FUNDAMENTALS Which assessment is most important for the nurse to make before advancing a client from liquid to solid food? • Bowel sounds • Chewing Ability • Current Appetite • Food Preferences Which assessment is most important for the nurse to make before advancing a client from liquid to solid food? • Bowel sounds • Chewing Ability • Current Appetite • Food Preferences A client experiences wound dehiscence when coughing. After assisting the client to a low fowler’s position with legs slightly elevated, what is the next best action? • • • Push the internal organs back into the abdominal opening. Cover the wound with a moist hydrocolloid dressing. Cover the wound with a sterile, saline, A client experiences wound dehiscence when coughing. After assisting the client to a low fowler’s position with legs slightly elevated, what is the next best action? • • • Push the internal organs back into the abdominal opening. Cover the wound with a moist hydrocolloid dressing. Cover the wound with a sterile, saline, A client is admitted to the cardiac intensive care unit following cardiac surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets that: • This is normal. • The tube may be occluded. • The lung has fully expanded. A client is admitted to the cardiac intensive care unit following cardiac surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets that: • This is normal. • The tube may be occluded. • The lung has fully expanded. The patient has a closed fracture of the right femur and tibia on xray with multiple contusions to the RLE. The nurse should: • Prepare for application of skeletal traction • Apply ice to the contusions • Prepare for open reduction • Assess the circulatory, motor, ad sensory status of the RLE The patient has a closed fracture of the right femur and tibia on xray with multiple contusions to the RLE. The nurse should: • Prepare for application of skeletal traction • Apply ice to the contusions • Prepare for open reduction • Assess the circulatory, motor, ad sensory status of the RLE The nurse is planning care for a patient with an internal radiation implant. Which intervention would be inappropriate to include in the plan of care? • • • Wear gloves when emptying patient’s bedpan Keep all linens in patient’s room until implant is removed Wear a lead apron when providing direct The nurse is planning care for a patient with an internal radiation implant. Which intervention would be inappropriate to include in the plan of care? • • • Wear gloves when emptying patient’s bedpan Keep all linens in patient’s room until implant is removed Wear a lead apron when providing direct What is the number one cause of injury that causes patients to be admitted to the hospital? • Falls • MVA • Medication errors • Brain Injury What is the number one cause of injury that causes patients to be admitted to the hospital? • Falls • MVA • Medication errors • Brain Injury Which of the following nursing interventions decreases a patient’s risk for falls? • Keeping the side rails up • Keeping socks on the patient • Keeping the call bell in reach • Keeping a chair away from the bed Which of the following nursing interventions decreases a patient’s risk for falls? • Keeping the side rails up • Keeping socks on the patient • Keeping the call bell in reach • Keeping a chair away from the bed The nurse is teaching a client with a history of falls about home safety. Which of the following statements indicates that the client understands the instructions? • • • “I will keep the ceiling light on in my room at all times.” “I will put a nonskid floor mat on the side of the bed that I exit.” “I will wear treaded slipper socks on my The nurse is teaching a client with a history of falls about home safety. Which of the following statements indicates that the client understands the instructions? • • • “I will keep the ceiling light on in my room at all times.” “I will put a nonskid floor mat on the side of the bed that I exit.” “I will wear treaded slipper socks on my What observation by the nurse indicates inappropriate restraint application by a CNA? • • • • CNA ties a safety knot in the restraint straps CNA secures the restraint straps to the bed frame CNA crosses vest behind patient CNA checks for 2 finger space between vest and skin What observation by the nurse indicates inappropriate restraint application by a CNA? • • • • CNA ties a safety knot in the restraint straps CNA secures the restraint straps to the bed frame CNA crosses vest behind patient CNA checks for 2 finger space between vest and skin The nurse prepares a client who is being discharged from the hospital to receive oxygen therapy at home. Which should the nurse include in client teaching about oxygen safety? • • Hold the oxygen tank on your lap when traveling. Light candles a few feet away from the oxygen tank. The nurse prepares a client who is being discharged from the hospital to receive oxygen therapy at home. Which should the nurse include in client teaching about oxygen safety? • • Hold the oxygen tank on your lap when traveling. Light candles a few feet away from the oxygen tank. A hospitalized client becomes disoriented frequently. Which should the nurse implement to ensure client safety at all times? • Request the family hire a sitter. • Check in with the client frequently. • Position the call bell within easy reach. • Keep all side rails in the raised position at all times. A hospitalized client becomes disoriented frequently. Which should the nurse implement to ensure client safety at all times? • Request the family hire a sitter. • Check in with the client frequently. • Position the call bell within easy reach. • Keep all side rails in the raised position at all times. A dangerous fire has occurred in the hospital and you must evacuate . Based on the following reports, which patient should be evacuated last? • • • Severe head injury, no DTR, receiving continuous IVs, and ventilated Right-sided paralysis, total bedrest s/p CVA, feeding tube, nonambulatory RLE long leg plaster cast, RUE external A dangerous fire has occurred in the hospital and you must evacuate . Based on the following reports, which patient should be evacuated last? • • • Severe head injury, no DTR, receiving continuous IVs, and ventilated Right-sided paralysis, total bedrest s/p CVA, feeding tube, nonambulatory RLE long leg plaster cast, RUE external A client is having a Cesarean section for failure to progress. The husband is present and is sitting next to his wife's head. As the surgical procedure is taking place, the surgeon asks the circulating nurse to get a specific type of suture that is not already on the sterile field. The circulating nurse hands the scrub nurse the size and type of suture the surgeon requested. The scrub nurse prepares the suture, and hands it off to the surgeon to use. A client is having a Cesarean section for failure to progress. The husband is present and is sitting next to his wife's head. As the surgical procedure is taking place, the surgeon asks the circulating nurse to get a specific type of suture that is not already on the sterile field. The circulating nurse hands the scrub nurse the size and type of suture the surgeon requested. The scrub nurse prepares the suture, and hands it off to the surgeon to use. The nurse teaches a client’s daughter to perform a dressing change using sterile technique. Which of the following actions by the daughter should indicate to the nurse that the daughter understands prevention of infection? • • The daughter washing her hands before applying gloves. The daughter placing herself between the sterile field and the client. The nurse teaches a client’s daughter to perform a dressing change using sterile technique. Which of the following actions by the daughter should indicate to the nurse that the daughter understands prevention of infection? • • The daughter washing her hands before applying gloves. The daughter placing herself between the sterile field and the client. The nurse must assess the temperature and blood pressure of a client on contact precautions every shift. Which is the appropriate nursing action to minimize the spread of microorganisms? • • • Keep the equipment in the client’s room. Store the equipment in the soiled utility room between uses. Cleanse the equipment after each use. The nurse must assess the temperature and blood pressure of a client on contact precautions every shift. Which is the appropriate nursing action to minimize the spread of microorganisms? • • • Keep the equipment in the client’s room. Store the equipment in the soiled utility room between uses. Cleanse the equipment after each use. Which measure used by the nurse would be most effective in preventing exposure when caring for a client with Hepatitis B? • • • Wearing a gown when changing an IV bag Applying a mask before entering the client’s room. Wearing gloves when taking the client’s pulse. Which measure used by the nurse would be most effective in preventing exposure when caring for a client with Hepatitis B? • • • Wearing a gown when changing an IV bag Applying a mask before entering the client’s room. Wearing gloves when taking the client’s pulse. Which of the following is required for a patient diagnosed with bacterial meningitis? • Contact isolation • Airborne precautions • Droplet precautions • Standard precautions Which of the following is required for a patient diagnosed with bacterial meningitis? • Contact isolation • Airborne precautions • Droplet precautions • Standard precautions The nurse prepares to provide colostomy care to a patient on contact precautions. Which of the following protective items is needed to perform this procedure? • Gloves and gown • Gloves, gown, goggles, and face shield • Gloves and goggles • Gloves The nurse prepares to provide colostomy care to a patient on contact precautions. Which of the following protective items is needed to perform this procedure? • Gloves and gown • Gloves, gown, goggles, and face shield • Gloves and goggles • Gloves A nurse is inserting an indwelling catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The appropriate nursing action is to: • • Aspirate the fluid, remove the catheter, and insert a new catheter. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon A nurse is inserting an indwelling catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The appropriate nursing action is to: • • Aspirate the fluid, remove the catheter, and insert a new catheter. