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Exit HESI (Actual hesi hints), EXIT HESI 2
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Exit HESI (Actual hesi hints), EXIT HESI 2 what is considered a postpartum infection? (correct ANS) - a
fever on 2 consecutive days for the first 10 days postpartum not including the first day wound infections
mastitis endometritis UTIs respiratory tract infections what do you suspect in a child with an irregular
pulse? (correct ANS) - Kawasaki disease what do you screen for on a newborn baby? (correct ANS) hypothyroidism check T4 level (decreased) what is an expected side effect of Solu-Medrol? (correct ANS)
- bleeding, bruising what does Pilocarpine treat? (correct ANS) - glaucoma antidote is atropine sulfate
may get a dry mouth TPN (correct ANS) - central venous catheter check for cloudiness refrigerate- warm
before administration monitor electrolytes everyday monitor for hyperglycemia and infection change
tubing with each new bag nothing else goes through this line what drug would you give is extravasation
has occurred? (correct ANS) - phentolamine (Regitine)- it's a vasodilator and will increase blood flow to
the area to prevent necrosiswhat diet would be chosen for a pt with CKD? (correct ANS) - bread & cream
of wheat pt receiving a blood transfusion develops fluid volume excess and dyspnea, what do you do?
(correct ANS) - increase O2 what should you be monitoring in a client who has had a nephrectomy?
(correct ANS) - UOP it is more important than drainage what is important when caring for pt in skeletal
traction? (correct ANS) - pin care; sterile technique; remove crust; serous drainage is ok how do you deal
with a rude doctor that is avoided by the nurses? (correct ANS) - staff meeting what is confrontation?
(correct ANS) - calling attention to inconsistent behaviors what is reflecting? (correct ANS) paraphrasing or repeating what client said what client would most likely be experiencing delirium?
(correct ANS) - a client with constant pain or insomnia what is the priority for a depressed client who has
not slept? (correct ANS) - sleep a client who is bipolar is going home for the weekend to adjust for
discharge. what do you tell the family? (correct ANS) - continue normal daily activities if a client has a
pulse with absent breath sounds on the left side what do you do? (correct ANS) - prepare to reposition
ETT what do you monitor for in adrenal insufficiency (no steroids)? (correct ANS) - shock hyperkalemia
increase sodium in dietif a client suddenly withdraws from steroids what do you do? (correct ANS) check VS what do you teach a client taking prednisone? (correct ANS) - monitor for hyperglycemia take
in morning you are caring for a client with AIDS and you accidentally stick yourself with a sterile needle.
what do you do? (correct ANS) - go get a new needle- no need to report what do you teach a pt taking
an antipyretic for and increased temp? (correct ANS) - give with fluids because fever can cause
dehydration what is suspected if there is an increase in serosanguineous drainage? (correct ANS) dehiscence what would you expect in a client with an epidural hematoma? (correct ANS) - temporary
loss of consciousness, followed by a lucid period, and then gradually leading to coma for maximum
effectiveness, what should older clients use for dry skin? (correct ANS) - petroleum based ointment what
are signs of pain in an infant? (correct ANS) - grimacing tachycardia restlessness irritability difficulty
feeding/sleeping increased RR diaphoresis decreased O2 levels what is priority for a client with renal
lithiasis? (correct ANS) - address pain- these pts get pain meds immediately (don't teach important of
straining urine- that's RNs job) what do you do for a pt on Amph B?(correct ANS) - monitor UOP- it's
nephrotoxic what is the priority assessment in a client who has lost a tooth and has an eye injury?
(correct ANS) - check pupils where should the level of water be in the water seal chamber? (correct ANS)
- at 2cm where should the level of water be in the suction control chamber? (correct ANS) - at 20cm how
does a client present with DM2? (correct ANS) - usually come back to doctor for wounds that won't heal
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or vaginal infections don't have enough insulin insulin doesn't work a client in hypovolemic shock would
present with what? (correct ANS) - weak thready pulse how would you teach someone to use an
inhaler? (correct ANS) - shake well for 5 seconds (if MDI) exhale completely press canister once and
inhale deeply and slowly hold breath for 10 seconds wait 1 min between each puff if using MDI- rinse
mouth & gargle after each use nebulizers are better for peds and clients with severe asthma because it
allows you to breath normally what is the appropriate action for a burn client in the emergent phase
whose UOP and BP are dropping? (correct ANS) - immediately call the HCP what do you monitor for in a
client with HHS and DKA with insulin drip? (correct ANS) - hypokalemia U wave what is priority discharge
teaching for a client with HHS?(correct ANS) - monitor for signs of dehydration what activity would you
choose for a person who attempting suicide? (correct ANS) - punching bag choose most exerting answer
what would you teach a client on peritoneal dialysis about self care? (correct ANS) - warm fluid before
administration increase protein and fiber in diet report any fever, abdominal pain that persists after 1-2
weeks, bloody, cloudy, urine colored outflow, outflow that is great than inflow, leakage around catheter
site what do you suspect with coffee ground emesis? (correct ANS) - peptic ulcer stomach cancer what
medications do you give with coffee ground emesis? (correct ANS) - 'prazole (proton pump inhibitors)
'tidine (h2 antagonist) antacids mylanta carafate what is the G&D of a toddler? (correct ANS) - toilet
training magical thinkers, egocentrism dramatic, pretend and parallel play learn to behave through
restrictions gender identity let child touch and hold equipment walks without help, creeps up stairs,
kneels without support builds tower of cubes, holds two cubes in one hand, scribbles, uses cups, but
struggles with spoons uses 4-5 words, uses 10 or more words, uses 2-3 phrases points and ask for
objects understand simple commands talk all the time tolerates separation from parents temper
tantrums are normaldependency on security items (blanket) what is suspected in a pediatric client with
croup and how do you treat?(correct ANS) - retractions & barking cough riding with windows down at
night steamy hot showers cool temp therapy nebulized epinephrine, corticosteroids what do you assess
for a femoral artery sheath?(correct ANS) - bleeding and hemorrhage how do you care for a hemiparesis
client?(correct ANS) - ambulate encourage independence with ADL's increase mobility as tolerated what
do you teach a client with asthma about taking beta agonists?(correct ANS) - if administered with
theophylline cardiac dysrythmias can occur avoid if taking beta blockers, MAOIs or tricyclic
antidepressants observe for chest, jaw, arm pain or palpitations report increase in pulse of 20-30bpm
how do you communicate with a client who has had a CVA has developed receptive aphasia?(correct
