While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement?

Promptly remove the arterial catheter from the radial artery.

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

Rapid onset of decreased level of consciousness.

The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?

Position a firm wedge to support pelvis and thorax at 30 degree tilt.

When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge teaching plan?

Report any signs of cloudy urine output.

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Tented skin turgor.

After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take?

Apply light pressure over the area.

The nurse enters a client’s room and observes the client’s wrist restraint secured as seen in the picture. What action should the nurse take?

Reposition the restraint tie onto the bedframe.

A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?

Diminished left lower lobe sounds

Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung.

The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom)

Arterial endothelium injury causes inflammation

Macrophages consume low density lipoprotein (LDL), creating foam cells

Foam cells release growth factors for smooth muscle cells

Smooth muscle grows over fatty streaks creating fibrous plaques

Vessel narrowing results in ischemia

Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse’s decision to report this finding to the healthcare provider?

Oliguria signals tubular necrosis related to hypoperfusion

A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?

Skills of staff and client acuity

When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?

Explain that the client may be placed in five positions

A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell’s palsy rather than a stroke?

Inability to close the affected eye, raise brow, or smile

The nurse is teaching a client how to perform colostomy irrigations. When observing the client’s return demonstration, which action indicated that the client understood the teaching?

Keeps the irrigating container less than 18 inches above the stoma

The nurse should teach the client to observe which precaution while taking dronedarone?

Avoid grapefruits and its juice

A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client’s risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?

Increased Glasgow coma scale score.

Nuchal rigidity and papilledema.

Confusion and papilledema

Periorbital ecchymosis.

Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.

The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Confirm the necessity for continued use of the CVC.

During an annual physical examination, an older woman’s fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?

Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?

Determine if she can ask for support from family, friend, or the baby’s father.

A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?

Stop the normal saline infusion.

An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care?

Ensure proper alignment of the leg in traction.

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Document the ongoing wound healing.

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, “I just know I can’t handle all the pain.” What is the priority nursing diagnosis for this client?

Anxiety

The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?

Elevate the presenting part off the cord.

A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client’s symptoms, what recommendation should the nurse give the healthcare provider?

Reassess readiness for SNF transfer.

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.)

Recognize signs and symptoms of hypoglycemia.

Report persist polyuria to the healthcare provider.

Take Glucophage with the morning and evening meal.

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply

Written at a twelfth grade reading level

Contains a list with definitions of unfamiliar terms

Uses common words with few Syllables

Printed using a 12 point type font

Uses pictures to help illustrate complex ideas

Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as a medical terminology that incline may not know and use common words that expresses information clearly and simply. Simple, attractive pictures help hold the learner’s attention. The reading level of material should be at the 4th to 5th grade level. Materials should be printed using large font (18-point or higher), not the standard 12-point font.

During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)

An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)

Notify the healthcare provider of the client’s change in mental status.

Include q2 hour’s reorientation in the client’s plan of care.

An older male comes to the clinic with a family member. When the nurse attempts to take the client’s health history, he does not respond to questions in a clear manner. What action should the nurse implement first?

Assess the surroundings for noise and distractions.

The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?

Large amounts of fluid and electrolyte replacement.

Which intervention should the nurse include in the plan of care for a child with tetanus?

Minimize the amount of stimuli in the room

Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client’s room. Which intervention is most important for the nurse to implement?

Remove cigarettes for the client’s room

A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)

A client must be willing to accept palliative care, not curative care.

The healthcare provider must project that the client has 6 months or less to live.

A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client’s teaching plan?

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).

A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?

A mother with an infected episiotomy

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Digoxin.

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Supervise a newly hired graduate nurse during an admission assessment.

While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

Ask the client what he is thinking about at his time.

After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

Administer PRN nebulizer treatment.

Obtain 12 lead electrocardiogram.

Monitor continuous oxygen saturation.

The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?

Administer a prescribed analgesia for pain.

A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Use sunblock or protective clothing when outdoors.

Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply)

Notify the food services department of the allergy.

Enter the allergy information in the client’s record.

Add egg allergy to the client’s allergy arm band.

The rapid response team’s detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?

Perform bilateral chest auscultation.

After administering an antipyretic medication. Which intervention should the nurse implement?

Encouraging liberal fluid intake

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?

Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?

Determine client’s pulse, blood pressure, and respirations

The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)

Take postoperative vital signs for a client who has an epidual following knee arthroplasty

Collect a sputum specimen for a client with a fever of unknown origin

Ambulate a client who had a femoral-popliteal bypass graft yesterday

A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?

Raise the head of the bed to a Fowler’s position and support his arms with a pillow

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?

Administer the analgesic as requested

Rationale: Chronic pain may be difficult to describe but should be treated with analgesics as indicated.

A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?

Crutches with 2 point gait.

Crutches with 3 point gait.