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon Which of the following statements by a client would alert the nurse that further teaching on the idea of a restful sleep is indicated? • • • “ I have a small snack and take a bath before going to bed each day.” “I went to bed earlier than usual and I rested and watched television until I fell asleep.” “I go to bed and get up routinely at the Which of the following statements by a client would alert the nurse that further teaching on the idea of a restful sleep is indicated? • • • “ I have a small snack and take a bath before going to bed each day.” “I went to bed earlier than usual and I rested and watched television until I fell asleep.” “I go to bed and get up routinely at the The nurse knows discharge teaching in relation to warfarin sodium (Coumadin) therapy has been understood when the client states, “I will: • Take Tylenol for my occasional headaches.” • Spend most of the day working at my desk.” • Ask the doctor for antibiotics before going to the dentist.” The nurse knows discharge teaching in relation to warfarin sodium (Coumadin) therapy has been understood when the client states, “I will: • Take Tylenol for my occasional headaches.” • Spend most of the day working at my desk.” • Ask the doctor for antibiotics before going to the dentist.” The nurse is reviewing medications on the MD’s order sheet and notes a medication with a dose that is two times greater than the customary amount. The nurse should: • • Understand that there may be special circumstances in which additional medication is needed and give the medication as ordered. Ask the client if he or she has been receiving the dose of medication as ordered. The nurse is reviewing medications on the MD’s order sheet and notes a medication with a dose that is two times greater than the customary amount. The nurse should: • • Understand that there may be special circumstances in which additional medication is needed and give the medication as ordered. Ask the client if he or she has been receiving the dose of medication as ordered. The nurse arrives for work and is asked to count the narcotics with the nurse finishing her shift duty. The arriving nurse should be the nurse who does which of the following? • • Visually counts the actual sign-out sheets for the balance of narcotics administered by nurses after the nurses leave the unit. Visually counts the actual sign-out sheets for the balance of narcotics administered by The nurse arrives for work and is asked to count the narcotics with the nurse finishing her shift duty. The arriving nurse should be the nurse who does which of the following? • • Visually counts the actual sign-out sheets for the balance of narcotics administered by nurses after the nurses leave the unit. Visually counts the actual sign-out sheets for the balance of narcotics administered by A nurse is preparing to administer medication through a nasogastric tube that is connected to suction. The nurse would: • • • lamp the nasogastric tube for 30 minutes C following administration of the medication. Aspirate the nasogastric tube after medication administration to maintain patency. Position the client supine to assist in A nurse is preparing to administer medication through a nasogastric tube that is connected to suction. The nurse would: • • • Clamp the nasogastric tube for 30 minutes following administration of the medication. Aspirate the nasogastric tube after medication administration to maintain patency. Position the client supine to assist in Ear drops are prescribed for an infant with otitis media. The most appropriate method to administer the ear drops to the infant is to: • • Pull down and back on the pinna and direct the solution toward the wall of the canal.42.86% Pull up and back on the earlobe and direct the solution toward the wall of the canal.5.71% Ear drops are prescribed for an infant with otitis media. The most appropriate method to administer the ear drops to the infant is to: • • Pull down and back on the pinna and direct the solution toward the wall of the canal.42.86% Pull up and back on the earlobe and direct the solution toward the wall of the canal.5.71% Nurse #1 has prepared an IM injection for a preoperative client. Suddenly, another of her clients becomes entangled in IV tubing and yells for help. The surgery orderly is waiting for the preoperative client, so nurse #1 asks nurse #2 to give the injection to the preoperative client so nurse #1 can assist the patient. Which of the following is the best response by nurse #2? • Help the second client. Nurse #1 has prepared an IM injection for a preoperative client. Suddenly, another of her clients becomes entangled in IV tubing and yells for help. The surgery orderly is waiting for the preoperative client, so nurse #1 asks nurse #2 to give the injection to the preoperative client so nurse #1 can assist the patient. Which of the following is the best response by nurse #2? • Help the second client. MED SURG A client who has acromegaly and diabetes undergoes a hypophysectomy. The nurse identifies that further teaching is needed when the client states, “I know I will: • • • Be sterile for the rest of my life.” Require larger doses of insulin than I did preoperatively.” Have to take thyroxine or similar preparation for the rest of my life.” A client who has acromegaly and diabetes undergoes a hypophysectomy. The nurse identifies that further teaching is needed when the client states, “I know I will: • • • Be sterile for the rest of my life.” Require larger doses of insulin than I did preoperatively.” Have to take thyroxine or similar preparation for the rest of my life.” A client is scheduled for a bilateral adrenalectomy. Before surgery, steroids are administered to the client. The nurse understands the reason for this is to: • • • Foster accumulation of glycogen in the liver Increase the inflammatory action to promote scar formation Facilitate urinary excretion of salt and water following surgery A client is scheduled for a bilateral adrenalectomy. Before surgery, steroids are administered to the client. The nurse understands the reason for this is to: • • • Foster accumulation of glycogen in the liver Increase the inflammatory action to promote scar formation Facilitate urinary excretion of salt and water following surgery The nurse is caring for a client with Addison’s disease. Which information should the nurse include in a teaching plan as a means of encouraging this client to improve dietary intake? • • Increased amounts of potassium are needed to replace renal losses Increased protein is needed to heal the adrenal tissue and thus cure the disease The nurse is caring for a client with Addison’s disease. Which information should the nurse include in a teaching plan as a means of encouraging this client to improve dietary intake? • • Increased amounts of potassium are needed to replace renal losses Increased protein is needed to heal the adrenal tissue and thus cure the disease A client is admitted for a head injury. The nurse identifies that the client’s urinary retention catheter is draining large amounts of clear, colorless, urine. What does the nurse identify as the most likely cause? • Poor renal perfusion • Increased serum glucose • Inadequate ADH secretion A client is admitted for a head injury. The nurse identifies that the client’s urinary retention catheter is draining large amounts of clear, colorless, urine. What does the nurse identify as the most likely cause? • Poor renal perfusion • Increased serum glucose • Inadequate ADH secretion After a surgical clipping of a cerebral aneurysm, the client develops syndrome of inappropriate antidiuretic hormone. The nurse should assess the client for which manifestations of excess levels of ADH? Select all that apply • Polyuria • Weight gain • Hypotension After a surgical clipping of a cerebral aneurysm, the client develops syndrome of inappropriate antidiuretic hormone. The nurse should assess the client for which manifestations of excess levels of ADH? Select all that apply • Polyuria • Weight gain • Hypotension What is important for the nurse to tell the client before a routine glycoslated hemoglobin (Hgb A1c) test? • • • NPO after midnight except AM po medications Eat a full breakfast and wait 2-4 hours before arriving at the testing site Expect to be at the testing site for several hours due to multiple blood draws What is important for the nurse to tell the client before a routine glycoslated hemoglobin (Hgb A1c) test? • • • NPO after midnight except AM po medications Eat a full breakfast and wait 2-4 hours before arriving at the testing site Expect to be at the testing site for several hours due to multiple blood draws When caring for a client with thyroid crisis, the nurse would question an order for: • IV fluids • Propanolol (Inderal) • Propylthiouracil (PTU) • Warming blanket When caring for a client with thyroid crisis, the nurse would question an order for: • IV fluids • Propanolol (Inderal) • Propylthiouracil (PTU) • Warming blanket The nurse is caring for several clients who have diabetes. When assessing these clients, the nurse should understand that a difference between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar State (HHS) (formally HHNS) is that a response in clients with DKA is: • Fluid loss • Glycosuria The nurse is caring for several clients who have diabetes. When assessing these clients, the nurse should understand that a difference between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar State (HHS) (formally HHNS) is that a response in clients with DKA is: • Fluid loss • Glycosuria Cardiac monitoring is initiated for a patient in DKA to identify: • Effects of fluid overload on cardiac output • Hypovolemic shock r/t osmotic diuresis • • CV collapse r/t effects of hypergylcemia on the myocardium Potassium imbalances Cardiac monitoring is initiated for a patient in DKA to identify: • Effects of fluid overload on cardiac output • Hypovolemic shock r/t osmotic diuresis • • CV collapse r/t effects of hypergylcemia on the myocardium Potassium imbalances The patient is receiving TPN (total parenteral nutrition) and complains of nausea, excessive thirst, and urinary frequency. Which of the following actions should the nurse complete initially? • Check the serum BUN and creatinine level • Take the patient’s temperature • Obtain a finger stick glucose The patient is receiving TPN (total parenteral nutrition) and complains of nausea, excessive thirst, and urinary frequency. Which of the following actions should the nurse complete initially? • Check the serum BUN and creatinine level • Take the patient’s temperature • Obtain a finger stick glucose A client is receiving TPN through a central venous catheter. The client suddenly complains of chest pain and shortness of breath and becomes pale and anxious. Which of the following is the most appropriate action by the nurse? • • Check the blood sugar Slow the rate of the TPN and notify the physician A client is receiving TPN through a central venous catheter. The client suddenly complains of chest pain and shortness of breath and becomes pale and anxious. Which of the following is the most appropriate action by the nurse? • • Check the blood sugar Slow the rate of the TPN and notify the physician The preoperative patient tells the nurse that he researched the surgical procedure on the Internet and has no questions at this time. Which of the following should the nurse do? • • Document that the patient studied the procedure on the Internet Assess the patient’s understanding of the procedure to supplement any areas not reviewed through the Internet The preoperative patient tells the nurse that he researched the surgical procedure on the Internet and has no questions at this time. Which of the following should the nurse do? • • Document that the patient studied the procedure on the Internet Assess the patient’s understanding of the procedure to supplement any areas not reviewed through the Internet A postoperative patient is demonstrating a distended abdomen with no bowel sounds. Which of the following should the nurse do to help the patient? • Advance to full diet • Restrict all fluids • Ambulate three times a day • Administer antiemetic medication A postoperative patient is demonstrating a distended abdomen with no bowel sounds. Which of the following should the nurse do to help the patient? • Advance to full diet • Restrict all fluids • Ambulate three times a day • Administer antiemetic medication A patient receiving a unit of PRBC’s complains of chest and back pain within 5 minutes of the start of the transfusion. What should the nurse do? • Slow the transfusion • Stop the transfusion, call a rapid response • Administer Epinephrine • Provide antipyretics A patient receiving a unit of PRBC’s complains of chest and back pain within 5 minutes of the start of the transfusion. What should the nurse do? • Slow the transfusion • Stop the transfusion, call a rapid response • Administer Epinephrine • Provide antipyretics A patient is admitted with rib fractures after falling from a ladder while on the job. Which of the following is a priority for the care of this patient? • Safety precautions • Pain management • Employment counseling • Rehabilitation therapy A patient is admitted with rib fractures after falling from a ladder while on the job. Which of the following is a priority for the care of this patient? • Safety precautions • Pain management • Employment counseling • Rehabilitation therapy Morning assessment for a patient with fluid volume excess includes bounding peripheral pulses, weight gain of two pounds, +3 pitting ankle edema and crackles bilaterally bottom 1/3rd of lung fields. Which of the following physician orders is the priority? • Weigh patient daily • Maintain strict I&O • Restrict fluid intake to 1500mL per day Morning assessment for a patient with fluid volume excess includes bounding peripheral pulses, weight gain of two pounds, +3 pitting ankle edema and crackles bilaterally bottom 1/3rd of lung fields. Which of the following physician orders is the priority? • Weigh