ANS) - picture board- they can't understand spoken or written words left hemisphere what does tadalafil
(Cialis) treat?(correct ANS) - erectile dysfunction BPH pulmonary HTN what is the side effect of
ondansetron (Zofran)?(correct ANS) - hives, chest tightness, trouble breathing if family refuses to discuss
funeral arrangements what do you do?(correct ANS) - remain with family member without discussing
(don't show acceptance of family member's feelings) how do you treat a client with swollen tongue, dry
mouth and excessive thirst?(correct ANS) - IV hypotonic solution0.2% NaCl 0.45% NaCl D5W what do
you teach a client with thrombocytopenia?(correct ANS) - watch for bleeding gums, hematuria, black
stools use electric razor use soft toothbrush no IM injections how do you care for a client with
AKI?(correct ANS) - restrict protein intake monitor for hyperkalemia if there is a staff conflict what do
you do?(correct ANS) - attend client assignments first what is initially used for a co-worker who is
abusing narcotics?(correct ANS) - employee assistance program a client is having a precipitate delivery
and you are waiting for the doctor. how do you position the client?(correct ANS) - lateral sims a client
who has a family history of malignant hyperthermia is going in to surgery and receiving general
anesthesia. how do you prepare?(correct ANS) - cooling blanket fluids when are febrile seizures most
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common?(correct ANS) - 9 months - 5 years old triggered by ear infection or viral illness what is the
priority of a client with febrile seizure?(correct ANS) - bring fever down a client with pancreatic cancer
should monitor for what?(correct ANS) - hypoglycemia with high levels of insulin and c-peptide
dizziness, fatigue, uncontrolled shaking, weakness, hunger, history of fainting what do you assess for in a
client with a facial injury?(correct ANS) - violence abusewhat is suspected in a pediatric client with
diaphoresis?(correct ANS) - diabetes what interventions do you implement for a client in shock?(correct
ANS) - O2 is priority- place client on high flow oxygen (100% nonrebreather) monitor VS, skin color,
temp, cap refill, LOC, UOP, cardio) place flat with legs elevated prepare for intubation maintain patent
IV- isotonic fluids what is a PICC used for?(correct ANS) - chemo blood transfusion antibiotics IV fluids
liquid food frequent blood draws what do you teach a person about their PICC line?(correct ANS) - can
go home with- stays in 3 week to months flush once a week use waterproof cover when showering
clamp should always be closed when not in use report swelling, redness, pain, discolored fluid at site or
fever how do you provide hospice care?(correct ANS) - talk about what the client wants to talk about
listen with compassion focus on creating a peaceful environment touch and facial expression are
important use lotion, give back rub, offer cool towel nutrition is less important when body is shutting
down- offer liquids and soft foods teach family that this is a normal process how do you care for a
pediatric client who is impulsive?(correct ANS) - distract by redirecting to other activities consequences
for bad behavior reward for good behavior what do you assess for in a victim of partner abuse?(correct
ANS) - chronic pain when can a venipuncture be given to a pediatric client?(correct ANS) - 2 years
oldmedian cubital, cephalic veins dorsal hand veins basilic vein on pinkie side of arm only used when
there is not another more prominent arm vein foot and ankle veins used as last resort Grave's disease
treatment(correct ANS) - -Goal: inhibit production of thyroid hormones and block effect on the body Radioactive iodine therapy: destroys overactive thyroid cells over time -Propylthiouracil, methimazole Betablockers -Subtotal or full thyroidectomy (risk of damaging vocal cords and parathyroid glands)
Describe Lupus and pt education(correct ANS) - -*Autoimmune disorder -Could have a decreased WBC
count; increased risk for infection -Avoid crowds, avoid sick people, avoid sunlight (trigger) Assessment
points for pt with constipation(correct ANS) - -Assess current medications -Check measures that they're
currently taking (daily enemas, laxatives, etc) -Assessment: no bowel sounds, abd distention -Make a
doctors appointment -Assess current nutrition, diet, and exercise -Drink more water Osteomalacia and
implications for pt teaching(correct ANS) - -Focus on nutritional support -Sunlight is a good source of
vitamin D -Vitamin D is important to absorb calcium and phosphorous -Check vitamin D levels
Osteomyelitis(correct ANS) - -Bone infection -Treat with antibiotics -Poor healing, injury entered the
bone UTI(correct ANS) - -Pt doesn't always report sx! -Urine sample is foul smelling and cloudy -Send
sample to lab for urinalysis -Order a secondary test (culture and sensitivity) to choose the correct
txAssessment and nursing interventions for hip fx(correct ANS) - -Assess for pain -Hip fracture
sometimes shortens the leg/rotates it -Treat like its a hip fracture even if no testing done yet -Assess
circulation (pulse, cap refill, feeling, movement, wiggle toes, color) -Don't elevate the leg -No extra
motion until hip is stabilized -Assess skin and circulation if in traction Care and assessment for
adrenalectomy(correct ANS) - -Pt at risk for electrolyte abnormalities -Put on telemetry -Daily serum
electrolytes -Monitor VS -Watch for dysrhythmias Tracheostomy pt teaching(correct ANS) - -Maintain
airway: suctioning -Communicate with white boards -Cough and suction on the way out -No more than
10 seconds Steps of the chain of infection(correct ANS) - -Causative agent -Reservoir -Portal of exit: ex:
wound, dressing change -Mode of transmission: nurse could be mode if they wear a gown in the hallway
-Portal of entry -Susceptible host: decreased immune system, also have wounds (entry site) *Ways to
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block transmission: precautions, wash hands Aseptic handwashing(correct ANS) - -Wash clean to dirty Point arms down so dirty water runs from clean to dirty Chrones Diet(correct ANS) - -Low fat -Highcalorie: dried fruit increases calories and nutrients -High nutrient foods -Ex: eggs w/o yolk, lean meat,
fish, seafood, chicken Heart Failure Diet(correct ANS) - -No canned/processed food -No cheese or salami
-Limit sodium (fluid retention)-Vegetables and fruits Mormon Diet(correct ANS) - -No alcohol -No
caffeine -Give milk, juice, or water -If diabetic, no juice -Church = latter day saints Enema administration
and nursing considerations(correct ANS) - -Monitor pt for cramping and abd pain -Coach and support pt
through this pain -Need to get procedure done, take break, deep breaths, then continue Trapeze bar
and considerations(correct ANS) - -Need upper body strength/upper extremities -Get history from pt:
make sure they don't have any problems with dislocated shoulder -Allows more independence and
participation with repositioning Manual bladder irrigation and CBI(correct ANS) - -CBI: 3 way catheter Check for kinks if not flowing properly -Manually irrigate CBI if there's a clot -If a clot is blocking, the