Crutches with 4 point gait.

A quad cane

The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)

Answer: 12160

Rationale: 4ml x 67kg x 40 (bsa) =12,160 ml

A client with leukemia undergoes a bone marrow biopsy. The client’s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Observe aspiration site.

Assess body temperature

Monitor skin elasticity

Measure urinary output

An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?

Reinforce the importance of annual papanicolaou (Pap) smears.

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Establish a structured routine for the client to follow.

A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Ventricular arrhythmias.

Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels.

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Instruct the mother to change the child’s diaper more often.

A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?

Encourage the client to eat finger foods.

A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?

Bowel patterns

Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.

While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?

Contact the medical records department supervisor.

A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer 83

Rationale: 1000 ml-----12hr.

Xml ---------1hr.

1000/12 = 83.33 = 83.

While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?

Submit a referral for an evaluation by a physical therapist.

A client has an intravenous fluid infusing in the right forearm. To determine the client’s distal pulse rate most accurately, which action should the nurse implement?

Palpate at the radial pulse site with the pads of two or three fingers.

A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

Reposition the client with the head of the bed elevated.

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?

Ask the older brother how he felt during the incident.

After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?

Hold oral intake until swallow evaluation is done.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)

Interacts with a flat affect.

Avoids eye contact.

Has a disheveled appearance.

A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?

Transfer the client to the surgical floor.

In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Place personal religious artifacts on the body.

Attach identifying name tags to the body.

Follow cultural beliefs in preparing the body.

An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Be alert for possible cross-sensitivity to cephalosporin agents.

A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?

The client’s need for pain medication should be determined.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)

Monitor abdominal girth.

Increase oral fluid intake to 1500 ml daily.

Report serum albumin and globulin levels.

Provide diet low in phosphorous.

Note signs of swelling and edema.

Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Report weight gain of 2 pounds (0.9kg) in 24 hours

Which problem, noted in the client’s history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?

Aural migraine headaches.

When implementing a disaster intervention plan, which intervention should the nurse implement first?

Initiate the discharge of stable clients from hospital units

Identify a command center where activities are coordinated

Assess community safety needs impacted by the disaster

Instruct all essential off-duty personnel to report to the facility

The nurse is evaluating a client’s symptoms, and formulates the nursing diagnosis, “high risk for injury due to possible urinary tract infection.” Which symptoms indicate the need for this diagnosis?

Fever and dysuria.

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?

Maintain both lower extremities elevated on pillows.

A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client’s plan of care?

Teach family proper range of motion exercises.

The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?

Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

When evaluating a client’s rectal bleeding, which findings should the nurse document?

Color characteristics of each stool.

The nurse is auscultating a client’s lung sounds. Which description should the nurse use to document this sound?

High pitched or fine crackles.

Rhonchi

High pitched wheeze

Stridor

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotics.

The nurse is managing the care of a client with Cushing’s syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Weigh the client and report any weight gain.

Report any client complaint of pain or discomfort.

Note and report the client’s food and liquid intake during meals and snacks.

Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client’s plan of care?

Medicate as needed for pain and anxiety.

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?

Decrease prevalence of glaucoma in the population.

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

Convey to the client that birth is imminent.

To evaluate the effectiveness of male client’s new prescription for ezetimibe, which action should the clinic nurse implement?

Remind the client to keep his appointments to have his cholesterol level checked.

Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?

Fall prevention measures.

A young adult client is admitted to the emergency room following a motor vehicle collision. The client’s head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as ” Risk of injury” What term best expresses the “related to” portion of nursing diagnosis?

Infection

Increase intracranial pressure

Shock

Head Injury.

An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

Identify pills in the bag.

A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?

New onset of purple skin lesions.

In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Ensure that no dependent loops are present in the tubing.

The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat?

Yogurt and/or buttermilk.

Avocados and cheese

Green leafy vegetables

Fresh fruits

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?

An adult female who has been depress for the past several month and denies suicidal ideations.

A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium.

A young male with schizophrenia who said voices is telling him to kill his psychiatric.

An elderly male who tell the staff and other client that he is superman and he can fly.

Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client’s acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk.

A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?

Maternal pulse rate of 162 beats per min

In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client’s appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?

Anxiety related to fear of suffocation.

A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client’s a plan of care?

Provide daily care of tong insertion sites using saline and antibiotic ointment

A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Determine the client’s vital sign.

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

No wheezing upon auscultation of the chest.

The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?

During acute illness

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?

Tell all their assigned clients to stay in their rooms.

The nurse is auscultating is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.)

Murmur

s1 s2

pericardial friction rub

s1 s2 s3

The healthcare provider changes a client’s medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?

Administer the medication via the oral route as prescribed

A client refuses to ambulate, reporting abdominal discomfort and bloating caused by “too much gas buildup” the client’s abdomen is distended. Which prescribed PRN medication should the nurse administer?

