change, catheter insertion, suctioningreinforce teaching; basic, simple teaching (turn, cough, deep breath)assist HCP in procedures when RN is unavailable (NGT insertion)can perform specific tasks in unstable situations
what can the RN not delegate? assessment, diagnose, analyze, plan, evaluate, teach, monitorreceive and give reporttriageinvasive linessterile techniquenew admissionspre-op & post-op assessment
what should you be monitoring in a client who has had a nephrectomy? UOPit is more important than drainage
what is important when caring for pt in skeletal traction? pin care; sterile technique; remove crust; serous drainage is ok
what do you do if the pins come out of someone with skeletal traction? immobilize extremitydo not re-insert
how do you deal with a rude doctor that is avoided by the nurses? staff meeting
what are some diet recommendations for a client with anorexia who has become hypoglycemic? simple sugars- milk, coke, juice, raisinsonce sugar is up, eat complex carbs & protein- PB and crackerslow fat, high calorie, high protein
what would you teach a pt taking disulfiram (Antabuse)? must sign consent form stating they will avoid all alcoholmany preparations contain alcohol- cough syrup, mouthwash, aftershave, cologne
what is confrontation? calling attention to inconsistent behaviors
what is reflecting? paraphrasing or repeating what client said
if a manic client is monopolizing group therapy what do you do? tell them to stop talking and try to listen to otherstell them to take a walk with you
how do you communicate with a client who has disordered thinking about food being poisoned? open-ended questions & silence
what client would most likely be experiencing delirium? a client with constant pain or insomnia
how would you reduce anxiety in a client who is OCD? allow them time to finish their ritual and then talk about it
what is the priority for a depressed client who has not slept? sleep
a client who is bipolar is going home for the weekend to adjust for discharge. what do you tell the family? continue normal daily activities
how do you position a client with an air embolism? trendelenburg (HOB down)
what do you do for a client with absent lung sounds? check pulse, if no pulse- perform CPRif they have a pulse perform rescue breaths- 1 every 6-8secs
if a client has a pulse with absent breath sounds on the left side what do you do? prepare to reposition ETT
what do you suspect in a child with an irregular pulse? Kawasaki disease
what do you monitor for in adrenal insufficiency (no steroids)? shockhyperkalemiaincrease sodium in diet
what do you monitor for in addisonian crisis? severe hypotensionhypoglycemia
if a client suddenly withdraws from steroids what do you do? check VS
what do you teach a client taking prednisone? monitor for hyperglycemiatake in morning
what do you teach a client with DM2? monitor blood sugar
where do you give an immunization to a peds client? vastus lateralis
you are caring for a client with AIDS and you accidentally stick yourself with a sterile needle. what do you do? go get a new needle- no need to report
what are s/s of hypocalcemia? rigid & tight musclesDTRs increasestridortrouble swallowingarrythmias+ Chovestek’s and Trousseau’s signseizuresmental changes
how do you check serum sodium? check osmolality
what do you teach a pt taking an antipyretic for and increased temp? give with fluids because fever can cause dehydration
what is suspected if there is an increase in serosanguineous drainage? dehiscence
what is a client at risk for who has a fractured femur? fat embolismpriority action- stay with client and reposition to relive dyspnea
what would you expect in a client with an epidural hematoma? temporary loss of consciousness, followed by a lucid period, and then gradually leading to coma
what would you tell a client on chemo or on a neutropenic diet? can’t eat anything rawfruits, vegetables, honey, etc.