pressure in the bladder could cause leakage around the catheter site AKI assessment(correct ANS) - Decreased kidney function because of secondary condition and output decreases -Oliguria: less than 400
cc in 24 hrs -Kidneys aren't producing urine -Possibly can't produce urine sample AKI
Interventions(correct ANS) - -Follow up and look at what drugs they're on -Monitor electrolytes Monitor weight and edema -Monitor VS: HTN/HypoTN, increased HR -Aggressive fluids: watch for fluid
overload, check lung sounds and vitals -Lasix or Mannitol IM Injections(correct ANS) - -If you stick
yourself, fill out appropriate paper work and get pts blood sample-If you think you're in the wrong
space, get a larger needle -If you aspirate and get blood return, take out and throw everything away
Safety concerns with Parkinson's(correct ANS) - -Early: falls, decreased mobility, risk for aspiration -Late:
wheelchair bound, ulcers, decreased muscle, decreased mobility Distracting Injury(correct ANS) - -Ex:
traumatic amputation, so focused on treating that you don't realize the pt isn't breathing -ABCs -C: know
the cause and how to control it 3 Middle ear bones(correct ANS) - Incus, Maleus (hammer), Stapes
Hearing(correct ANS) - -Maleus (hammer) is first small bone hit from the eardrum vibrations -Sound
waves go to tiny hair cells in cochlea and communicate with the brain to perceive sound
Stapedectomy(correct ANS) - -Performed for otosclerosis -Incision behind inner ear, stapes removed and
implant inserted -Allows sound and vibrations to pass from eardrum to inner ear fluids Stapedectomy pt
teaching(correct ANS) - -Improvement of hearing isn't immediate, can initially be worse -Hearing
improves in 3 weeks, maximum hearing takes 6 months -Dressing on the ear Polycystic Kidney Disease
treatments(correct ANS) - -Need pain relievers -NO NSAIDS (advil, naproxin sodium, motrin) -Can have
tylenol Neurogenic Diabetes Insipidus assessment(correct ANS) - -Very high urine output, very dilute Monitor sodium *Monitor osmolarity and osmolality: abnormal means its dilute urine -Mostly from
trauma to hypothalamus Emphysema treatment(correct ANS) - -Sit pt up in bed -Pursed lip breathing
doesn't make the pt work less-Need to rest...might need bipap Trouble shooting for pulse ox(correct
ANS) - -Warm up the extremity -Change site: nose, toes, earlobes Trouble shooting for BP
machine(correct ANS) - -Get a different machine! Herpes Zoster(correct ANS) - -Rash along the nerves of
the side of the body (usually one side) -Very painful Herpes Zoster treatment(correct ANS) - -Try to stop
the replication of the virus; can still have symptoms -Pain meds throughout: narcotics Wernicke's
syndrome(correct ANS) - -Common in alcoholics -Sx: confusion, memory loss, ataxia, nystagmus, ptosis,
abnormal gait Degenerative Joint Disease(correct ANS) - -Assess kidney function before giving pain meds
-Assess pain -Pain meds: NSAIDS (motrin, aspirin, naproxin sodium) are better for inflammation Nonpharmacological measures: ice, rest, warm compresses Assessing radial and pedal pulses(correct
ANS) - -If you can't find a pulse, use doppler ultrasound; keep looking! -Don't take pulse at same time as
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BP -Compare pulses bilaterally Influences on blood sugar levels(correct ANS) - -Illness/infection: check
glucose more frequently -Check sugar levels before/after meals and at night -Exercise can decrease
sugar: monitor before Palliative care patient care(correct ANS) - -Goal: improve quality of life, caring not
curing -Still treat symptoms like pain/whatever impacts QOL -Still take meds for managing
problemsHerniated disc(correct ANS) - -Thorough pain assessment -Assess quality of pain -Radiating
pain and numbness bc the bulge is pressing on nerves Teaching points for multiple sclerosis(correct ANS)
- -Need more rest periods -They will have periods of exacerbation -Be aware of triggers: infection,
trauma, immunization, childbirth, stress, change in climate Neuropathic pain(correct ANS) - -Numbing,
burning, shooting, stabbing, sharp pain -Caused by trauma, inflammation, infection (herpes zoster, HIV),
diabetes -Get a good pain assessment Treatment for anaphylaxis(correct ANS) - -Need meds! -1st:
epinepherine for emergent anaphylaxis; can be given IM, SubQ, IV -Benedryl -H2 blocker to stop
histamine release Decorticate posturing(correct ANS) - -Flexing towards core -3 on GCS -Indicates brain
injury Decerebrate posturing(correct ANS) - -Extension of extremities -2 on GCS (worse than decorticate)
-Indicates brain injury DNR(correct ANS) - -Do not resuscitate -Need a document stating they're DNR,
otherwise you're "failing to rescue" -Can't just take family's word for the pts code status Job
responsibilities only LPN can do(correct ANS) - -Take the more stable patients -Insert NG tubes, foleys,
IVs -Wound care Job responsibilities only UAP can do(correct ANS) - -Vitals -Can do home visits to help a
pt shower -No dressing changesHospital emergency response plan in case of an external disaster(correct
ANS) - - Central control center manages care to decrease chaos How the nurse provides continuity of
care(correct ANS) - -Verbal reports -Pt handoff: verbal and continuity of care form -Communication
ensures continuity of care Actions of a supervisor when an employer has poor behavior(correct ANS) - Talk to employer 1:1 -Document the incident (time, day, exactly what happened) Primary
interventions(correct ANS) - -Aimed to prevent -Immunizations, education (ex: posters around the
hospital) Secondary interventions(correct ANS) - -Reduce a problem that already exists -Screenings Ecoli
investigation(correct ANS) - -Infected from eating/drinking something contaminated with animal/human
fecal matter -Look at method of storage -Temperature of storage Normal lymph node
characteristics(correct ANS) - -Pea sized, nontender, movable Concerning lymph node
characteristics(correct ANS) - -Enlarged, tender, nonmovable BMI assessment(correct ANS) - -Age/sex
specific -Assess pts nutrition -Do they have money for food? -Assess activity level -Assess who is
providing the pt with food and assess their knowledge of food/educate that person on healthy choices
Viral meningitis(correct ANS) - -Supportive care, rest, fluids -Sx: fever, lethargy -Biggest risk factor: being
exposed to other viruses/having other infection -Vaccinations decrease the risk of getting thisCongenital
adrenal hyperplasia(correct ANS) - -A healthy baby starts to develop problems: start telemetry -Severe
form symptoms: abnormal heart rhythm, change in electrolytes, poor feeding, vomiting, dehydration Exams: check electrolytes -Treatment: goal is to return hormones to normal/near normal, cortisol,
steroids Risk for adrenal crisis(correct ANS) - -When pt with congenital adrenal hyperplasia becomes
symptomatic -Stopping steroid treatment abruptly Von Willebrand's disease signs/symptoms(correct
ANS) - -Sx: recurrent/prolonged nose bleeds, bleeding gums, increased menstrual flow, excessive
bleeding from cut, blood in stool/urine Lithium Carbonate(correct ANS) - -Mood stabilizer, antimanic,
antidepressive -For bipolar disorder: affects storage, relsease, and reuptake of neurotransmitters Adverse reactions/side effects: nausea, fatigue, hand tremors, weight gain, hypothyroid, renal