Simethicone (Mylicon)

The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse’s proposal?

Case management and screening for clients with HIV.

Regional relocation center for earthquake victims

Vitamin supplements for high-risk pregnant women.

Lead screening for children in low-income housing.

Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental.

When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement?

Arrange to transport the client to the hospital

Instruct the client to keep a food journal, including portions size.

Review the client’s use of over the counter (OTC) medications.

Reinforce the importance of keeping the feet elevated.

Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology.

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?

Multiple organ dysfunction syndrome (MODS)

Disseminated intravascular coagulation (DIC)

Chronic obstructive disease.

Acquired immunodeficiency syndrome (AIDS)

Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.

A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?

Provide the man and his mother with a copy of the Patient’s Bill of Rights

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?

Administer naloxone (Narcan) per PNR protocol

Initiate seizure precautions

Obtain a serum drug screen

Instruct the family about withdrawal symptoms.

Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client.

The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?

Jaundice

Nausea

Fever

Fatigue

A client with Alzheimer’s disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client’s mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?

Explain that it may take several weeks for the medication to be effective

Confirm the desired effect of the medication has been achieved.

Notify the health care provider than a change may be needed.

Evaluate when and how the medication is being administered to the client.

Rationale: Trazodone o Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep.

A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?

Reduced level of pain

Full volume of pedal pulses

Granulating tissue in foot ulcer

Improved visual acuity

A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization’s budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

How many departments can use this equipment?

Will the equipment require annual repair?

Is the cost of the equipment reasonable?

Can the equipment be updated each year?

While receiving a male postoperative client’s staples de nurse observe that the client’s eyes are closed and his face and hands are clenched. The client states, “I just hate having staples removed”. After acknowledgement the client’s anxiety, what action should the nurse implement?

Encourage the client to continue verbalize his anxiety

Attempt to distract the client with general conversation

Explain the procedure in detail while removing the staples

Reassure the client that this is a simple nursing procedure.

Rational: Distract is an effective strategy when a client experience anxiety during an uncomfortable procedure. (A & D) increase the client’s anxiety.

A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.)

Collect multiple site screening culture for MRSA

Call healthcare provider for a prescription for linezolid (Zyrovix)

Place the client on contact transmission precautions

Obtain sputum specimen for culture and sensitivity

Continue to monitor for client sign of infection.

Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated9D) based on the client’s history is a wound infection.

A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device?

Ensure the transparent dressing has no tears that might create vacuum leaks

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of “Ineffective airway clearance related to thick pulmonary secretions.” Which intervention is most important for the nurse to include in the client’s plan of care?

Increase fluid intake to 3,000 ml/daily

The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle

Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.

For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens.

Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours.

Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided specimen invalidate the test.

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Decreases the amount of HCL secretion by the parietal cells in the stomach

The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug’s effectiveness?

Hemoglobin A1C (HbA1C) reading less than 7%

The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication?

Antibiotics

Anticoagulants

Antihypertensive

Anticholinergics

A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant’s plan of care?

Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%

Administer diuretics via secondary infusion in the morning only

Evaluate heart rate for effectiveness of cardio tonic medications

Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples

Ensure Interrupted and frequent rest periods between procedures.

Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary.

The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.)

Start chest compressions with assisted manual ventilations

Administer epinephrine 0.01 mg/kg intraosseous (IO)

Apply pads and prepare for transthoracic pacing

Review the possible underlying causes for bradycardia

An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition?

Delirium

Depression

Dementia

Psychotic episode

Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply.

Prepare medication reversal agent

Check oxygen saturation level

Apply oxygen via nasal cannula

Initiate bag- valve mask ventilation.

Begin cardiopulmonary resuscitation

Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary.

The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement?

Give the child syringes or hospital mask to play it at home prior to hospitalization.

Include the child in pay therapy with children who are hospitalized for similar surgery.

Provide a family tour of the preoperative unit one week before the surgery is scheduled.

Provide doll an equipment to re-enact feeling associated with painful procedures.

Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking.

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm?

Assess IV site frequently for signs of extravasation

When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur?

Resume normal physical activity

Drink electrolyte fluid replacement

Give a dose of regular insulin per sliding scale

Measure urinary output over 24 hours.

Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and self-administer a dose of regular insulin per sliding scale.

The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?

Protect joint function

Improve circulation

Control tremors

Increase weight bearing

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?

9 %

18 %

36 %

45 %

Rational: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equals 36% TBSA, other options are incorrect.

A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect?

Decrease in serum T4 levels

Increase in blood pressure

Decrease in pulse rate

Goiter no longer palpable

An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?

Consistently applies TED hose before getting dressed in the morning.

Frequently elevated legs thorough the day.

Inspect the leg frequently for any irritation or skin breakdown

Completely stop cigarette/ cigar smoking.

Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity.

A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem?

Establish trust with community leaders and respect cultural and family values

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine?

The client’s previous GCS score

When the client’s stroke symptoms started

If the client is oriented to time

The client’s blood pressure and respiration rate

Rationale: The normal GCS is 15, and it is most important for the nurse to determine if it abnormal score a sign of improvement or a deterioration in the client’s condition

The charge nurse in a critical care unit is reviewing clients’ conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?

Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

Based on principles of asepsis, the nurse should consider which circumstance to be sterile?

One inch- border around the edge of the sterile field set up in the operating room

A wrapped unopened, sterile 4x4 gauze placed on a damp table top.

An open sterile Foley catheter kit set up on a table at the nurse waist level

Sterile syringe is placed on sterile area as the nurse riches over the sterile field.

Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1-inch border (A). A sterile objects become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface.

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take?

Ask the UAP to take the blood pressure in the other arm

Tell the UAP to use a different sphygmomanometer.

Review the client’s serum calcium level

Administer PRN antianxiety medication.

Rationale: Trousseau’s sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.

A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse?

Provide an opportunity for him to clarify his values related to the decision

Encourage him to share memories about his life with his wife and family

Advise him to seek several opinions before making decision

Offer to contact the hospital chaplain or social worker to offer support.

Rationale: When a client is faced with a decisional conflict, the nurse should first provide opportunities for the client to clarify values important in the decision. The rest may also be beneficial once the client as clarified the values that are important to him in the decision-making process.

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client’s discharge teaching plan?

Weigh every morning

Eat a high protein diet

Perform range of motion exercises

Limit fluid intake to 1,500 ml daily

A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest?

Encourage screening for a peptic ulcer

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques

A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain?

Cardiac rhythm and heart rate.

Daily intake of foods rich in potassium.

Hourly urinary output

Thirst ad skin turgor.

The nurse note a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Encourage the client’s family to visit more often

Schedule a daily conference with the social worker

Encourage the client to participate in group activities

Engage the client in a non-threatening conversation.

Rationale: Consistent attempts to draw the client into conversations which focus on non-threatening subjects can be an effective means of eliciting a response, thereby decreasing isolation behaviors. There is not sufficient data to support the effectiveness of A as an intervention for this client. Although B may be indicated, nursing interventions can also be used to treat this client. C is too threatening to this client.

A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider?

Headache

Joint stiffness

Persistent fever

Increase hunger and thirst

Rationale: Enbrel decrease immune and inflammatory responses, increasing the client’s risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider.

The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes?

The fating blood sugar was 120 mg/dl this morning.

Urine ketones have been negative for the past 6 months

The hemoglobin A1C was 6.5g/100 ml last week

No diabetic ketoacidosis has occurred in 6 months.

Rationale: A hemoglobin A1C level reflects he average blood sugar the client had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client understand long-term diabetes control. Normal value in a diabetic patient is up to 6.5 g/100 ml.

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?

Ask the wife to stop and assess the client’s swallowing reflex

A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse implement next?

Administer antiemetic agents

Bivalve the cast for distal compromise

Provide high- calorie, high-protein diet

Begin parenteral antibiotic therapy

Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After bond and blood aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

Recommend weigh bearing physical activity

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?

Administer the analgesic as requested

A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?

Send stool sample to the lab for a guaiac test

Observe stool for a day-colored appearance.

Obtain specimen for culture and sensitivity analysis

Asses for fatty yellow streaks in the client’s stool.

Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac (occult blood test) test of the stool should be evaluated to detect bleeding in the intestinal tract.

The mother of a child with cerebral palsy (CP) ask the nurse if her child’s impaired movements will worsen as the child grows. Which response provides the best explanation?

Brain damage with CP is not progressive but does have a variable course

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

Respiratory apnea of 30 seconds

In early septic shock states, what is the primary cause of hypotension?

Peripheral vasoconstriction

Peripheral vasodilation

Cardiac failure

A vagal response

Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider’s attention?

Allopurinol (Zyloprim)

Aspirin, low dose

Furosemide (lasix)

Enalapril (vasote)

A male client’s laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client’s plan of care?

Cluster care to conserve energy

Initiate contact isolation

Encourage him to use an electric razor

Asses him for adventitious lung sounds

Rationale: This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving, should be encouraged to reduce the risk of bleeding.

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?

Abnormal responses for cranial nerves I and II

Persistent coughing while drinking

Unilateral facial drooping

Inappropriate or exaggerated mood swings

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client’s medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation:

Remove sequential compression devices.

Apply PRN oxygen per nasal cannula.

Administer a PRN dose of an antipyretic.

Reinforce the surgical wound dressing.

Rationale: Sequential compression devices should be removed prior to ambulation and there is no indication that this action is contraindicated. The client’s oxygen saturation levels have been within normal limits for the previous four hours, so supplemental oxygen is not warranted.

Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider?

Sudden dysphagia

Blurred visual field

Gradual weakness

Profuse diarrhea

A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take?

Ask a chemotherapy-certified nurse to administer the Zofran

Administer the Zofran after flushing the saline lock with saline

Hold the scheduled dose of Zofran until the client awakens

Awaken the client to assess the need for administration of the Zofran.

Rationale: Zofran is an antiemetic administered before and after chemotherapy to prevent vomiting. The nurse should administer the antiemetic using the accepter technique for IV administration via saline lock. Zofran is not a chemotherapy drug and does not need to be administered by a chemotherapy- certified nurse.

When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client?

High protein

Low fat

Low sodium

High carbohydrate.

Rationale: A client with cholecystitis is at risk of gall stones that can be move into the biliary tract and cause pain or obstruction. Reducing dietary fat decrease stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine.

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse?

Jaundice skin tone

Muffled heart sounds

Pitting peripheral edema

Bilateral scleral edema

Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium and is life- threatening. The other one are signs of end stage liver disease related to alcoholism but are not immediately life- threatening.

When entering a client’s room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next?

Prepare to administer atropine 0.4 mg IVP

Gather emergency tracheostomy equipment

Prepare to administer lidocaine at 100 mg IVP

Place cardiac monitor leads on the client’s chest.

Rationale: Before further interventions can be done, the client’s heart rhythm must be determined. This can be done by connecting the client to the monitor. A or C are not a first line drug given for any of the life threatening, pulses dysrhythmias

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?

Replace the IV site with a smaller gauge.

Redress the abdominal incision

Leave the lights on in the room at night.

Apply soft bilateral wrist restraints.

Rationale: The abdominal incision should be redressed using aseptic-techniques. The IV site should be assessed to ensure that it has not been dislodged and a dressing reapplied, if need it. Leaving the light on at night may interfere with the client’s sleep and increase confusion. Restraints are not indicated and should only be used as a last resort to keep client from self-harm.

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)?

Lethargy

Decorticate posturing

Fixed dilated pupil

Clear drainage from the ear.

Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increase ICP is the client’s level or responsiveness or consciousness. B and C are very late signs of ICP.

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?

Prepare the client to independently treat their disease process

Reduce healthcare costs related to diabetic complications

Enable clients to become active participating in controlling the disease process

Increase client’s knowledge of the diabetic disease process and treatment options.

Rationale: The primary goal of diabetic self- management education is to enable the client to become an active participant in the care and control of disease process, matching levels of self- management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professional rather than (A)

To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented?

Confirm that all the staff nurses are being assigned to equal number of clients.

Review the staff nurse job description to ensure that it is clear, accurate, and recurrent.

Assign each staff nurse a turn unit charge nurse on a regular, rotating basis.

Analyze the amount of overtime needed by the nursing staff to complete assignments.

Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one’s role. C is not related to ambiguity.

The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding?

Supplemental feedings with formula

Maternal diet high in protein

Maternal intake of increased oral fluid

Breastfeeding every 2 or 3 hours.

Rationale: Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the production of milk, the nurse should explain that supplemental bottle formula feeding minimizes the infant’s time at the breast and decreases milk supply. B promotes milk production and healing after delivery. C support milk production. C is recommended routine for breast feeding that promote adequate milk supply.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?

Range of Motion

Distal pulse intensity

Extremity sensation

Presence of exudate

Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity. Range of motions evaluates the possibility of long term contractures sensation. C evaluates neurological involvement, and exudate. D provides information about wound infection, but this assessment do not have the priority of determining perfusion to the extremity.

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse’s response should be based on which information about assistive devices?

They decrease the risk for joint trauma

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?

Crying

Straining on stool

Vomiting

Sitting upright.

Rationale: The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up and may indicated an increase in cerebrospinal fluid. Activities that reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause a normal transient increase in intracranial pressure.

A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching?

Engage in physical exercise immediately after eating to help decrease cholesterol levels.

Walk briskly in cold weather to increase cardiac output

Keep nitroglycerin in a light-colored plastic bottle and readily available.

Avoid all isometric exercises, but walk regularly.

Rationale: Isometric exercise can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking provides aerobic conditioning that improves ling, blood vessel, and muscle function. Client with angina should refrain from physical exercise for 2 hours after meals, but exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that may cause chest pain. Nitroglycerin should be readily available and stored in a dark-colored glass bottle not C, to ensure freshness of the medication.

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump?

Initiate the dosage lockout mechanism on the PCA pump

Instruct the client to use the medication before the pain becomes severe

Assess the abdomen for bowel sounds.

Assess the client ability to use a numeric pain scale

While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first?

Raise the client’s legs and feet

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn’s survival?