for maximum effectiveness, what should older clients use for dry skin? petroleum based ointment
how do you communicate with an AIDS client that is anxious and reluctant to ask questions? discuss common fears and questions expressed by other clients with the same diagnosis
on a breast exam, what finding would you report? dimpling
clients with multiple sex partners and STDs are at risk for what? prostate cancerteach them importance of early detection with screening
what are signs of pain in an infant? grimacingtachycardiarestlessnessirritabilitydifficulty feeding/sleepingincreased RRdiaphoresisdecreased O2 levels
what is priority for a client with renal lithiasis? address pain- these pts get pain meds immediately (don’t teach important of straining urine- that’s RNs job)
what is suspected in a pediatric client with severe edema? nephrotic syndrome
what do you do for a pt on Amph B? monitor UOP- it’s nephrotoxic
what is the priority assessment in a client who has lost a tooth and has an eye injury? check pupils
what is suspected in a client who is hypoventilating? increased CO2decreased O2decreased LOCpH is acidic
what is the plan of care goal for a client with COPD? decrease risk of infection
where should the level of water be in the water seal chamber? at 2cm
where should the level of water be in the suction control chamber? at 20cm
how do you evaluate the knowledge of cataracts and hearing in a geriatric client with lens implants? simple gestures & repetition
how does a client present with DM2? usually come back to doctor for wounds that won’t heal or vaginal infectionsdon’t have enough insulininsulin doesn’t work
what do you do when caring for a client that is in 4 restraints? check every 15 minutesnutrition, hydration, eliminationcirculation
what should a client with an h.pylori infection get screened for? stomach ulcersstomach cancer
how would a pediatric client with asthma present? prolonged expiratory wheezingcoughinflammation and constriction of airways resulting in obstruction
a client in hypovolemic shock would present with what? weak thready pulse
TB precautions negative pressure roomN95 respirator maskairborne precautions
MRSA precautions glovesgownmask and goggle if possible splashing or spraying of secretions, excretions, body fluids, bloodcontact & standard precautions
how would you teach someone to use an inhaler? shake well for 5 seconds (if MDI)exhale completelypress canister once and inhale deeply and slowlyhold breath for 10 secondswait 1 min between each puffif using MDI- rinse mouth & gargle after each usenebulizers are better for peds and clients with severe asthma because it allows you to breath normally
what degree burn would present with leathery eschar and slough? full-thickness
partial thickness client with 60% burns who has a fever, increased RR and TPN infusing. what is your initial action? check patient for signs of infection
what is the appropriate action for a burn client in the emergent phase whose UOP and BP are dropping? immediately call the HCP
what do you monitor for in a client with HHS and DKA with insulin drip? hypokalemiaU wave
what is priority discharge teaching for a client with HHS? monitor for signs of dehydration
how would a person present who is having alcohol withdrawals? tremorsnervousnauseahyperactivenightmaresdisorientationhallucinationsincreased pulseincreased BPseizures
how would you care for a patient who has attempted suicide? safe environment is priority- safe-proof roomcontract for safety and renewdirect, closed ended statementsre-channel anger through exercise
what activity would you choose for a person who attempting suicide? punching bagchoose most exerting answer
what would you teach a client on peritoneal dialysis about self care? warm fluid before administrationincrease protein and fiber in dietreport any fever, abdominal pain that persists after 1-2 weeks, bloody, cloudy, urine colored outflow, outflow that is great than inflow, leakage around catheter site
what do you suspect with coffee ground emesis? peptic ulcerstomach cancer
what medications do you give with coffee ground emesis? ‘prazole (proton pump inhibitors)’tidine (h2 antagonist)antacidsmylantacarafate
how do you prevent ICP? maintain oxygenation- decreased O2 can increase ICPmaintain CO2 30-35- increased CO2 can increase ICPkeep CSP <100
what is the G&D of a toddler? toilet trainingmagical thinkers, egocentrismdramatic, pretend and parallel playlearn to behave through restrictionsgender identitylet child touch and hold equipmentwalks without help, creeps up stairs, kneels without supportbuilds tower of cubes, holds two cubes in one hand, scribbles, uses cups, but struggles with spoonsuses 4-5 words, uses 10 or more words, uses 2-3 phrasespoints and ask for objectsunderstand simple commandstalk all the timetolerates separation from parentstemper tantrums are normaldependency on security items (blanket)
what is suspected in a pediatric client with croup and how do you treat? retractions & barking coughriding with windows down at nightsteamy hot showerscool temp therapynebulized epinephrine, corticosteroids
what do you assess for a femoral artery sheath? bleeding and hemorrhage
how do you care for a client who has had a knee arthroplasty? continuous passive motion- keeps knee in motion and prevents formation of scar tissuePT sets machine to gradually increase flexion and extensionnever hyperextend or hyper flex the kneeaddress pain- or they will not participate in activities
in a client with myasthenia gravis, how do you know if Mestinon has been effective? muscle strength improvestake before activities such as eating and working
how would a client present who has had a contact allergic reaction? pruritisedemaerythemavesiclespapulescrusting and thickening of skinoccurs 6-48 hours following exposure
what do you instruct the client to do before obtaining a sputum specimen? rinse mouth outobtain in morning