impairment -Toxicity: diarrhea, muscle weakness, unsteady gait, slurred speech -Nursing considerations:
maintain adequate serum levels (0.6-1.2), toxicity over 1.5, check renal, cardiac, thyroid levels, Na, do
not use with diuretics Displacement(correct ANS) - -Transference of feelings to another group/object -
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Ex: after being yelled at by supervisor, person comes home and kicks dog for barking
Identification(correct ANS) - -Attempt to be like someone else -Ex: teenager dresses like favorite singer
Intellectualization(correct ANS) - -Using reason to avoid emotional conflicts -Ex: wife of substance
abuser describes the dynamics of enabling behavior yet continues to call her husband's work and report
he was missing bc of illness Introjection(correct ANS) - -Incorporation of values or qualities of an
admired person/group into one's own ego -Ex: young man deal with business in same fashion father did
Isolation(correct ANS) - -Separation-Ex: ER nurse is able to care for pts by isolating feelings and emotions
r/t pts injuries Passive-aggression(correct ANS) - -Indirectly expressing aggression toward others -Ex:
employee arrives late and disrupts others after being reminded of the meeting earlier that day and
promising to be on time Projection(correct ANS) - -Attributing one's own thoughts or impulses to
another person -Ex: sexual feelings toward her teacher tells her friends the teacher is coming onto her
Rationalization(correct ANS) - -Offering an acceptable, logical explanation for unacceptable
feelings/behavior -Ex: Student did bad on test and says the course was poorly taught Reaction
formation(correct ANS) - -Conscious attitudes and behaviors that are the opposite of what if really felt Ex: a person who dislikes animals volunteers for Humane Society Sublimation(correct ANS) - Substitution of an acceptable feeling by a more socially acceptable one -Ex: a student who feels to small
to play football becomes a marathon swimmer; pt takes unacceptable feelings and takes them out
during contact sports Undoing(correct ANS) - -Communication or behavior done to negate a previously
unacceptable act -Ex: young man who used to hunt animals is now on committee for protecting them;
mom yells at child then offers to get icecream Teaching for mom breast feeding(correct ANS) - -If
engorged, feed the baby or pump Education early in pregnancy(correct ANS) - -Assess their support
system -Are they homeless? This impacts care -Assess environment, living situation, age,
cultural/religious expectations -Are they happy about the pregnancy? Magnesium Sulfate(correct ANS) -Pharmacological treatment for preterm labor -Therapeutic level is 4-7.5-Watch for adverse effects: loss
of DTR, resp rate <12, UO <30 ml/hr -Anecdote = calcium gluconate Terbutaline(correct ANS) - -Causes
uterine muscle relaxation -Helps delay birth for hours/days -Increases mom/fetal HR -d/c if HR mom HR
is >130 -Notify HCP Biophysical profile(correct ANS) - -Assessment of the fetus -Failure of stress test
indicates you need the biophysical profile -Scores 0-10; 2 points for normal, 0 for abnormal -Low score =
increased rate of infant mortality; possible emergent c-section -High score = continued monitoring 5
variables of biophysical profile(correct ANS) - 1. Fetal breathing movements 2. Gross body movements 3.
Fetal tone 4. Reactive FHR 5. Qualitative amniotic fluid volume Interventions for low biophysical profile
score(correct ANS) - -<2: labor induction -4: labor induction if >32 weeks; repeat the test the same day if
<32 weeks then induce labor if <6 -6: Labor induction if >36 weeks, repeat testing in 24 hrs if <36 weeks
-8: labor induction if presence of oligohydramnios (lack of amniotic fluid surrounding fetus) Vaginal
laceration care plan considerations(correct ANS) - -No straining, stool softeners -Ice packs to minimize
edema -Sitz baths -Stitches Apgar scale(correct ANS) - -Performed at 1 min and 5 min -7-10 is good -4-6
needs moderate resuscitative efforts -0-3 is severe need for resuscitation -5 Components: heart rate,
resp effort, muscle tone, reflex irritability, colorApgar score for Heart Rate(correct ANS) - 0 = absent 1 =
<100 2 = >100 Apgar score for resp effort(correct ANS) - 0 = no cry 1 = weak cry 2 = vigorous cry Apgar
score for muscle tone(correct ANS) - 0 = flaccid 1 = some flexion 2 = total flexion Apgar score for reflex
irritability(correct ANS) - 0 = no response to foot tap 1 = slight response (grimace) 2 = quick foot removal
Apgar score for color(correct ANS) - 0 = dusky/cyanotic 1 = acrocyanotic 2 = pink Assessment of
postpartum pt(correct ANS) - -Massage the fundus -Soft or boggy = concern, massage -If fundus is off to
the side, empty bladder -Fundus should be midline -Assess blood: saturating a pad in an hour is too
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much Prednisone(correct ANS) - -Class: Adrenal corticosteroid -Inhibits accumulation of inflammatory
cells at inflammation site -Prevents/suppresses immune reactions -Frequent side effects: puffy round
face, insomnia, nervousness, mood swings, increased appetite, delayed wound healing, increased
susceptibility to infection -Adverse effects: muscle wasting, cushings syndrome, rebound inflammation,
abrupt withdrawal, could be fatal -Nursing implications: watch for mania, monitor BP, serum
electrolytes, glucose, bone mineral density test, ht/wt in children, increased risk for candida, be alert to
infection, avoid alcohol, minimize use of caffeine Diphenhydramine (Benedryl)(correct ANS) - -Class:
antihistamine -Indications/Action: decreases inflammatory reaction associated with allergy, decreases
urticaria-Adverse reactions/side effects: dry mouth, may have paradoxical effect in children (euphoria,
agitation), may cause drowsiness, confusion, dizziness, watch for CNS depression with overdose -Nursing
implications: avoid alcohol, safety considerations associated with drowsiness, dizziness Orlistat (Xenical,
Alli)(correct ANS) - -Class: obesity management agent, gastric/pancreatic lipase inhibitor) Indications/Action: inhibits absorption of dietary fats, may improve weight loss -Adverse reactions:
headache, flatulence, abd discomfort, fatty stool, fecal urgency -Nursing implications: for use with
reduced calorie diet, fat soluble vitamins should be taken at least two hours apart from med to allow for
absorption, administer during or up to 1 hr after meal containing fat Ezetimibe (Zetia)(correct ANS) - Class: antihyperlipidemic -Indications/Actions: reduces serum cholesterol, inhibits cholesterol
absorption in small intestine -Adverse reactions: may increase liver enzyme, hepatitis, arthralgia,
rhabdomyolysis -Nursing implications: don't use with pt with liver disease/damage, get baseline hepatic
function labs, monitor cholesterol, report muscle/bone pain Ramelteon (Rozeram)(correct ANS) - -Class:
hypnotic, melatonin receptor agonist -Indications/action: prevents insomnia, characterized with
difficulty falling asleep -Adverse reactions: may cause sleepwalking, sleepcooking, sleepeating
(somnambulism), may decrease testosterone, increase prolactin -Nursing implications: don't use with