patient daily • Maintain strict I&O • Restrict fluid intake to 1500mL per day The nurse is caring for a patient with pneumonia who has an ABG of pH=7.20, CO2=75, HCO3=28, and PaO2 =44. Which of the following would be a priority for this patient? • Assist the patient to breathe into a paper bag • Prepare to administer sodium bicarbonate • Place the patient in high Fowler’s position The nurse is caring for a patient with pneumonia who has an ABG of pH=7.20, CO2=75, HCO3=28, and PaO2 =44. Which of the following would be a priority for this patient? • Assist the patient to breathe into a paper bag • Prepare to administer sodium bicarbonate • Place the patient in high Fowler’s position A client with active TB continues to have positive sputum cultures after 6 months of treatment because she says she cannot remember to take the medication all the time. The best action by the nurse is to: • • Schedule the client to come to the clinic every day Have a client who has recovered from TB tell the client about his successful treatment A client with active TB continues to have positive sputum cultures after 6 months of treatment because she says she cannot remember to take the medication all the time. The best action by the nurse is to: • • Schedule the client to come to the clinic every day Have a client who has recovered from TB tell the client about his successful treatment A client with pneumonia has a nursing diagnosis of ineffective airway clearance r/t thick secretions. An appropriate nursing intervention for the client is to: • • • Encourage a fluid intake of 3L/day Administer oxygen as prescribed to maintain SpO2 95% Place the client in a semi-Fowler’s position A client with pneumonia has a nursing diagnosis of ineffective airway clearance r/t thick secretions. An appropriate nursing intervention for the client is to: • • • Encourage a fluid intake of 3L/day Administer oxygen as prescribed to maintain SpO2 95% Place the client in a semi-Fowler’s position Two days after pelvic surgery a client develops marked dyspnea and anxiety. What action should the nurse take first? • Raise the head of the bed • Notify the healthcare provider • Take the client’s pulse and BP • Determine the client’s SpO2 Two days after pelvic surgery a client develops marked dyspnea and anxiety. What action should the nurse take first? • Raise the head of the bed • Notify the healthcare provider • Take the client’s pulse and BP • Determine the client’s SpO2 To decrease the client’s sense of panic during an asthma attack, the best action of the nurse is to: • • • Leave the client alone in a quiet, calm environment Stay with the client and encourage slow, purse-lip breathing Reassure the client that the attack can be controlled To decrease the client’s sense of panic during an asthma attack, the best action of the nurse is to: • • • Leave the client alone in a quiet, calm environment Stay with the client and encourage slow, purse-lip breathing Reassure the client that the attack can be controlled The husband of a client with COPD tells the nurse that they have not had sexual activity since the client was diagnosed with COPD because she becomes too short of breath. The best response by the nurse is: • • “You need to discuss your feelings with your wife so she knows what you expect of her.” “There are other ways to maintain intimacy besides sexual intercourse that will not make The husband of a client with COPD tells the nurse that they have not had sexual activity since the client was diagnosed with COPD because she becomes too short of breath. The best response by the nurse is: • • “You need to discuss your feelings with your wife so she knows what you expect of her.” “There are other ways to maintain intimacy besides sexual intercourse that will not make A client with mitral valve prolapse tells the nurse during a clinic visit that she is scheduled to get her teeth cleaned. Which response by the nurse is most appropriate? • • • The physician will need to evaluate your heart prior to your dental visit Be sure to remind your dentist that you have a heart condition It is important that you care for your teeth A client with mitral valve prolapse tells the nurse during a clinic visit that she is scheduled to get her teeth cleaned. Which response by the nurse is most appropriate? • • • The physician will need to evaluate your heart prior to your dental visit Be sure to remind your dentist that you have a heart condition It is important that you care for your teeth A client who has had her jaws wired is vomiting and appears cyanotic. What should be the nurse’s first action? • Insert an NG tube and connect to suction • Use the wire cutters to cut the wire • Suction the client’s airway • Administer an antiemetic intravenously A client who has had her jaws wired is vomiting and appears cyanotic. What should be the nurse’s first action? • Insert an NG tube and connect to suction • Use the wire cutters to cut the wire • Suction the client’s airway • Administer an antiemetic intravenously During assessment of a client’s mouth, the nurse notes the absence of saliva. The client also complains of pain around the ear. The client has been NPO for several days because of the insertion of a NG tube. The nurse suspects which of the following conditions? • Stomatitis • Oral candidiasis • Parotitis During assessment of a client’s mouth, the nurse notes the absence of saliva. The client also complains of pain around the ear. The client has been NPO for several days because of the insertion of a NG tube. The nurse suspects which of the following conditions? • Stomatitis • Oral candidiasis • Parotitis A client admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops sudden, sharp, midepigastric pain and a rigid abdomen. These clinical manifestations indicate which of the following? • An intestinal obstruction • Additional ulcers have developed • The esophagus has become inflamed A client admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops sudden, sharp, midepigastric pain and a rigid abdomen. These clinical manifestations indicate which of the following? • An intestinal obstruction • Additional ulcers have developed • The esophagus has become inflamed The nurse finds a client diagnosed with PUD surrounded by papers from his briefcase and arguing on the phone with one of his coworkers. The nurse’s response to observing these actions should be based on the knowledge that: • • Involving the client’s job will prevent boredom A relaxing environment will promote ulcer The nurse finds a client diagnosed with PUD surrounded by papers from his briefcase and arguing on the phone with one of his coworkers. The nurse’s response to observing these actions should be based on the knowledge that: • • Involving the client’s job will prevent boredom A relaxing environment will promote ulcer Fluid intake for clients suffering from dumping syndrome should be: • Between meals • Only with meals • Any time they want • Restricted to 1200ml/day Fluid intake for clients suffering from dumping syndrome should be: • Between meals • Only with meals • Any time they want • Restricted to 1200ml/day Which would the nurse expect to see with dumping syndrome? • Feeling of hunger • Constipation • Increased strength • Diaphoresis Which would the nurse expect to see with dumping syndrome? • Feeling of hunger • Constipation • Increased strength • Diaphoresis A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication? The client: • Complains of a sore throat • Displays signs of sedation • Experiences a sudden increase in temperature A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication? The client: • Complains of a sore throat • Displays signs of sedation • Experiences a sudden increase in temperature A client diagnosed with GERD complains of a chronic cough. The nurse understands that this symptoms may be indicative of which of the following conditions? • Development of laryngeal cancer • Aspiration of gastric contents • Esophageal scar tissue formation • Irritation of the esophagus A client diagnosed with GERD complains of a chronic cough. The nurse understands that this symptoms may be indicative of which of the following conditions? • Development of laryngeal cancer • Aspiration of gastric contents • Esophageal scar tissue formation • Irritation of the esophagus The nurse instructs the client on health maintenance activities to help control symptoms of a hiatal hernia. Which of the statements if made by the client indicates the client has understood the instructions? • “I’ll avoid laying down after meals” • “I wish I didn’t have to give up swimming” • “If I wear a girdle, I’ll have more support for my stomach” The nurse instructs the client on health maintenance activities to help control symptoms of a hiatal hernia. Which of the statements if made by the client indicates the client has understood the instructions? • “I’ll avoid laying down after meals” • “I wish I didn’t have to give up swimming” • “If I wear a girdle, I’ll have more support for my stomach” While changing the client’s colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting the following? • • • The client asks about the doctor’s next visit The client asks about the supplies used during the dressing change The client talks about an article she read in the newspaper While changing the client’s colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting the following? • • • The client asks about the doctor’s next visit The client asks about the supplies used during the dressing change The client talks about an article she read in the newspaper A client who has a history of Crohn’s disease is admitted to the hospital for fever, diarrhea, cramping, abdominal pain, and weight loss. Which of the following laboratory conditions would be anticipated for the client? • Hyperalbuminemia • Thrombocytopenia • Hypokalemia A client who has a history of Crohn’s disease is admitted to the hospital for fever, diarrhea, cramping, abdominal pain, and weight loss. Which of the following laboratory conditions would be anticipated for the client? • Hyperalbuminemia • Thrombocytopenia • Hypokalemia During a postoperative period following an open cholecystectomy, the client has a t-tube connected to gravity drainage. The nurse knows that the purpose of the t-tube is to: • • • Maintain patency of the common bile duct Reduce the occurrence of postoperative hemorrhage Prevent infection During a postoperative period following an open cholecystectomy, the client has a t-tube connected to gravity drainage. The nurse knows that the purpose of the t-tube is to: • • • Maintain patency of the common bile duct Reduce the occurrence of postoperative hemorrhage Prevent infection A client hospitalized for pancreatitis does not drink alcohol because of religious reasons. The client becomes upset when the nurse asks her questions about alcohol intake. The nurse should explain the reason for these questions is that • • There is a strong link between alcohol use and pancreatitis Alcohol intake can interfere with the tests A client hospitalized for pancreatitis does not drink alcohol because of religious reasons. The client becomes upset when the nurse asks her questions about alcohol intake. The nurse should explain the reason for these questions is that • • There is a strong link between alcohol use and pancreatitis Alcohol intake can interfere with the tests The nurse notes that a client with acute pancreatitis is occasionally experiencing muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? The client • • • May be developing hypocalcemia Is experiencing a reaction to prescribed opioids Has a nutritional imbalance The nurse notes that a client with acute pancreatitis is occasionally experiencing muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? The client • • • May be developing hypocalcemia Is experiencing a reaction to prescribed opioids Has a nutritional imbalance What would be the nurse’s best response to the client’s feelings of isolation as a result of having viral hepatitis? • • Don’t worry. It’s normal to feel that way Your friends are probably afraid of contracting the disease • I’m sure you’re imagining that • Tell me more about your feelings of What would be the nurse’s best response to the client’s feelings of isolation as a