how do you care for a hemiparesis client? ambulateencourage independence with ADL’sincrease mobility as tolerated
what do you teach a client with asthma about taking beta agonists? if administered with theophylline cardiac dysrythmias can occuravoid if taking beta blockers, MAOIs or tricyclic antidepressantsobserve for chest, jaw, arm pain or palpitationsreport increase in pulse of 20-30bpm
what is the goal in the rehabilitation phase with a burn client? pt gains independence and achieves maximum functionprovide emotional support
how do you communicate with a client who has had a CVA has developed receptive aphasia? picture board- they can’t understand spoken or written wordsleft hemisphere
what does tadalafil (Cialis) treat? erectile dysfunctionBPHpulmonary HTN
how do you administer dobutamine IV? dilute in 50ml solution- can cause extravasationstarted at low doses (0.5-1.0 mcg/kg/min)titrated at intervals of a few minutesnot to exceed 40 mcg/kg/minshort term
what do you monitor for in a client with MI developing cardiogenic shock? ventricular dysrhythmiastachycardiaconfusionhypotension
what do you teach the client taking warfarin (Coumadin)? limit green leafy vegetablesbleeding precautions
what is a side effect of eptifibatide? bleeding
what do you care for after chemo treatment? nausea and vomiting
what is the side effect of ondansetron (Zofran)? hives, chest tightness, trouble breathing
what is considered a postpartum infection? a fever on 2 consecutive days for the first 10 days postpartum not including the first daywound infectionsmastitisendometritisUTIsrespiratory tract infections
if family refuses to discuss funeral arrangements what do you do? remain with family member without discussing (don’t show acceptance of family member’s feelings)
how do you treat a client with swollen tongue, dry mouth and excessive thirst? IV hypotonic solution0.2% NaCl0.45% NaClD5W
what do you teach a client with thrombocytopenia? watch for bleeding gums, hematuria, black stoolsuse electric razoruse soft toothbrushno IM injections
how do you care for a client with AKI? restrict protein intakemonitor for hyperkalemia
males should get monthly testicular exams starting when? 15 years old to 36 years old
what do you monitor for in a client with hypothyroidism? neuro changesslow, deliberate speech
what is the peak? highest acting level of drugcollected 30min-1hr after administration
what is trough? lowest acting level of drugcollected 30min prior to next administration
if there is a staff conflict what do you do? attend client assignments first
what is initially used for a co-worker who is abusing narcotics? employee assistance program
what do the nurse practice acts state that you must do if you suspect a co worker is intoxicated? report the information to a nursing supervisor
what is the priority nursing diagnosis for a client with thyroid storm? risk for decreased CO
a client is having a precipitate delivery and you are waiting for the doctor. how do you position the client? lateral sims
a client who has a family history of malignant hyperthermia is going in to surgery and receiving general anesthesia. how do you prepare? cooling blanketfluids
when are febrile seizures most common? 9 months – 5 years oldtriggered by ear infection or viral illness
what is the priority of a client with febrile seizure? bring fever down
a client with pancreatic cancer should monitor for what? hypoglycemia with high levels of insulin and c-peptidedizziness, fatigue, uncontrolled shaking, weakness, hunger, history of fainting
what do you assess for in a client with a facial injury? violenceabuse
what do you assess for in a client suspected of having a fecal impaction? abdominal distentioncan cause autonomic dysreflexia
what is the home plan of care for a client with ALS? breathing devices, wheelchair, braces, rehab, and physical therapynutritionist; may need gastrectomy d/t risk for choking and aspirationsupport groupsriluzole slows down symptoms and helps live longerbaclofen or diazepam helps with spasticityamitriptyline for swallowingno cure- typically only live 3-5 years past diagnoses
what is suspected in a pediatric client with diaphoresis? diabetes
what interventions do you implement for a client in shock? O2 is priority- place client on high flow oxygen (100% nonrebreather)monitor VS, skin color, temp, cap refill, LOC, UOP, cardio)place flat with legs elevatedprepare for intubationmaintain patent IV- isotonic fluids
what is a PICC used for? chemoblood transfusionantibioticsIV fluidsliquid foodfrequent blood draws
what do you teach a person about their PICC line? can go home with- stays in 3 week to monthsflush once a weekuse waterproof cover when showeringclamp should always be closed when not in usereport swelling, redness, pain, discolored fluid at site or fever
how do you care for a client with liver failure at the end of life? decrease medsgive antacids, vitamins, diureticsI&O’s, daily weights, restdecrease protein and sodiumbleeding precautions
how do you provide hospice care? talk about what the client wants to talk aboutlisten with compassionfocus on creating a peaceful environmenttouch and facial expression are importantuse lotion, give back rub, offer cool towelnutrition is less important when body is shutting down- offer liquids and soft foodsteach family that this is a normal process
where is the apical pulse? 5th ICS MCL
how do you care for a pediatric client who is impulsive? distract by redirecting to other activitiesconsequences for bad behaviorreward for good behavior
what do you assess for in a victim of partner abuse? chronic pain
when can a venipuncture be given to a pediatric client? 2 years oldmedian cubital, cephalic veinsdorsal hand veinsbasilic vein on pinkie side of arm only used when there is not another more prominent arm veinfoot and ankle veins used as last resort