alcohol, take 30 min before bed, provide restful and quiet environment Linezolid (Zyvox)(correct ANS) - Class: antibiotic -Indications/actions: treatment of nosocomial infections, VRI -Adverse reactions:
thrombocytopenia, myelodepression -Other superinfections: watch for severe watery diarrhea (may
result from altered bacterial balance in gut) -Nursing implications: monitor bowel consistency, GI effects,
monitor CBC, platelets, hgb, electrolytes, monitor for superinfections, avoid tyramine containing
foods/alcohol Sulcrafate (Carafate)(correct ANS) - -Class: antiulcer-Indications/action: protective agent
in stomach, forms adhesive barrio on mucosa in stomach/duodenum, treatment of ulcer, ulcer
prevention -Adverse reactions: constipation, can make bezoars -Nursing implications: take 1 hr before
meals and before bedtime Mesalamine (5-aminosalicylic acid)(correct ANS) - -Class: antiinflammatory,
salicylic acid derivative -Indications: blocks prostaglandins, diminishes inflammation in colon, used for tx
of ulcerative colities, sigmoiditis, and proctitis -Adverse reaction/side effects: abd cramping, flatulence,
alopecia (rare) -D/c if rash, fever, abd pain -Nursing implications: encourage fluids, monitor bowel
activity, assess for GI disturbances, may turn urine yellow/brown Penicillin G Potassium(correct ANS) - Class: antibiotic -Indications/action: treatment of infections, including sepsis, meningitis, endocarditis,
pneumonia -Adverse reactions/side effects: electrolyte imbalances, may increase liver enzymes, risk for
seizures (rare) -Nursing implications: monitor I&O, use caution in renal/hepatic impairment,
hypersensitivity to cephalosporins, seizure disorder Colorectal cancer - Surgical Care and care of
Colostomy(correct ANS) - Monitor vital signs, stoma, Q 4 hours Should be Beefy Red (normal) Dusky
appearance (necrotic) Small amount of bleeding is normal NG suctioning until bowel sounds are present
No lifting greater than 10 lbs or pulling for 6 weeks wash with mild soap, warm H20, pat dry do not wash
off markings KNOW! Low fat, high fiber cruciferous diet (Brussel Sprouts, cauliflower, broccoli, cabbage )
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Osteoporosis plan of care(correct ANS) - RISK IS LOW CALCIUM INTAKE Watch for stairs, waxed floor,
rugs, medicate for pain High Protein, High calcium, High iron diet Weight bearing and strengthening
exercises fall prevention: Non-skid socksencourage activity of D.L. Side rails in bathrooms Ectopic
Pregnancy(correct ANS) - HCG Elevation Transvaginal ultrasound unilateral or bilateral abd. pain medical
emergency Burn Neck Contractures(correct ANS) - Neck stabilized and aligned Airway management
Splinting, neck collars Pedicuosis (head lice)(correct ANS) - Direct contact No sharing personal items Nits
(whitish sacs) Keeping staff separate SCHOOL NURSE - send note home to parents Date Rape(correct
ANS) - Ask if consensual - had any conceptual sex recently DKA Labs(correct ANS) - ANION GAP
Metabolic Acidosis - PH < 7.15 Cystectomy / Urinary Diversion(correct ANS) - Bricker Ileal Conduit
Proximal end of ileal is closed Distal end out through Stoma in Abdominal wall Pouch for urine collection
worn continuously Stent may be in place for 3 weeks after surgery to promote Urine Flow KNOW - Clean
skin with mild soap, warm water, pat dry Don't wash off ink mark outlining radiation field.
Alcoholism(correct ANS) - Hypo magnesium Detox Unna Boot(correct ANS) - Treats Venous Stasis Ulcers
Layers of Gauze and Unna Paste Near Drowning(correct ANS) - Can cause PTSDVentilated / Intubated
Patient(correct ANS) - Check for necrosis / erosion from bleeding and trauma related to tube insertion or
balloon overinflated Medications delayed due to Procedure(correct ANS) - Give when PT comes back an
reschedule next dose accordingly Hearing Aid(correct ANS) - Make sure accurate fit If it's whistling, take
it out and re-insert Femur Fracture(correct ANS) - Monitor for Compartment syndrome and bleeding
Endo f life care?(correct ANS) - Dehydration Thyroid Tumor - removed(correct ANS) - Monitor for
Thyroid storm Airway Bleeding Head of bed 35-45 degrees No talking to family Talk to nurse only for
assessment OB Meds - Antepartum Meds(correct ANS) - Antacid can't be sodium based DO NOT give
sodium based drugs Don't give anything with sodium DKA infusion(correct ANS) - Stop insulin infusion is
blood sugar is < 50 and begin sliding insulin scale Insulin(correct ANS) - Upper arm, thighs, abdomen,
buttocks kids 4-6 mm needles Intradermal injection(correct ANS) - inner forearm 27-30 g needle 1/4=3/8
10-15 degrees 0.1-0.2 mg administered Eardrops(correct ANS) - Adults and kids > 3 straight back kids < 3
years old - down and backBP measurement in legs(correct ANS) - Mid thigh - listen over popliteal artery
behind knee in prone position Handwashing(correct ANS) - hands lower than elbows water flows from
elbows to fingertips pat dry fingers to forearm Braden Scale(correct ANS) - Pressure ulcers lower the
number, higher the risk 4-23 less than 17 = risk for pressure ulcers VFib(correct ANS) - No P waves No
QRS complex Chaotic Rhythm **Intubation, rapid D-Fib, Epinephrine, Lidocaine Cirrhosis(correct ANS) Turn PT and deep breath Q 2 hours Monitor for : Hypovolemia Stools/Emesis for blood Breaksin skin
LOOK for behavior changes - stupor, lethargy, hallucinations, level of consciousness. TEACH - Don't strain
for bowel movement, blow nose, sneeze soft toothbrush, electric razor egg grate/ air mattress apply
lotion Tetanus / Lockjaw(correct ANS) - Airway management / suctioning ABC's - seizure precaution quiet dark room, put into coma and maintain airway Parkinson's disease(correct ANS) - No Dopamine Pill
rolling Kidney Stones - Renal Calculi(correct ANS) - Flank pain radiating to lower abdomen and groin
Keep hydrated 200 ml/Hr and 2.5 L a day PO Manage pain Hemodialysis(correct ANS) - Low Sodium Diet
- TUREY IS OKRisk for Deficient fluid volume and excess fluid volume Fractured Skull(correct ANS) When in vault of skull bone is depressed - driven upward Must operate Spinal cord injury (SCI)(correct
ANS) - Airway then immobilization Myelosuppression(correct ANS) - Inhibition of bone marrow function
- immunosuppressed Lupus(correct ANS) - Can flare up immune system dysfunction susceptible to
viruses UV radiation Drugs Genetics Bucks Traction(correct ANS) - Adhesive tape to skin - perform lots of
skin care and monitor closely Circular bandaging Align long axis of gone arm or leg weights applied by
rope for free motion *** Fractured Hip*** Bowel Surgery(correct ANS) - Provide comfort prevent
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complications promote return of bowel function low continuous suction until bowel sounds return note
color and amount of drainage abdominal distention Muscular Dystrophy(correct ANS) - Facilitate
ambulation have family help with ROM exercise Urinary Catheters(correct ANS) - To remove clots by a
triple lumen 3 way catheter Irrigate and flush Burns(correct ANS) - Prevent contractures splint pt, neck
collars, 3/4 mattress (extension)Diabetes Mellitus(correct ANS) - type 1 usually under age 20 type 2
usually over 30 years old excessive thirst, urination, hunger, fatigue, blurred vision, infections,