result of having viral hepatitis? • • Don’t worry. It’s normal to feel that way Your friends are probably afraid of contracting the disease • I’m sure you’re imagining that • Tell me more about your feelings of The client with cirrhosis has developed ascites. The nurse should recognize that the pathological basis for the development of ascites in clients with cirrhosis is portal hypertension and • An excess of serum sodium level • An increased metabolism of aldosterone • A decreased flow of hepatic lymph The client with cirrhosis has developed ascites. The nurse should recognize that the pathological basis for the development of ascites in clients with cirrhosis is portal hypertension and • An excess of serum sodium level • An increased metabolism of aldosterone • A decreased flow of hepatic lymph A male patient is admitted for a suspected myocardial infarction and is attached to a cardiac monitor and has an IV in place. His cardiac rhythm has been normal sinus. Suddenly the nurse notes that the cardiac monitor is very irregular chaotic-looking pattern. The client appears to be sleeping. The most appropriate action by the nurse is to... • Administer a precordial thump A male patient is admitted for a suspected myocardial infarction and is attached to a cardiac monitor and has an IV in place. His cardiac rhythm has been normal sinus. Suddenly the nurse notes that the cardiac monitor is very irregular chaotic-looking pattern. The client appears to be sleeping. The most appropriate action by the nurse is to... • Administer a precordial thump A client with acute renal failure develops severe hyperkalemia. The nurse anticipates which of the following medications will be used to treat this imbalance? • Furosemide (Lasix) • Amphojel (aluminum hydroxide) • 50% glucose and regular insulin • Epoetin (Procrit) A client with acute renal failure develops severe hyperkalemia. The nurse anticipates which of the following medications will be used to treat this imbalance? • Furosemide (Lasix) • Amphojel (aluminum hydroxide) • 50% glucose and regular insulin • Epoetin (Procrit) The nurse is admitting a client to the hospital who has a diagnosis of Guillain-Barre syndrome. During history-taking, the nurse asks the family member if the client has recently experienced which of the following? • Meningitis • Seizures or head trauma • A back injury or spinal cord trauma The nurse is admitting a client to the hospital who has a diagnosis of Guillain-Barre syndrome. During history-taking, the nurse asks the family member if the client has recently experienced which of the following? • Meningitis • Seizures or head trauma • A back injury or spinal cord trauma A patient comes to the clinic with a history of headaches. Which of the following manifestations leads the nurse to believe that the patient may be experiencing migraines? Select all that apply. • Photophobia • Nausea and vomiting • Headache throbbing A patient comes to the clinic with a history of headaches. Which of the following manifestations leads the nurse to believe that the patient may be experiencing migraines? Select all that apply. • Photophobia • Nausea and vomiting • Headache throbbing A client is scheduled for a labyrinthectomy to treat Meniere’s syndrome. The nurse concludes that the client understood preoperative instructions when the client identifies that the surgery results in: • Anosmia • Absence of pain • Decreased cerumen A client is scheduled for a labyrinthectomy to treat Meniere’s syndrome. The nurse concludes that the client understood preoperative instructions when the client identifies that the surgery results in: • Anosmia • Absence of pain • Decreased cerumen LEADERSHIP A client was admitted to the nursing unit with a closed head injury six hours ago. During the initial assessment the nurse finds that the client has vomited, is confused, and complains of dizziness and headache. Which of the following is the most important nursing action? • Notify the physician. • Administer an antiemetic. A client was admitted to the nursing unit with a closed head injury six hours ago. During the initial assessment the nurse finds that the client has vomited, is confused, and complains of dizziness and headache. Which of the following is the most important nursing action? • Notify the physician. • Administer an antiemetic. A primigravida is admitted to the labor unit. During the assessment of her client, her membranes rupture spontaneously. The priority nursing action is which of the following? • Monitor the contraction pattern. • Assess the fetal heart rate. • Note the color, amount, and odor of the amniotic fluid. A primigravida is admitted to the labor unit. During the assessment of her client, her membranes rupture spontaneously. The priority nursing action is which of the following? • Monitor the contraction pattern. • Assess the fetal heart rate. • Note the color, amount, and odor of the amniotic fluid. The RN listens to the report from the previous shift. Which patient should the nurse see first? • • • Room 7204, a six month old with dehydration, IV decreased to 42mL/hr last shift Room 7201, a six year old with diabetes, blood sugar ordered this morning Room 7202, a 2 month old with pertussis, O2 3L mask The RN listens to the report from the previous shift. Which patient should the nurse see first? • • • Room 7204, a six month old with dehydration, IV decreased to 42mL/hr last shift Room 7201, a six year old with diabetes, blood sugar ordered this morning Room 7202, a 2 month old with pertussis, O2 3L mask A teenager arrives by private car. He is alert and ambulatory, but his shirt and pants are covered with blood. He and hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? • “There was a lot of blood and we used three bandages.” A teenager arrives by private car. He is alert and ambulatory, but his shirt and pants are covered with blood. He and hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? • “There was a lot of blood and we used three bandages.” A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse reviews the plan of care and notes documentation of four nursing diagnoses. Which diagnosis would the nurse select as the priority? • Activity intolerance • Ineffective coping • Imbalanced nutrition: less than body A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse reviews the plan of care and notes documentation of four nursing diagnoses. Which diagnosis would the nurse select as the priority? • Activity intolerance • Ineffective coping • Imbalanced nutrition: less than body The nurse receives a hand-off communication report for the change of shift. Which client should the nurse see first? • • • A 50 year old woman who is scheduled for a breast biopsy this morning and is crying. An 85 year old man admitted during the night because of increasing confusion who remains disoriented this morning. A 65 year old woman who had a The nurse receives a hand-off communication report for the change of shift. Which client should the nurse see first? • • • A 50 year old woman who is scheduled for a breast biopsy this morning and is crying. An 85 year old man admitted during the night because of increasing confusion who remains disoriented this morning. A 65 year old woman who had a When caring for a client with mental illness, which initial nursing intervention is the most essential? • • • Administering prescribed anti-anxiety drugs. Decreasing the noise level and the harsh lighting. Removing phone cords and oxygen tubing from the room. When caring for a client with mental illness, which initial nursing intervention is the most essential? • • • Administering prescribed anti-anxiety drugs. Decreasing the noise level and the harsh lighting. Removing phone cords and oxygen tubing from the room. A client with arthritic pain is considering taking an herbal supplement to relieve arthritic pain. What teaching is most important for the nurse to carry out with this client? • • • Inform any health care providers about the use of this supplement. Practice imagery along with the herbal supplement. Take only herbal supplements that are A client with arthritic pain is considering taking an herbal supplement to relieve arthritic pain. What teaching is most important for the nurse to carry out with this client? • • • Inform any health care providers about the use of this supplement. Practice imagery along with the herbal supplement. Take only herbal supplements that are A nurse is called to a client’s room by another nurse. When the nurse arrives at the room, she discovers that a fire has occurred in the client’s wastebasket. The first nurse has removed the client from the room. What is the second nurse’s next action? • Confine the fire. • Evacuate the unit. • Extinguish the fire. A nurse is called to a client’s room by another nurse. When the nurse arrives at the room, she discovers that a fire has occurred in the client’s wastebasket. The first nurse has removed the client from the room. What is the second nurse’s next action? • Confine the fire. • Evacuate the unit. • Extinguish the fire. A nurse in the newborn nursery receives a telephone call and is informed that a newborn infant with APGAR scores of 1 and 4 will be brought to the nursery. The nurse quickly prepares for the arrival of the newborn and determines that the priority intervention is to: • • Connect the resuscitation bag to the oxygen. Turn on the apnea and cardio-respiratory A nurse in the newborn nursery receives a telephone call and is informed that a newborn infant with APGAR scores of 1 and 4 will be brought to the nursery. The nurse quickly prepares for the arrival of the newborn and determines that the priority intervention is to: • • Connect the resuscitation bag to the oxygen. Turn on the apnea and cardio-respiratory You are caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which post-operative finding requires immediate intervention? • Presence of glucose in the nasal drainage. • Presence of nasal packing in the nares. • Urine output of 40 to 50 mL/hr. • Patient complaints of thirst. You are caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which post-operative finding requires immediate intervention? • Presence of glucose in the nasal drainage. • Presence of nasal packing in the nares. • Urine output of 40 to 50 mL/hr. • Patient complaints of thirst. The nurse on the postpartum unit is preparing 4 clients for discharge. It would be most important for the nurse to refer which of the following clients for home care? • • • A 15 year old primipara who delivered a 7 lb. male 2 days ago. An 18 year old multipara who delivered a 9 lb. female by cesarean section 2 days ago. A 20 year old multipara who delivered 1 day The nurse on the postpartum unit is preparing 4 clients for discharge. It would be most important for the nurse to refer which of the following clients for home care? • • • A 15 year old primipara who delivered a 7 lb. male 2 days ago. An 18 year old multipara who delivered a 9 lb. female by cesarean section 2 days ago. A 20 year old multipara who delivered 1 day A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant? • • • Collecting a urine specimen from a client. Obtaining frequent oral temperatures on a client. Accompanying a man being discharged to transportation to home. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant? • • • Collecting a urine specimen from a client. Obtaining frequent oral temperatures on a client. Accompanying a man being discharged to transportation to home. Which of the following tasks is appropriate for the nurse to delegate to an experienced nursing assistant? • • • Obtain a 24 hour diet recall from a client recently admitted with anorexia nervosa. Obtain a clean catch urine specimen from a client suspected of having a urinary tract infection. Observe the amount and characteristics of Which of the following tasks is appropriate for the nurse to delegate to an experienced nursing assistant? • • • Obtain a 24 hour diet recall from a client recently admitted with anorexia nervosa. Obtain a clean catch urine specimen from a client suspected of having a urinary tract infection. Observe the amount and characteristics of Which of the following clients should the nurse on a pediatric unit assign to a LPN? • • • A 3 year old girl admitted yesterday with laryngotracheobronchitis who has a tracheosotomy. A 5 year old girl admitted after gastric lavage for Tylenol ingestion. A 6 year old boy admitted for a fracture of the femur, in balanced suspension traction. Which of the following clients should the nurse on a pediatric unit assign to a LPN? • • • A 3 year old girl admitted yesterday with laryngotracheobronchitis who has a tracheosotomy. A 5 year old girl admitted after gastric lavage for Tylenol ingestion. A 6 year old boy admitted for a fracture of the femur, in balanced suspension traction. The nurse is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first? • • A 35 year old admitted 3 hours ago with a gunshot wound; 1.5cm area of dark drainage noted on the dressing. A 43 year old who had a mastectomy 2 days ago; 23mL of serosanguinous fluid noted in The nurse is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first? • • A 35 year old admitted 3 hours ago with a gunshot wound; 1.5cm area of dark drainage noted on the dressing. A 43 year old who had a mastectomy 2 days ago; 23mL of serosanguinous fluid noted in The nurse is on duty on a busy cardiac telemetry unit. Which of the following situations requires the nurse’s immediate attention? • • The wife of a cardiac client states that his IV pump is alarming and he is not receiving the pain medication dose due to the pump malfunctioning. The daughter of an elderly client states that her mother is uncomfortable and that her The nurse is on duty on a busy cardiac telemetry unit. Which of the following situations requires the nurse’s immediate attention? • • The wife of a cardiac client states that his IV pump is alarming and he is not receiving the pain medication dose due to the pump malfunctioning. The daughter of an elderly client states that her mother is uncomfortable and that her A registered nurse (RN) is planning the assignments for the day and is leading a team composed of a licensed practical nurse (LPN) and an nursing assistant (NA). The RN assigns which client to the LPN? • A client with dementia. • A two day postoperative mastectomy client. • A client who requires some assistance with bathing. A registered nurse (RN) is planning the assignments for the day and is leading a team composed of a licensed practical nurse (LPN) and an nursing assistant (NA). The RN assigns which client to the LPN? • • • A client with dementia. A two day postoperative mastectomy client. A client who requires some assistance with A 69 year old female client admitted with pneumonia is receiving gentamicin (Garamycin). For this client, which of the following laboratory values would be most important for the nurse to monitor? • BUN and creatinine • Hemoglobin and hematocrit • Sodium and potassium A 69 year old female client admitted with pneumonia is receiving gentamicin (Garamycin). For this client, which of the following laboratory values would be most important for the nurse to monitor? • BUN and creatinine • Hemoglobin and hematocrit • Sodium and potassium The RN is preparing the assignment for the day shift. Which patient is appropriate for the RN to assign to the LPN? • • • Mrs. Johnson, age 66, pleural effusion, bilateral chest tubes to Pleurovac. Mrs. Smith, age 44, chronic renal failure, admitted for peritoneal dialysis this afternoon Miss Andrews, age 48, total right hip replacement, two days post-operative The RN is preparing the assignment for the day shift. Which patient is appropriate for the RN to assign to the LPN? • • • Mrs. Johnson, age 66, pleural effusion, bilateral chest tubes to Pleurovac. Mrs. Smith, age 44, chronic renal failure, admitted for peritoneal dialysis this afternoon Miss Andrews, age 48, total right hip replacement, two days post-operative You are the charge nurse on a medical surgical unit and are working with a newly graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? • • A 34 year old who was just admitted to the unit with periorbital cellulitis. A 40 year old who needs discharge instructions after having skin grafts to the You are the charge nurse on a medical surgical unit and are working with a newly graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? • • A 34 year old who was just admitted to the unit with periorbital cellulitis. A 40 year old who needs discharge instructions after having skin grafts to the A nursing team consists of an RN, LPN, and a CAN. The nurse should assign which of the following clients to the LPN? • • • A 72 year old client with diabetes who requires a dressing change for a stasis ulcer. A 42 year old client with cancer of the bone complaining of pain. A 55 year old client with terminal cancer being transferred to hospice home care. A nursing team consists of an RN, LPN, and a CAN. The nurse should assign which of the following clients to the LPN? • • • A 72 year old client with diabetes who requires a dressing change for a stasis ulcer. A 42 year old client with cancer of the bone complaining of pain. A 55 year old client with terminal cancer being transferred to hospice home care. You are the charge nurse in the intensive care unit (ICU) tonight. The Central Staffing office has informed you that a medical-surgical nurse will be floated to your unit to replace a nurse who called out due to illness. Which of the following patients would be the best assignment for the medical-surgical nurse? • A 23 year old woman admitted with a diagnosis of intravenous drug abuse who is complaining of abdominal cramps and severe You are the charge nurse in the intensive care unit (ICU) tonight. The Central Staffing office has informed you that a medical-surgical nurse will be floated to your unit to replace a nurse who called out due to illness. Which of the following patients would be the best assignment for the medical-surgical nurse? • A 23 year old woman admitted with a diagnosis of intravenous drug abuse who is complaining of abdominal cramps and severe As the charge nurse, you are making assignments for the next shift. Which client should be assigned to the fairly new nurse (2 months) pulled from the surgical unit to the medical unit? • • A 58 year old client on airborne precautions for tuberculosis (TB). A 65 year old client who just returned from bronchoscopy procedure. As the charge nurse, you are making assignments for the next shift. Which client should be assigned to the fairly new nurse (2 months) pulled from the surgical unit to the medical unit? • • A 58 year old client on airborne precautions for tuberculosis (TB). A 65 year old client who just returned from bronchoscopy procedure. Which client in the neurologic intensive care unit will be best to assign to an RN who has been pulled from the medical unit? • • A 26 year old with a basilar skull fracture who has clear drainage coming out of the nose. A 42 year old admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm. Which client in the neurologic intensive care unit will be best to assign to an RN who has been pulled from the medical unit? • • A 26 year old with a basilar skull fracture who has clear drainage coming out of the nose. A 42 year old admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm. A hospitalized client with a diagnosis of anorexia nervosa and in a state of starvation is placed in a two bed hospital room. A newly admitted client will be admitted to this room. Which client would be inappropriate to assign to this two bed hospital room? • A client with pneumonia • A client who can perform self care • A client with a fractured leg that is casted A hospitalized client with a diagnosis of anorexia nervosa and in a state of starvation is placed in a two bed hospital room. A newly admitted client will be admitted to this room. Which client would be inappropriate to assign to this two bed hospital room? • A client with pneumonia • A client who can perform self care • A client with a fractured leg that is casted The nurse is responsible for ensuring the safety of the client. The nurse is providing care to a client in a full length leg cast. The nurse is legally obligated to check blood circulation in the toes: • On the basis of nursing judgment • Only with a physicians order • If checking blood circulation is mentioned in the nursing care plan The nurse is responsible for ensuring the safety of the client. The nurse is providing care to a client in a full length leg cast. The nurse is legally obligated to check blood circulation in the toes: • On the basis of nursing judgment • Only with a physicians order • If checking blood circulation is mentioned in the nursing care plan The physician has ordered a bronchoscopy for a client with a chronic cough. The nurse brings the informed consent document into the client’s room for a signature. The client asks the nurse to explain why the process of informed consent is necessary. The nurse responds that informed consent means: • The client agrees to a procedure ordered by the physician, even if he/she does not understand what the outcome will be. The physician has ordered a bronchoscopy for a client with a chronic cough. The nurse brings the informed consent document into the client’s room for a signature. The client asks the nurse to explain why the process of informed consent is necessary. The nurse responds that informed consent means: • The client agrees to a procedure ordered by the physician, even if he/she does not understand what the outcome will be. A woman identifying herself as a family friend telephones the home health nurse to inquire if there is anything she can do, as a friend, to assist her neighbors, the parents with an infant who has a tracheoesophageal fistula. The parents expressed nervousness about giving enteral feedings. The best nursing action is to: • Inform the friend to directly contact the family and offer her assistance to them. A woman identifying herself as a family friend telephones the home health nurse to inquire if there is anything she can do, as a friend, to assist her neighbors, the parents with an infant who has a tracheoesophageal fistula. The parents expressed nervousness about giving enteral feedings. The best nursing action is to: • Inform the friend to directly contact the family and offer her assistance to them. A nurse is morally opposed to abortion during any time of a pregnancy. Which statement best describes the nurse’s responsibility related to this belief? • • The nurse must make this position known before being employed at an agency that provides abortions. The nurse may decline in participating in abortions, but must care for women after the A nurse is morally opposed to abortion during any time of a pregnancy. Which statement best describes the nurse’s responsibility related to this belief? • • The nurse must make this position known before being employed at an agency that provides abortions. The nurse may decline in participating in abortions, but must care for women after the WOMEN’S The nurse correctly calculates the EDC of a client with a last menstrual period of April 11 as: • January 4 • January 25 • January 18 • February 14 The nurse correctly calculates the EDC of a client with a last menstrual period of April 11 as: • January 4 • January 25 • January 18 • February 14 Using the gravida and para system, how would the nurse record the obstetric history of a client who is currently pregnant, has 7-yearold twins, a 2-year-old son, and had a spontaneous abortion at 12 weeks gestation last year? • Gravida 3, Para 3 • Gravida 3, Para 2 • Gravida 4, Para 3 Using the gravida and para system, how would the nurse record the obstetric history of a client who is currently pregnant, has 7-yearold twins, a 2-year-old son, and had a spontaneous abortion at 12 weeks gestation last year? • Gravida 3, Para 3 • Gravida 3, Para 2 • Gravida 4, Para 3 A pregnant woman with 4 children reports the following obstetric history: a still birth at 32 weeks of gestation, triplets (2 sons and a daughter) born via cesarean section at 30 weeks gestation, a spontaneous abortion at 8 weeks ,and a daughter born vaginally at 39 weeks of gestation. Which of the following accurately expresses this woman’s current obstetric history using the 5 digit system? • 5-1-4-1-4 A pregnant woman with 4 children reports the following obstetric history: a still birth at 32 weeks of gestation, triplets (2 sons and a daughter) born