Heat loss

Hypoglycemia

Fluid balance

Bleeding tendencies

The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?

Tell the staff to keep all clients and visitors in the client rooms with the doors closed

A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client’s history is a possible contraindication for the use of HRT?

Her mother and sister have a history of breast cancer

A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is “starving” because he has had no “real food” since before the surgery. Prior to advancing his diet, which intervention should the nurse implement?

Auscultate bowel sounds in all four quadrants

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

A family member of a client with dementia who has been missing for five hours

During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client’s multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom).

Assess the client’s skin and circulation for impairment related to the restrains

Evaluate the client’s mentation to determine need to continue the restrains

Assign unlicensed assistive personnel to remove restrains and remain with client

Contact the client’s surgeon and primary healthcare provider

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first?

Notify the healthcare provider and obtain a tracheostomy tray

After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first?

Epinephrine Injection, USP IV

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?

Evaluate both client’s pain using a standardized pain scale

A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?

Administer the medication as prescribed with a glass of water

Which client should the nurse assess frequently because of the risk for overflow incontinence? A client

Who is confused and frequently forgets to go to the bathroom

While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)

Move obstacle away from client

Monitor physical movements

Observe for a patent airway

Record the duration of the seizure

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client’s plan of care?

Determine client’s level current blood alcohol level.

Observe for changes in level of consciousness.

Involve the client’s family in healthcare decisions.

Provide grief counseling for client and his family.

Rationale: Based on the client’s history of drinking, he may be exhibiting sing of hepatic involvement and encephalopathy. Changes in the client’s level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority.

An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client’s ABG finding, which action is required?

Report the results to the healthcare provider.

Increase ventilator rate.

Administer a dose of sodium carbonate.

Decrease the flow rate of oxygen.

Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate.

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide?

Perform CPT after meals to increase appetite and improve food intake.

CPT should be performed more frequently, but at least an hour before meals.

Stop using CPT during the daytime until the child has regained an appetite.

Perform CPT only in the morning, but increase frequency when appetite improves.

Rationale: CPY with inhalation therapy should be performed several times a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals.

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?

Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care?

Fingerstick glucose assessment q6h with meals

Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose

Review with the client proper foot care and prevention of injury

Do not contaminate the insulin aspart so that it is available for iv use

Coordinate carbohydrate controlled meals at consistent times and intervals

Teach subcutaneous injection technique, site rotation and insulin management

Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse?

Diarrhea and flatulence

Abdominal cramps

Muscle pain

Altered taste

Rationale: statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized by myoglobinuria and manifested with muscle pain, so this symptom should immediately be reported to the HCP.

While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement?

Provide supplemental oxygen

Auscultate bilateral lung fields

Administer a nebulizer treatment

Reinforce occlusive CT dressing

Give PRN dose of pain medication

Rationale: the air bubbles indicate an air leak from the lungs, the chest tube site, or the chest tube collection system. Providing oxygen improves the oxygen saturation until the leak has been resolved. Auscultating the lung fields helps to identify absent or decrease lung sound due to collapsing lung.

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Ensure that the knot can be quickly released.

Tie the knot with a double turn or square knot.

Move the ties so the restraints are secured to the side rails.

Ensure that the restraints are snug against the client's wrist.

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution?

Place the dropper on the upper outer ear canal and instill the medication slowly.

Warm the medication in the microwave for 10 seconds before instilling.

Keep the medication refrigerated between administrations.

Have the child lie with the ear up for one to two minute after installation.

An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?

Limit the intake of high calorie foods.

Eat meals at the same time daily.

Maintain a low protein diet.

Restrict daily fluid intake.

Rationale: the client is exhibiting signs of cor pulmonale, a complication of COPD that causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day, eating a high-calorie diet at small frequent meals with foods that are high in protein and low in sodium can help relive the edema and decrease workload on the right-side of the heart.

The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?

Remove the catheter and insert into urethral opening

Observe for urine flow and then inflate the balloon.

Insert the catheter further and observe for discomfort.

Leave the catheter in place and obtain a sterile catheter.

Rationale: the catheter is in the vaginal opening.

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?

Prepare the skin for procedure.

Identify client's pulse points

Witness consent for procedure

Check telemetry monitoring

Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take?

Review the immunization records of all children in the elementary school

Report the measles outbreak to all community health organizations

Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated children.

Restrict unvaccinated children from attending school until measles outbreak is resolved.

A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement?

discontinue the magnesium sulfate immediately

Decrease the client's iv rate to 50 ml per hour

Continue with the plan of care for this client

Change the client's to NPO status

Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improvement perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

Express feelings of sadness and loneliness

Neglects personal hygiene and has no appetite

Lacks interest in the activity of the family and friends

Begin to show signs of improvement in affect

Rationale: when a depressed client begins to show signs of improvement, it can be because the client has "figured out" how to be successful in committing suicide. Depressed clients, particularly those who have shown signs of potentially becoming suicidal, should be watched with care for an impending suicide attempt might be greater when the client appear suddenly happy, begin to give away possessions, or becomes more relaxed and talkative.