numbness, tingling PAXIL(correct ANS) - Depression / panic disorder don't take with MAOI's, tricyclic
antidepressants, SNRI's, DEPAKOKE(correct ANS) - Anticonvulsant / headache suppressant/ migraines
Liver transplant(correct ANS) - Eat healthy foods to heal faster risk for skin cancer increases wait 2 years
to become pregnant immunosuppressed avoid crowds **Antirejection meds for life **Steroids - prevent
rejection, lower inflammation METHOTREXATE(correct ANS) - used for leukemia immunosuppressant
Side effect is renal failure CATOPRIL - CAPOTEN(correct ANS) - Antihypertensive Lowers BP NOT for OB
No NSAIDS Avoid salt substitutes and sodium Penicilli Allergy(correct ANS) - Adverse reaction Give EPI in
case of anaphylaxis pt. didn't have reaction the first time but had reaction the second time - CAN"T
HAVE DRUG IN FUTURE Mesalamine(correct ANS) - GI Ant-inflammatory ulcerative colitis **MONITOR
BOWELS PATTERN ** Should decrease diarrhea and lessen abd. pain abdominal pain and frequence
quality and consistency of stoolslook for bloody diarrhea, fever, headache, cramping, rash Central Line
Video(correct ANS) - D/C Syringe Resume Iv Monitor for infiltration What do you use for an implanted
port to administer fluid?(correct ANS) - Looks like a port at the end Pt that is weak and refuses
help(correct ANS) - 4 point crutch End Stage Liver Disease(correct ANS) - SELECT ALL Measure abdominal
Girth Serum Albumin and Globulin Note Swelling and Edema What is a sign of Autism in
toddlers?(correct ANS) - Hands Flapping Giving a pt with an SSRI, when you do provide to
provider?(correct ANS) - They are taking headache or migraine medicine. RISK FOR SERATONIN
SYNDROME** Pt. with otosclerosis gets a stapedectomy(correct ANS) - Hear muffled hearing at first get
to destat and assess a young person not breathing(correct ANS) - look at airway to see if they take
spontaneous breaths Older client discharge teaching you tell them what?(correct ANS) - Don't share
meds with family and friends (older people like to share medicine) When giving medicine to a patient
with issues from a CVA(correct ANS) - Assess for what side the weak side is and then give it on the strong
side Patient needs help with sleep, what statement do you report to provider?(correct ANS) Somnabulism What do you tell a mom who has a baby with a red area on buttocks?(correct ANS) Change diaper more oftenYou find an alert patient with osteoporosis on the floor, what do you
implement(correct ANS) - fall precautions Client that lost a son from a drunk drivers states "I should
have made him stay home that night" - what are they experiencing?(correct ANS) - Delayed Grief Patient
with cancer, pitting 4+ Edema(correct ANS) - Elevate on pillows - palliative care Right sign absent lung
sounds, trachea is deviated, nurse already called the code... what's next?(correct ANS) - Position pt. in a
comfortable position Pt. with pain recovering from abdominal surgery and respiration of 8/min on
morphine - what do you give?(correct ANS) - Naxolone (narcan) Patient has Muscular Dystrophy and
wants to be independent, what is best to do?(correct ANS) - Have family help perform ROM Hand
washing(correct ANS) - Hands and forearms lower than elbows Patient with HF and osteoarthritis , what
action to take?(correct ANS) - Refer to physical Therapy Pt. experiencing hallucination, what question to
ask for assessment?(correct ANS) - What are the voices saying? Pt. comes to ER after Cholysisectomy,
having pain and has ascites(correct ANS) - Auscultate all quadrants of the abdomen (possible bowel
obstruction from surgery) Patient complains of pain in the ART line...(correct ANS) - Remove it
immediately (it can mean swelling and decreased flow, remove to avoid necrosis) charge nurse gets a
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complaint that the maching is not working and is getting wrong temperatures. Best thing to do?(correct
ANS) - Take temps and compare two machines 18 year old being assessed.. what needs to be reported
to hCP right away?(correct ANS) - large, warm tender preauricular nodesOlder adult that becomes
confused - nurse advises him to what?(correct ANS) - Have an alert family member give him his
medications (NOT give him verbal and written instructions) Older lady with anemia husband calls in to
say his wife hasn't had a change in memory - she is still confused(correct ANS) - common when there is a
decrease in B-12 Client with Hunington's disease is going to cafeteria, what should nurse do?(correct
ANS) - Escort him there. Pt. experiencing fast speech, flight of ideas, only slept 3 hours in pas 48 hours what lab value needs to be assessed?(correct ANS) - Divalproex labs Pt. had surgery but has an Aldrete
post score of 8. what to do?(correct ANS) - Transfer the patient - 7-8 is normal - this is a scale that tells
when the patient is ready to leave the PACU. Patient has AFib - what question to report to
provider(correct ANS) - Dabigatran - it's an anticoag - NO NSAIDS Nurse needs UAP to change the
dressing of what pt. first?(correct ANS) - Pt. that's skin is damp every time the sheets are changed or
turned Pt. has AIDS - prior to administering medication combination, what needs to be made sure
of?(correct ANS) - Willingness to comply Pt. that has cushings that when the nurse goes to administer
Heparin, notices purple and red stria. What do do?(correct ANS) - Nothing. Document finding and give
med. This is normal. Plavix(correct ANS) - Antiplatelet drug Cephradine (Cephalosporin)(correct ANS) Antibiotics Respt infection , UTI Finish full course Controlled Hyperventilation(correct ANS) - Decrease
PO2, Cerebral vaso constriction, HOB raised to 30 degrees, head alignmentNurse planning care for child
who has scabies and keeps itching(correct ANS) - keep nails trimmed and have him wear mittens
Metabolic syndrome - wants to start exercising(correct ANS) - monitor BP as exercise increases pain
distal to insertion site(correct ANS) - remove DNR in another state doesn't honor it(correct ANS) - honor
clients wishes sample of sputum from water chamber for chest tube. where to you take sample
from?(correct ANS) - Rubberized port at bottom of catheter chamber Acute phase of burn - how to
change dressings?(correct ANS) - Change each dressing separately Morning meds, pt will take them
later...(correct ANS) - Make pt a deal on a time to return and give the meds Client with SARS(correct
ANS) - Gown, gloves and N95 mask client in DKA - receiving insulin sliding scale, blood sugarhas been
520 = what action?(correct ANS) - Get order for IV insulin Child with cystic fibrosis what treatments
?(correct ANS) - Give pancreatic enzymes with each snack at home Punishing child for wetting
pants(correct ANS) - provid toilet training pants and calm the mother Pt. comes in vomiting(correct ANS)
- Maintain NPO status Inverted nipples(correct ANS) - Use breast shield anxiety when driving over
bridge?(correct ANS) - Listen to music MONO kissing disease(correct ANS) - ellenBarre patient with
hearing aid is ringing(correct ANS) - have pt. reinsert themGuillen Bare Syndrom - cause?(correct ANS) Cold within last two weeks Nurse usually works on step down unit - moved to critical care - which
patient do you assign?(correct ANS) - Chronic COPD Terminally ill child and death is immnent - what do