via cesarean section at 30 weeks gestation, a spontaneous abortion at 8 weeks ,and a daughter born vaginally at 39 weeks of gestation. Which of the following accurately expresses this woman’s current obstetric history using the 5 digit system? • 5-1-4-1-4 Which woman should receive RhoGAM immune globulin after birth? • • • Rh negative mother; Rh positive infant; positive direct Coombs’ test Rh positive mother; Rh negative infant; negative direct Coombs’ test Rh negative mother; Rh positive infant; negative direct Coombs’ test Which woman should receive RhoGAM immune globulin after birth? • • • Rh negative mother; Rh positive infant; positive direct Coombs’ test Rh positive mother; Rh negative infant; negative direct Coombs’ test Rh negative mother; Rh positive infant; negative direct Coombs’ test The nurse reviews the results of the following stress test performed on a pregnant client and interprets the finding as which of the following? • Reactive non-stress test • Nonreactive non-stress test • Negative contraction stress test • Positive contraction stress test The nurse reviews the results of the following stress test performed on a pregnant client and interprets the finding as which of the following? • Reactive non-stress test • Nonreactive non-stress test • Negative contraction stress test • Positive contraction stress test A client who is undergoing a non-stress test asks the nurse to explain why she is using an acoustic vibration device. The nurse states that the device is used to: • Stimulate uterine contractions • Relax uterine contractions • Soothe the baby to sleep • Awaken the sleeping fetus A client who is undergoing a non-stress test asks the nurse to explain why she is using an acoustic vibration device. The nurse states that the device is used to: • Stimulate uterine contractions • Relax uterine contractions • Soothe the baby to sleep • Awaken the sleeping fetus A client who is 29 weeks pregnant comes to the labor and delivery unit. She states that she’s having contractions every eight minutes. The client is also 3cm dilated. Which medications can the nurse expect to administer? Select all that apply. • Folic Acid (Folvite) • Terbutaline (Brethine) • Betamethasone A client who is 29 weeks pregnant comes to the labor and delivery unit. She states that she’s having contractions every eight minutes. The client is also 3cm dilated. Which medications can the nurse expect to administer? Select all that apply. • Folic Acid (Folvite) • Terbutaline (Brethine) • Betamethasone The health care provider prescribes Terbutaline (Brethine) for a client in preterm labor. Before initiating this order, it is most important for the nurse to assess the client for which condition? • Gestational diabetes • Elevated blood pressure • Urinary tract infection The health care provider prescribes Terbutaline (Brethine) for a client in preterm labor. Before initiating this order, it is most important for the nurse to assess the client for which condition? • Gestational diabetes • Elevated blood pressure • Urinary tract infection During active labor, a client’s membranes rupture and her cervix is 5 cm dilated and 50% effaced. The fluid is clear and the fetal heart rate is stable. The nurse should anticipate that: • Birth of the fetus will occur within 24 hours. • The second stage of labor will be prolonged. • An oxytocin infusion will be required to stimulate labor. During active labor, a client’s membranes rupture and her cervix is 5 cm dilated and 50% effaced. The fluid is clear and the fetal heart rate is stable. The nurse should anticipate that: • Birth of the fetus will occur within 24 hours. • The second stage of labor will be prolonged. • An oxytocin infusion will be required to A nurse applies an external fetal monitor and tocotransducer to monitor the fetal heart rate (FHR) and contractions of a client in labor. The FHR is in the 140s. Contractions are every 5 min and 45-50 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2cm dilated, 50% effaced, and the fetus is -2 station. One hour later the dilation is still 2 cm, but now the effacement is 80%. Which of the following stages and phases of labor is this A nurse applies an external fetal monitor and tocotransducer to monitor the fetal heart rate (FHR) and contractions of a client in labor. The FHR is in the 140s. Contractions are every 5 min and 45-50 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2cm dilated, 50% effaced, and the fetus is -2 station. One hour later the dilation is still 2 cm, but now the effacement is 80%. Which of the following stages and phases of labor is this A 21 year old gravida 1 para 0 is in labor. The nurse observes that the patient is having intense contractions 2-3 minutes apart lasting 80-90 seconds. She says she has an urge to push sometimes and is irritable. The nurse would expect to find her: • dilated 3-4 cm and 100% effaced. • dilated 5-6 cm and 75% effaced. • dilated 7-8 cm and 50% effaced. A 21 year old gravida 1 para 0 is in labor. The nurse observes that the patient is having intense contractions 2-3 minutes apart lasting 80-90 seconds. She says she has an urge to push sometimes and is irritable. The nurse would expect to find her: • dilated 3-4 cm and 100% effaced. • dilated 5-6 cm and 75% effaced. • dilated 7-8 cm and 50% effaced. A client has been in active labor for 10 hours. Contractions are every 3 minutes and last for 60 seconds. Further findings include: cervix 100% effaced and 6 cm dilated; membranes ruptured; vertex at +1 station. The nurse determines that an appropriate nursing diagnosis at this time would be: • ineffective coping related to loss of control. • high risk for fetal injury related to prolapsed A client has been in active labor for 10 hours. Contractions are every 3 minutes and last for 60 seconds. Further findings include: cervix 100% effaced and 6 cm dilated; membranes ruptured; vertex at +1 station. The nurse determines that an appropriate nursing diagnosis at this time would be: • ineffective coping related to loss of control. • high risk for fetal injury related to prolapsed Emergency Medical Service brings a woman into the emergency room on a stretcher. She is in active labor and on physical examination, crowning is noted. The nurse is aware that the priority action is to: • get the patient to the labor unit as quickly as possible. • provide gentle pressure on the fetal head. • maintain a sterile environment for the Emergency Medical Service brings a woman into the emergency room on a stretcher. She is in active labor and on physical examination, crowning is noted. The nurse is aware that the priority action is to: • get the patient to the labor unit as quickly as possible. • provide gentle pressure on the fetal head. • maintain a sterile environment for the A client with a large fetus is to have a pudendal block during the second stage of labor. The nurse plans to instruct the client that once the block is working she: • May lose bladder sensation • Will not feel an episiotomy • May lose the ability to push • Will no longer feel contractions A client with a large fetus is to have a pudendal block during the second stage of labor. The nurse plans to instruct the client that once the block is working she: • May lose bladder sensation • Will not feel an episiotomy • May lose the ability to push • Will no longer feel contractions As you evaluate a 29-year-old gravida 2 para 1, which of the following would determine that she is in true labor? • • • Her cervix has dilated an additional 2 cm in the last 3 hours. Fetal heart tones have remained in the range of 130-140 beats per minute. Her contractions have remained every 10 minutes lasting 25 seconds for the past 4 As you evaluate a 29-year-old gravida 2 para 1, which of the following would determine that she is in true labor? • • • Her cervix has dilated an additional 2 cm in the last 3 hours. Fetal heart tones have remained in the range of 130-140 beats per minute. Her contractions have remained every 10 minutes lasting 25 seconds for the past 4 • The nurse interprets a deceleration pattern when monitoring a laboring client. This pattern inversely mirrors the contraction and rises to baseline as the contraction ends. The nurse interprets this pattern as a(n): • sinusoidal pattern. • variable deceleration. • early deceleration. The nurse interprets a deceleration pattern when monitoring a laboring client. This pattern inversely mirrors the contraction and rises to baseline as the contraction ends. The nurse interprets this pattern as a(n): • sinusoidal pattern. • variable deceleration. • early deceleration. The nurse's rapid response to late decelerations is based on the knowledge that these fetal heart rate patterns are due to: • umbilical cord compression. • head compression. • uteroplacental insufficiency. • intact nervous system. The nurse's rapid response to late decelerations is based on the knowledge that these fetal heart rate patterns are due to: • umbilical cord compression. • head compression. • uteroplacental insufficiency. • intact nervous system. A patient has been admitted to the labor and delivery unit; an electronic fetal monitor is in use. The patient's coach wants to know how to elicit information from the monitor strip. The nurse correctly teaches the patient's coach that measuring the beginning of one contraction to the beginning of the next contraction will tell the: • Frequency A patient has been admitted to the labor and delivery unit; an electronic fetal monitor is in use. The patient's coach wants to know how to elicit information from the monitor strip. The nurse correctly teaches the patient's coach that measuring the beginning of one contraction to the beginning of the next contraction will tell the: • Frequency A nurse's first response to late decelerations would be: • call the birth attendant immediately. • turn the client to her left side. • increase the IV flow rate. • place the client in Trendelenburg. A nurse's first response to late decelerations would be: • call the birth attendant immediately. • turn the client to her left side. • increase the IV flow rate. • place the client in Trendelenburg. A 25 year old primigravida at 40 weeks gestation is in the active stage of labor. She is being monitored with an internal transducer and a fetal scalp clip. Upon reviewing the monitoring strip, the nurse notices decelerations of the fetal heart rate. Which pattern will most likely indicate fetal hypoxia and acidosis? • Decelerations that are mirror images of the uterine contractions. A 25 year old primigravida at 40 weeks gestation is in the active stage of labor. She is being monitored with an internal transducer and a fetal scalp clip. Upon reviewing the monitoring strip, the nurse notices decelerations of the fetal heart rate. Which pattern will most likely indicate fetal hypoxia and acidosis? • Decelerations that are mirror images of the uterine contractions. If the physician plans to do a speculum exam on a client with a marginal placenta previa, the nurse should have available • One unit of freeze dried plasma • Vitamin K for intramuscular injection • Two units of type and screened blood • Heparin sodium for intravenous injection If the physician plans to do a speculum exam on a client with a marginal placenta previa, the nurse should have available • One unit of freeze dried plasma • Vitamin K for intramuscular injection • Two units of type and screened blood • Heparin sodium for intravenous injection A pregnant woman at 32 weeks of gestation comes to the emergency room because she has begun to experience bright red vaginal bleeding. She reports that she is experiencing no pain. The admission nurse suspects • Abruptio placentae • Disseminated intravascular coagulation • Placenta previa • A pregnant woman at 32 weeks of gestation comes to the emergency room because she has begun to experience bright red vaginal bleeding. She reports that she is experiencing no pain. The admission nurse suspects • Abruptio placentae • Disseminated intravascular coagulation • Placenta previa During an admission assessment, a woman in active labor informs you that she is positive for HIV. What will be included in your plan of care that will decrease the chance of HIV transmission to the fetus? • • All healthcare personnel