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

Massage the uterus to decrease atony

Check for a destined bladder

Increase intravenous infusion

Review the hemoglobin to determined hemorrhage

Rationale: a fundus that is dextroverted (up to the right) and elevated above the umbilicus is indicative of bladder distension/urine retention.

A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement?

Evaluate postural blood pressure measurements

Obtain specimen for uranalysis

Encourage popsicles and fluids of choice

Assess bowel sounds in all quadrants

Rationale: specific gravity of urine is a measurement of hydration status (normal range of 1.010 to 1.025) which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated.

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement?

Obtain a urine specimen for culture and sensitivity

Palpate the client's suprapubic area for distention

Advise the client to maintain a voiding diary for one week

Instruct in effective technique to cleanse the glans penis

Rationale: the client is exhibiting classic signs of an enlarge prostate gland, which restricts urine flow and cause bothersome lower urinary tract symptoms (LUTS) and urinary retention, which is characterized by the client's voiding patterns and perception of incomplete bladder emptying.

The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include?

Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection

Administer into the deltoid muscle while the parent holds the infant securely

Divide the medication into two injection with volumes under 1ml

Use a quick dart-like motion to inject into the dorsogluteal site.

Rationale: IM injection for children under 3 of age should not exceed 1ml. divide the dose into smaller volumes for injection in two different sites.

A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful?

Research indicates that mirror therapy is effective in reducing phantom limb pain

You can try mirror therapy, but do not expect to complete elimination of the pain

Transcutaneous electrical nerve stimulators (TENS) have been found to be more effective

Where did you learn about the use of mirror therapy in treating in treating phantom limb pain?

Rationale: pain relief associated with mirror therapy may be due to the activation of neurons in the hemisphere of the brain that is contralateral to the amputated limb when visual input reduces the activity of systems that perceive protopathic pain.

An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Observe neck for jugular vein distention

Notify healthcare provider to prepare for pericardiocentesis

Asses for paradoxical blood pressure

Monitor oxygen saturation (Sp02) via continuous pulse oximetry

Rationale: Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully. The excess pressure from the fluid prevents the heart from working properly. As a result, the body does not get enough blood.

A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take?

Move to welcome and accommodate a new person

Ask the new person to move belonging to accommodate others

Tell the new person to move belongings because of limited space

Bring in additional chairs so that all staff members can be seated

The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication?

Poor feeding and vomiting

Leakage of CSF from the incisional site

Hyperactive bowel sound

Abdominal distention

WBC count of 10000/mm3

The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)

8

Calculate the client’s weigh in kg: 220 pounds divides by 2.2 pounds/kg ꞊100 kg Calculate the client’s dose, 80 units x 100 kg ꞊ 8,000 units Use the formula, D / H X Q ꞊ 8,000 units / 1,000 units x 1ml ꞊ 8

In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care?

Evaluate closet proximal pulse.

Asses skin elasticity of the stump.

Observe for swelling around the stump.

Note amount color of wound drainage.

Rationale: A primary focus of care for a client with an AKA is monitoring for signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment of pulse strength.

The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take?

Remove the heating pads and place a soft blanket over the client’s leg and feet.

Advise the UAP to observe the client’s skin while the heating pads are in place.

Elevate the client’s feet on a pillow and monitor the client’s pedal pulses frequently.

Instruct the UAP to reposition the heating pads to the sides of the legs and feet.

A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client?

Chew food slowly and thoroughly before attempting to swallow

Plan volume-controlled evenly-space meal thorough the day

Sip fluid slowly with each meal and between meals

Eliminate or reduce intake fatty and gas forming food

Rationale: It is most important for the client to learn how to eat without damaging the surgical site and to keep the digestive system from dumping the food instead of digesting it. Eating volume-control and evenly-space meals thorough the day allows the client to fill full, avoid binging, and eliminate the possibility of eating too much one time. Chewing slowly and thoroughly helps prevent over eating by allowing a filling of fullness to occur. Taking sips, rather than large amounts of fluids keeps the stomach from overfilling and allow for adequate calories to be consumed. Gas forming foods and fatty foods should be avoiding to decrease risk of dumping syndrome and flatulence.

If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding?

The intravenous fluid replacement contains a hypertonic solution of sodium chloride

Urinary and Gastrointestinal fluid loss reduce blood viscosity and stimulate thirst

Insensible loss of body fluids contributes to the hemoconcentration of serum solutes

Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat

Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.

During a Woman’s Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)

Encourage the woman at risk for cancer to obtain colonoscopy.