you tell parents?(correct ANS) - discuss hospice Knee surgery can't transfer to bedside commode due to
pain(correct ANS) - Get assistive devices for weight bearing can't swallow, on palliative care, dehydrated,
doesn't want IV(correct ANS) - Keep him comfortable Bipolar client - not taking medications(correct
ANS) - AFFECT Date rape 2 days ago...what do you ask?(correct ANS) - Find out if she had any consensual
sex in the last couple of days Child with juvenile arthritis develops low grade fever and is already taking
aspirin - what does the nurse tell the mom to give the child?(correct ANS) - Stop aspirin and give NSAIDS
RN assess client one hour after administration of blood, what instruction does she tell the UAP to
do?(correct ANS) - continue monitoring vitals q 30 min Burns - don't want them to become
contracted(correct ANS) - turn head side to side 90 degrees 4 pts in ER 15 min apart, who do you see
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first?(correct ANS) - 2 year old with Stridor Lupus - information you would give?(correct ANS) Characterized by periods of flare-ups and remission client is admitted with acute pancreatitis and admits
drinking bourbon daily, what would your report immediately?(correct ANS) - Confusion and tremors Pt.
with Cirrhosis has new onset of dyspepsia (heartburn)(correct ANS) - Tell client to see HCPPt. receiving
Lovastatin - what do you monitor for?(correct ANS) - Hypokalemic Dissociate disorder -(correct ANS) constantly changes the subject Older male client comes in with confusion - what lab do you
perform?(correct ANS) - Urine culture Admitted to rehab following CVA has aphasia, LS paralysis,
difficulty swallowing - what is most important?(correct ANS) - Obtain consult with speech therapist Total
laryngectomy 2 days ago being transferred from ICU to unit, client is anxious, what intervention is most
important?(correct ANS) - respond to call light immediately When obtaining isolation supplies for client,
what information is most important for nurse to obtain?(correct ANS) - How is or will the infection be
transmitted? Child arriving by ambulance with flu like symptoms, R 16, BP 9060, HR 168 - (correct ANS) Start an IV Acuity of group of clients in ICU has matrix system, a nurse calls off, what should the charge
nurse do now?(correct ANS) - Client acuity Mix Saline lock to be d/c in client receiving antiplatelet meds
-(correct ANS) - apply pressure for 3-5 minutes after removing Pt. admitted with hypopituitarism and is
hypotensive, diaphoretic - what requires immediate action?(correct ANS) - Lethargy male client with
bipolar disorder reports he hasn't been taking meds(correct ANS) - intellect of speech VFib and
defibrillator nurse giving CPR which action should the nurse give UAP after getting crash cart?(correct
ANS) - take over CPR Nurse has home visit for client with symptoms that should be controlled with
medication prescribed - what nursing diagnosis?(correct ANS) - Ineffective health maintenancept. living
with son comes in with ulcer smelling of urine(correct ANS) - Contact adult services Pt. says she may be
pregnant and is on medicine for acne(correct ANS) - Stop the medication Female client cries that her
family hasnt' visited her in an long time(correct ANS) - determine when they last visited. where is pain
for renal calculi?(correct ANS) - intense pain radiating through groin Parkinsons disease lacks?(correct
ANS) - dopamine and aceticholine high school football team travels on a bus together - all contact MRSA
-(correct ANS) - Hand sanitizer Female client frequently tells the nurse that she is thinking of hurting
herself(correct ANS) - taking your own life? 11 year old client - how to get him to verbalize ways to deal
with things at home?(correct ANS) - Play a board game Multiple response: nurse teaching pt. about s/s
of preeclampsia(correct ANS) - edema, headache, blurred vision nures manager observes staff nurse
persuading a student nurse to do her job(correct ANS) - Written contract Drag and Drop: UAP leaves
floor without permission on several occasions -how to handle it?(correct ANS) - Document behavior
have a private conversation set up breaks make sure she is complying Pt. with breast cancer - started
chemo - what shows she understands ?(correct ANS) - picks out movies and books to pass the time at
home Prevention of osteoperosos - client who is post menopausal -(correct ANS) - increase calcium NOT QUIT SMOKING! - not the right answerMale client is admitted to ER with COPD - breathing is
getting worse - what intervention?(correct ANS) - intubate Pt. who is feeding herself - has inelastic skin
laceration -(correct ANS) - keep skin dry in folds male client born at 28 weeks gestation(correct ANS) give surfactant Ischemia / GI bleed(correct ANS) - hypovolemic pt. in constant pain is at risk for(correct
ANS) - Delirium Pancreatitis(correct ANS) - confusion and tremors Post-op patient with urinary drainage
/ clot(correct ANS) - make sure they are having output and no kinks in tubing Question about T waves
and PVC's(correct ANS) - repolarization Patient in ICU(correct ANS) - MODS left foot tingling and pulses
diminished(correct ANS) - compartment syndrome Multiple response about hypopituitarism(correct
ANS) - Hypotension bradycardia Multiple response: Rheumatoid arthritis(correct ANS) - Low grade fever
and cough swollen dn tender bruising over several areas Juvinile rheumatoid arthritis(correct ANS) - use
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warm blanket before getting them up Patient hit by a car(correct ANS) - Hypercapnea In assessing a
client twelve hours following 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 nurseimplement?(correct ANS) - 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?(correct ANS) - Yogurt and/or buttermilk. 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?(correct ANS) - 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?(correct ANS) - 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?(correct ANS) - 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?(correct ANS) - Determine the client's vital sign. 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?(correct ANS) - During acute
illness 191. The nurse 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.)(correct ANS) Murmur 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 reducebioavailability. What action should the nurse
implement?(correct ANS) - 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?(correct ANS) 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?(correct ANS) - Vitamin
supplements for high-risk pregnant women. 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?(correct ANS) - Review the client's use of
over the counter (OTC) medications. 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?(correct ANS) - Multiple organ
dysfunction syndrome (MODS) 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?(correct
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ANS) - Provide the man and his mother with a copy of the Patient's Bill of Rights 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?(correct ANS) - Jaundice A client with
Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant.