will be required to wear gloves. The patient will receive intravenous antiviral medications prior to delivery. During an admission assessment, a woman in active labor informs you that she is positive for HIV. What will be included in your plan of care that will decrease the chance of HIV transmission to the fetus? • • All healthcare personnel will be required to wear gloves. The patient will receive intravenous antiviral medications prior to delivery. A client is progressing in normal labor when her membranes rupture; the nurse notes that the fluid is greenish-brown in color. The nurse caring for this client would give highest PRIORITY to: • helping the client in to the knee-chest position. • preparing the client for a cesarean section. • observing for signs of a precipitate birth. A client is progressing in normal labor when her membranes rupture; the nurse notes that the fluid is greenish-brown in color. The nurse caring for this client would give highest PRIORITY to: • helping the client in to the knee-chest position. • preparing the client for a cesarean section. • observing for signs of a precipitate birth. Five minutes after a spontaneous vaginal delivery, a full-term newborn presents with the following: apical heart rate: 120; respirations: 24 and shallow; position: partial flexion; cry when suctioned; bluish extremities. The nurse would determine that the APGAR score is: • 5 • 7 Five minutes after a spontaneous vaginal delivery, a full-term newborn presents with the following: apical heart rate: 120; respirations: 24 and shallow; position: partial flexion; cry when suctioned; bluish extremities. The nurse would determine that the APGAR score is: • 5 • 7 A preterm newborn of 34 weeks gestation is born limp and pale. Her respirations are slow, weak and irregular; heart rate is 90. She has a facial grimace when suctioned. At one minute after birth, the nurse would assess this newborn's APGAR score as: • 0 • 3 • 5 A preterm newborn of 34 weeks gestation is born limp and pale. Her respirations are slow, weak and irregular; heart rate is 90. She has a facial grimace when suctioned. At one minute after birth, the nurse would assess this newborn's APGAR score as: • 0 • 3 • 5 A client at 36 weeks gestation attends the prenatal clinic for a routine exam. The nurse identifies that the client’s blood pressure has increased from 102/60 to 134/88 and is concerned she may be developing mild preeclampsia. The nurse should also assess the client for: • Proteinuria • Mild ankle edema A client at 36 weeks gestation attends the prenatal clinic for a routine exam. The nurse identifies that the client’s blood pressure has increased from 102/60 to 134/88 and is concerned she may be developing mild preeclampsia. The nurse should also assess the client for: • Proteinuria • Mild ankle edema Magnesium Sulfate is being administered intravenously to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates Magnesium Sulfate toxicity. • Respirations less than 12/min • Urinary output less than 50mL/hour • Hyper-reflexic deep tendon reflexes Magnesium Sulfate is being administered intravenously to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates Magnesium Sulfate toxicity. • Respirations less than 12/min • Urinary output less than 50mL/hour • Hyper-reflexic deep tendon reflexes PEDS Which of the following is a developmental red flag for a 3 month old infant? • • The child does not pick up objects with his fingers. The child does not attempt to raise his head when placed on his stomach. • The child has intense stranger anxiety. • The child does not attempt to sit without Which of the following is a developmental red flag for a 3 month old infant? • • The child does not pick up objects with his fingers. The child does not attempt to raise his head when placed on his stomach. • The child has intense stranger anxiety. • The child does not attempt to sit without The mother of a 3 month old asks the nurse about starting solid foods. What is the most appropriate response by the nurse? • • • “It’s okay to start pureed solids at this age if fed via the bottle.” “Infants don’t require solid food until 12 months of age.” “Solid food should be delayed until age 6 months, when the infant can handle a spoon The mother of a 3 month old asks the nurse about starting solid foods. What is the most appropriate response by the nurse? • • • “It’s okay to start pureed solids at this age if fed via the bottle.” “Infants don’t require solid food until 12 months of age.” “Solid food should be delayed until age 6 months, when the infant can handle a spoon The father of a 2 month old girl is expressing concern that his infant may be getting spoiled. The nurse’s best response is: • • • “She just needs love and attention. Don’t worry; she’s too young to spoil.” “Consistently meeting the infant’s needs helps promote a sense of trust.” “Infants need to be fed and cleaned; if you’re sure those needs are met, just let her The father of a 2 month old girl is expressing concern that his infant may be getting spoiled. The nurse’s best response is: • • • “She just needs love and attention. Don’t worry; she’s too young to spoil.” “Consistently meeting the infant’s needs helps promote a sense of trust.” “Infants need to be fed and cleaned; if you’re sure those needs are met, just let her The nurse is assessing development of a 4 month old boy during a regular visit. Which of the following observations may be a warning sign? • • • The infant focuses on near or high contrast objects. The infant responds to his mother only when he sees her. The infant makes babbling sounds, but no The nurse is assessing development of a 4 month old boy during a regular visit. Which of the following observations may be a warning sign? • • • The infant focuses on near or high contrast objects. The infant responds to his mother only when he sees her. The infant makes babbling sounds, but no The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should do which of the following? • Administer oxygen • Record data on nurses’ notes • Report data to the practitioner • Place child in high Fowler position The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should do which of the following? • Administer oxygen • Record data on nurses’ notes • Report data to the practitioner • Place child in high Fowler position A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in: • cyanosis. • congestive heart failure. • decreased pulmonary blood flow. • bounding pulses in upper extremities A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in: • cyanosis. • congestive heart failure. • decreased pulmonary blood flow. • bounding pulses in upper extremities The nurse is examining an 8 month old girl for appropriate development during a regular checkup. Which of the following observations is most likely a warning sign? • Cannot sit from standing. • Crawling on hands and knees. • Cannot pull herself to standing. • Using only the left hand to grasp. The nurse is examining an 8 month old girl for appropriate development during a regular checkup. Which of the following observations is most likely a warning sign? • Cannot sit from standing. • Crawling on hands and knees. • Cannot pull herself to standing. • Using only the left hand to grasp. An 11 month old infant has Ibuprofen (Advil) ordered every 6 hours. It has been 6 hours since the last dose and his parent has requested that he receive his pain medication. When the nurse enters the room, the child is asleep. The parent requests that the pain medication be given because the child is still restless in sleep. What is the best nursing action? • Refuse to awaken the child. An 11 month old infant has Ibuprofen (Advil) ordered every 6 hours. It has been 6 hours since the last dose and his parent has requested that he receive his pain medication. When the nurse enters the room, the child is asleep. The parent requests that the pain medication be given because the child is still restless in sleep. What is the best nursing action? • Refuse to awaken the child. When evaluating the growth and development of a healthy 6 month old infant, which activities should the nurse expect the infant to perform? • • • Sit alone, display a pincer grasp, and wave bye-bye. Crawl, transfer a toy from one hand to the other, and be fearful of strangers. Pull up to a standing position, release a toy When evaluating the growth and development of a healthy 6 month old infant, which activities should the nurse expect the infant to perform? • • • Sit alone, display a pincer grasp, and wave bye-bye. Crawl, transfer a toy from one hand to the other, and be fearful of strangers. Pull up to a standing position, release a toy The nurse must assess 10-month-old Chad. He is sitting on his father’s lap and appears to be afraid of the nurse and of what might happen next. Which of the following initial actions by the nurse would be most appropriate? • • • Initiate a game of peek-a-boo. Ask father to place Chad on the examination table. Talk softly to Chad while taking him from his The nurse must assess 10-month-old Chad. He is sitting on his father’s lap and appears to be afraid of the nurse and of what might happen next. Which of the following initial actions by the nurse would be most appropriate? • • • Initiate a game of peek-a-boo. Ask father to place Chad on the examination table. Talk softly to Chad while taking him from his In assessing the physical development of a 12 month old, the nurse observes that there is still a slight opening in the baby’s anterior fontanel. Which of the following actions would be most appropriate for the nurse to take? • • Notify the physician immediately because this could be a sign of a serious problem Initiate a series of neurological assessments In assessing the physical development of a 12 month old, the nurse observes that there is still a slight opening in the baby’s anterior fontanel. Which of the following actions would be most appropriate for the nurse to take? • • Notify the physician immediately because this could be a sign of a serious problem Initiate a series of neurological assessments The nurse is examining a 2 year old for speech and language development. Which finding would suggest a delay in speech development? • • • The child repeats what the mother says out of context. The child sometimes repeats or elongates words. The child doesn’t use the names of familiar The nurse is examining a 2 year old for speech and language development. Which finding would suggest a delay in speech development? • • • The child repeats what the mother says out of context. The child sometimes repeats or elongates words. The child doesn’t use the names of familiar A home care nurse provides instructions to the mother of a toddler with croup. The mother expresses concern regarding the occurrence of an acute spasmodic episode, and the nurse instructs the mother regarding management if an acute episode occurs. Which statement by the mother indicates a need for further instructions? • “I will place a steam vaporizer in my child’s room.” A home care nurse provides instructions to the mother of a toddler with croup. The mother expresses concern regarding the occurrence of an acute spasmodic episode, and the nurse instructs the mother regarding management if an acute episode occurs. Which statement by the mother indicates a need for further instructions? • “I will place a steam vaporizer in my child’s room.” The nurse is teaching the mother of a 2 year old boy about age appropriate toys. Which suggestion would most likely be successful? • • • Giving the child a child-size toy vacuum cleaner. Giving the child old bowls, pans, and large spoons. Offering the child a variety of large stuffed toys. The nurse is teaching the mother of a 2 year old boy about age appropriate toys. Which suggestion would most likely be successful? • • • Giving the child a child-size toy vacuum cleaner. Giving the child old bowls, pans, and large spoons. Offering the child a variety of large stuffed toys. A nurse is admitting a 13 month old child with a tentative diagnosis of intussusception. What question to the mother would be most helpful in obtaining additional information to confirm the diagnosis? • • • “Does your child vomit after each feeding?” “What does the child do when experiencing pain?” “Is