Present a class of breast-self examination

Prepare a woman for a bone density screening

Explain the follow-up need it for a client with prehypertension.

Rationale: A bone density screening is a fast, noninvasive screening test for osteoporosis that can be explained by the PN. There is no additional preparation needed (A) required a high level of communication skill to provide teaching and address the client’s fear. (B) Requires a higher level of client teaching skill than responding to one client. (D) Requires higher level of knowledge and expertise to provide needed teaching regarding this complex topic.

An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi’s sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take?

Ask family member to wear gloves when touching the patient

Send family to the waiting area while the client’s history is taking

Obtain a blood sample to determine is the client is HIV positive

Complete the head to toes assessment to identify other sign of HIV

Rationale: To protect the client privacy, the family member should be asked to wait outside while the client’s history is take. Gloves should be worn when touching the client’s body fluids if the client is HIV positive and these lesion are actually Kaposi sarcoma lesion. HIV testing cannot legally be done without the client explicit permission. A further assessment can be implemented after the family left the room.

An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week “I’m trying to start a new business and “I’m too busy to eat”. The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority?

Hygiene-self-care deficit

Imbalance nutrition

Disturbed sleep pattern

Self-neglect

Rationale: The client’s nutritional status has the highest priority at this time, and finger foods are often provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition. Other options are nursing problems that should also be addresses with the client’s plan of care, but at this stage in the client’s treatment, adequate nutrition is a priority

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?

Limit intake fatty foods for one month after surgery.

Notify the healthcare provider if edema occurs.

Increase activity and exercise gradually, as tolerated.

Avoid crowds for first two months after surgery.

Rationale: Cyclosporine immunosuppression therapy is vital in the success of liver transplantation and can increase the risk for infection, which is critical in the first two months after surgery. Fever is often.

The nurse is assessing a client’s nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia?

A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement?

Arrange transport for admission to the hospital.

Insert saline lock for IV diuretic therapy.

Assess compliance with routine prescriptions.

Instruct the client to monitor daily caloric intake.

Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction range is 50 to 75%)

The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is

Two days postoperative bladder surgery with continuous bladder irrigation infusing.

One day postoperative laparoscopic cholecystectomy requesting pain medication.

Three days postoperative colon resection receiving transfusion of packed RBCs.

Preoperative, in buck’s traction, and scheduled for hip arthroplasty within the next 12 hours.

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching?

Do not read without direct lighting for 6 weeks.

Avoid straining at stool, bending, or lifting heavy objects.

Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment.

Limit exposure to sunlight during the first 2 weeks when the cornea is healing.

Rationale: after cataract surgery, the client should avoid activities which increase pressure and place strain on the suture line.

The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, “10 mEq/5ml.” how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.)

12.5

Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml

At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take?

Encourage the client to turn on her left side.

Place a pillow under the client’s head and knees.

Explain to the client that her position is not safe.

Place a wedge under the client’s right hip.

Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client. Placing a wedge under the right hip will relieve pressure on the vena cava. Other options will either not relieve pressure on the vena cava or would not allow the client the remaining her position of choice.

A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client’s blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client’s average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement?

Irrigate the indwelling urinary catheter.

Prepare the client for external pacing.

Obtain capillary blood glucose measurement.

Titrate the dopamine infusion to raise the BP.

Rationale: the client is experiencing cardiogenic shock and requires titration per protocol of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low hourly urine output is due to shock and does not indicate a need for catheter irrigation. Pacing is not indicated based on the client’s capillary blood glucose should be monitored, but is not directly indicated at this time.

The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam?

Determine the client’s level of emotional functioning’

Assess functional ability of the primary support system.

Evaluate the client’s mood, cognition and orientation.

Review the client’s pattern of adaptive coping skill

Rational: the mental status exam assesses the client for abnormalities in cognitive functioning; potential thought processes, mood and reasoning, the other options listed are all components of the client’s psychosocial assessment.

An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client’s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)

Administer a daily dose of lisinopril as scheduled.

Assess the client for postural hypotension.

Notify the healthcare provider immediately

Provide a PRN dose of acetaminophen for headache

Withhold the next scheduled daily dose of warfarin.

Rational: the client’ routinely scheduled medication, lisinopril, is an antihypertensive medication and should be administered as scheduled to maintain the client’s blood pressure. A PRN dose of acetaminophen should be given for the client’s headache. The other options are not indicated for this situation.

When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply)

Pasta, noodles, rice.

Egg, tofu, ground meat.

Mashed, potatoes, pudding, milk.

Brussel sprouts, blackberries, seeds.

Corn bran, whole wheat bread, whole grains.

Rational: a client’s postoperative diet is commonly progressed as tolerated. A soft diet includes foods that are mechanically soft in texture (pasta, egg, ground meat, potatoes, and pudding. High fiber foods that require thorough chewing and gas