The caregiver tells the home health nurse thatthe client's mood and sleep patterns are improved, but
there is no change in cognitive ability. How should the nurse respond to this information?(correct ANS) Confirm the desired effect of the medication has been achieved. 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?(correct ANS) - Reduced level of pain 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?(correct ANS) - How many departments can use this equipment? 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?(correct ANS) - Attempt to distract the client with
general conversation 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?(correct ANS) - Ensure the
transparent dressing has no tears that might create vacuum leaks 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?(correct ANS) - 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?(correct ANS) - 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?(correct ANS) - Antibiotics212. 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.)(correct ANS) - 1. Start chest compressions with assisted manual
ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for
transthoracic pacing 4. 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?(correct ANS) - Delirium 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.(correct ANS) Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula 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?(correct ANS) Provide a family tour of the preoperative unit one week before the surgery is scheduled. 217. When
development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that
an increase thirst is an early sign of diabetes ketoacidosis (DKA), which action should the nurse instruct
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the client to implement if this sign of DKA occur?(correct ANS) - Give a dose of regular insulin per sliding
scale 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)?(correct ANS) - 36 %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?(correct ANS) - Completely stop cigarette/ cigar smoking. 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?(correct ANS) - The client's previous GCS score 224. 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?(correct ANS) - 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?(correct ANS)
- An open sterile Foley catheter kit set up on a table at the nurse waist level Heart Audio Sounds(correct
ANS) - S3 What to chart about Coumadin(correct ANS) - 2 mg. Oral route The patient with the baby that
has baby acne across the cheeks?(correct ANS) - Tell her it's normal, and will resolve on it's own. What's
the order of trache care?(correct ANS) - 1. Hperoxygenate, 2. Insert, 3. Suction, 4. Withdrawl The picture
with the finger stick, what should they have done differently?(correct ANS) - Wear Gloves The doctor
tells the nurse to cut a patient with diabetic toenails. How should the nurse respond?(correct ANS) - The
nurse should inform the doctor that this is not hospital policy.A wheelchair patient with left hemiplegia,
how would you place their wheelchair when they are in bed?(correct ANS) - Place the wheelchair at the
right side of the bed. When should you start screening kids for childhood obesity?(correct ANS) Kindergarten With patient's with hyperthyroidism, what type of diet should you expect them to be
ordered to have?(correct ANS) - Continue with a high calorie diet. When a patient experiences
symptoms of alcohol withdrawal, what medication can the PN expect to be ordered?(correct ANS) Ativan (Lorazepam) The patient with liver cirrhosis needs an assessment, what findings would you be
looking for in this assessment? Select all that apply.(correct ANS) - Assess the legs, feet, and look for
jaundice. (Assessing the legs shows any signs of edema) The baby just threw up their dose of Digoxin.
What should the PN do next?(correct ANS) - Nothing, monitor, document, and wait for the next
scheduled dose. The patient's husband has been told his wife is dying. What do you suggest he do
next?(correct ANS) - Suggest hospice care. The patient refused to bathe for 3 days, what should the PN
do to address this issue?(correct ANS) - Ask him why. The patient with cataracts just had surgery on his
right side. How would you assist him with movement to promote safety?(correct ANS) - Guide him on
the right side. What type of cancer does a TN01n show?(correct ANS) - Node Video for shoulder
extension -(correct ANS) - Arm abduction, elbow flexion, and arm supine. The PN reinforces information
with a client about portion control and diet management. Which portion description indicates that the
client understands the instructions?(correct ANS) - Four small cookies are about the size of four poker
chips.When reading a prescription, what should the PN verify in addition to the "five rights" of
medication administration?(correct ANS) - Prescriber's Signature Before performing a fecal occult blood
test or guiac test on a stool specimen, the PN should ask the client about the regular use of which
vitamin?(correct ANS) - Vitamin C While performing colostomy care, the PN observes skin irritation
around the stomal site. What action should the PN take when reapplying the colostomy bag?(correct
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ANS) - Ensure that the hydrocolloidal stomal wafer covers the peristomal skin. Which client finding
requires further action by the PN?(correct ANS) - The drainage tube of an indwelling catheter is looped
below the client's bladder. To administer a saline enema to a client, the PN inserts the enema tubing 3
inches into the client's rectum, and elevates the saline container 6 inches above the client's body. After
the PN opens the clamp, the saline solution does not infuse. What is the best action for the PN to
take?(correct ANS) - Raise the saline container 6 MORE inches above the body. What does TRUE labor
consist of?(correct ANS) - Pain in the lower back that radiates to abdomen Accompanied by regular,
rhythmic contractions Contractions that intensify with ambulation Progressive cervical dilation and
effacement What does FALSE labor consist of?(correct ANS) - Discomfort is localize in the abdomen No
lower back pain Contractions decrease in intensity and or frequency with ambulation No cervical
changes Catheterization steps(correct ANS) - prepare the patient get kit in between the legs What are
the most appropriate food choices for furosemide?(correct ANS) - Lima beans (anything with beans)
Yogurt BananaWhy give the patient with cirrhosis more protein?(correct ANS) - to repair tissue, but they
are unable to process it prevent hepatic encephalopathy How would you treat some disease question on
the exam?(correct ANS) - Antiinfective In which room would you place a patient with COPD?(correct
ANS) - Pait with someone not infective What do you give for a gout attack?(correct ANS) - Give
cinnamon apple sauce Which patient will you see first?(correct ANS) - Look at the critical patient with
blood pressure complications Which patient do you see first?(correct ANS) - Patient receiving blood
Nurse is instructing CNA on care of elderly client that is bedfast. How should the nurse instruct the
CNA?(correct ANS) - Encourage client to drink water when CNA repositions If a client has several burns
how do you minimize infection?(cor
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