your child passing ribbon-like stools? A nurse is admitting a 13 month old child with a tentative diagnosis of intussusception. What question to the mother would be most helpful in obtaining additional information to confirm the diagnosis? • • • “Does your child vomit after each feeding?” “What does the child do when experiencing pain?” “Is your child passing ribbon-like stools? The father of a 4 year old boy has contacted the nurse because he is concerned that his son is always touching his genitals. The nurse explains that this is very normal. Which of the following statements by the father would indicate a need for further teaching? • • “I should teach him certain rules about this activity.” “I will eventually need to punish him if this The father of a 4 year old boy has contacted the nurse because he is concerned that his son is always touching his genitals. The nurse explains that this is very normal. Which of the following statements by the father would indicate a need for further teaching? • • “I should teach him certain rules about this activity.” “I will eventually need to punish him if this The nurse is conducting a well-child examination of a 4 year old boy. Which of the following statements would alert the nurse that the child is at risk for iron deficiency? • “He enjoys fortified cereals and eggs.” • “He would drink milk all day if I let him.” • “He eats a well-balanced diet.” • “He does not like spinach, but he does like The nurse is conducting a well-child examination of a 4 year old boy. Which of the following statements would alert the nurse that the child is at risk for iron deficiency? • “He enjoys fortified cereals and eggs.” • “He would drink milk all day if I let him.” • “He eats a well-balanced diet.” • “He does not like spinach, but he does like A preschool child is admitted for treatment of pneumonia. The mother is embarrassed because the child has wet the bed, which he hasn’t done since he was toilet trained. Which of the following statements might the nurse make to the mother? • “This happens quite often with children when they are admitted to the hospital. When he feels better, his toileting skills will return to normal.” A preschool child is admitted for treatment of pneumonia. The mother is embarrassed because the child has wet the bed, which he hasn’t done since he was toilet trained. Which of the following statements might the nurse make to the mother? • “This happens quite often with children when they are admitted to the hospital. When he feels better, his toileting skills will return to normal.” The parent of a preschooler hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. The nurse’s reply should be based on knowledge of which of the following? • • The antibiotic therapy contributes to labile blood pressure values. Hypotension leading to sudden shock can develop at any time. The parent of a preschooler hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. The nurse’s reply should be based on knowledge of which of the following? • • The antibiotic therapy contributes to labile blood pressure values. Hypotension leading to sudden shock can develop at any time. PHARM A client recently began med therapy with propanolol (Inderal). The nurse would be most concerned if which of the following was noted? • complaints of insomnia • audible expiratory wheezes • bp 136/84 from 162/90 • HR 86 down to 78 A client recently began med therapy with propanolol (Inderal). The nurse would be most concerned if which of the following was noted? • complaints of insomnia • audible expiratory wheezes • bp 136/84 from 162/90 • HR 86 down to 78 Patient receiving Clonidine (Catapres) 0.1mg/24hr transdermal patch. Desired effect is? • denies recent angina • change in edema from +3 to +1 • denies n/v • BP from 180/120 to 140/70 Patient receiving Clonidine (Catapres) 0.1mg/24hr transdermal patch. Desired effect is? • denies recent angina • change in edema from +3 to +1 • denies n/v • BP from 180/120 to 140/70 New prescription for ACE inhibitor. What contraindicates its use? • asthma • HF • renal artery stenosis • CAD New prescription for ACE inhibitor. What contraindicates its use? • asthma • HF • renal artery stenosis • CAD CHF client discharged with ACE inhibitor Captopril (Capoten). Discharge instructions include reporting which problem? • weight loss • dizziness • muscle cramps • dry mucus mucus membranes CHF client discharged with ACE inhibitor Captopril (Capoten). Discharge instructions include reporting which problem? • weight loss • dizziness • muscle cramps • dry mucus mucus membranes Nurse is giving a new medication of enalapril (Vasotec). Which is an unpleasant SE? • rapid pulse • persistent cough • hypokalemia • alopecia Nurse is giving a new medication of enalapril (Vasotec). Which is an unpleasant SE? • rapid pulse • persistent cough • hypokalemia • alopecia Nursing dx with client receiving the ARB irbesartan (Avapro)? • fluid volume deficit • risk for infection • risk for injury • impaired sleep patterns Nursing dx with client receiving the ARB irbesartan (Avapro)? • fluid volume deficit • risk for infection • risk for injury • impaired sleep patterns Lasix is prescribed for L HF. Which instructions apply? • restrict fluid intake • expect muscle weakness • take meds at bedtime • expect increased UO • eat foods high in K • Lasix is prescribed for L HF. Which instructions apply? • restrict fluid intake • expect muscle weakness • take meds at bedtime • expect increased UO • eat foods high in K Client with HF prescribed spironalactone (Aldactone). Which is most important for diet? • do no add salt • refrain from high K foods • restrict to 1000mL per day fluid • increase intake of milk and milk products Client with HF prescribed spironalactone (Aldactone). Which is most important for diet? • do no add salt • refrain from high K foods • restrict to 1000mL per day fluid • increase intake of milk and milk products Before administering digoxin (Lanoxin) the apical pulse is 54. What actions should the nurse take? • assess the client for signs of dig toxicity • notify the physician of the apical pulse rate • check results of most recent dig level • check results of most recent K level • give dig and recheck the apical pulse 1 hour Before administering digoxin (Lanoxin) the apical pulse is 54. What actions should the nurse take? • assess the client for signs of dig toxicity • notify the physician of the apical pulse rate • check results of most recent dig level • check results of most recent K level • give dig and recheck the apical pulse 1 hour When assessing prior to giving digoxin, which is most important to consider? • presence of grade 2 murmur • nail bed cap refill of 5 seconds • irregular apical pulse of 87 • bilateral LE dependent rubor When assessing prior to giving digoxin, which is most important to consider? • presence of grade 2 murmur • nail bed cap refill of 5 seconds • irregular apical pulse of 87 • bilateral LE dependent rubor Client receiving digoxin. Which correlates with dig level of 2.4ng/mL • nausea • drowsiness • photophobia • increased appetite • increased energy level Client receiving digoxin. Which correlates with dig level of 2.4ng/mL • nausea • drowsiness • photophobia • increased appetite • increased energy level Following sublingual nitro, which assessment indicates effectiveness? • chest pain is relieved • pulse decrease from 120 to 90 • systolic bp decreases from 180 to 90 • SaO2 increases from 92% to 96% Following sublingual nitro, which assessment indicates effectiveness? • chest pain is relieved • pulse decrease from 120 to 90 • systolic bp decreases from 180 to 90 • SaO2 increases from 92% to 96% New nitro tablet prescription. What is proper teaching? • • • • take at least one hour before a meal monitor pulse for 60 seconds before administration place under tongue as needed every 5 minutes up to 3 times resume normal activities after chest pain is New nitro tablet prescription. What is proper teaching? • • • • take at least one hour before a meal monitor pulse for 60 seconds before administration place under tongue as needed every 5 minutes up to 3 times resume normal activities after chest pain is Which instructions for nitro patch (Nitro-dur)? • • • • apply to a nonhairy, nonfatty area of upper torso or arms apply to the same site each day if you get a headache remove patch for four hours and reapply if you get chest pain, apply a second patch next to the first one Which instructions for nitro patch (Nitro-dur)? • • • • apply to a nonhairy, nonfatty area of upper torso or arms apply to the same site each day if you get a headache remove patch for four hours and reapply if you get chest pain, apply a second patch next to the first one Sublingual nitro prescribed for acute angina. Which instructions to provide? • take tab at first sign of pain • take while sitting or lying down • check expiration date • • swallow for most effective ness and rapidness keep bottle away from light and moisture Sublingual nitro prescribed for acute angina. Which instructions to provide? • take tab at first sign of pain • take while sitting or lying down • check expiration date • • swallow for most effective ness and rapidness keep bottle away from light and moisture After abdominal surgery patient is prescribed Lovenox, why is he receiving it? • • med is a blood thinner to prevent blood clot formation med enhances antibiotics to prevent infection • med dissolves clots that develop in the legs • abdominal injection assists with healing of After abdominal surgery patient is prescribed Lovenox, why is he receiving it? • • med is a blood thinner to prevent blood clot formation med enhances antibiotics to prevent infection • med dissolves clots that develop in the legs • abdominal injection assists with healing of Plan of care for heparin. Which interventions included? • provide soft toothbrush • monitor for bruising and bleeding • have antidote available • • apply pressure to venipuncture and other injection sites allow client to take acetylsalicylic acid Plan of care for heparin. Which interventions included? • provide soft toothbrush • monitor for bruising and bleeding • have antidote available • • apply pressure to venipuncture and other injection sites allow client to take acetylsalicylic acid Warfarin sodium (Coumadin) has been instructed to limit vitamin K. Avoid what? • tea • romaine lettuce • oranges • cabbage • broccoli Warfarin sodium (Coumadin) has been instructed to limit vitamin K. Avoid what? • tea • romaine lettuce • oranges • cabbage • broccoli CAD client on digoxin. Gets new prescription for avorstatin (Lipitor). 2 weeks later the nurse assesses, which requires immediate intervention • heartburn • HA • constipation • vomiting • CAD client on digoxin. Gets new prescription for avorstatin (Lipitor). 2 weeks later the nurse assesses, which requires immediate intervention • heartburn • HA • constipation • vomiting DM patient receives NPH at 7am. Nurse most carefully monitors for hypoglycemia between: • 9am-11am • 1pm-7pm • 7pm-11pm • midnight-6am DM patient receives NPH at 7am. Nurse most carefully monitors for hypoglycemia between: • 9am-11am • 1pm-7pm • 7pm-11pm • midnight-6am Nurse teaches family of a new DM client. Nurse evaluates understanding of glucagon for emergency by indicating the purpose for: • DKA • hypoglycemia from insulin OD • hyperglycemia from insufficient insulin • hyperglycemia occurring on "sick days" Nurse teaches family of a new DM client. Nurse evaluates understanding of glucagon for emergency by indicating the purpose for: • DKA • hypoglycemia from insulin OD • hyperglycemia from insufficient insulin • hyperglycemia occurring on "sick days" Nurse provides which instructions for levothyroxine (Synthroid)? • monitor pulse rate • take med in the morning • notify physician if chest pain occurs • take med at the same time each day • expect the pulse to be greater than 100 Nurse provides which instructions for levothyroxine (Synthroid)? • monitor pulse rate • take med in the morning • notify physician if chest pain occurs • take med at the same time each day • expect the pulse to be greater than 100 DC prednisone for COPD. What instructions to give? • • lifelong treatment tis common for chronic disease drug should be stopped immediately if no longer needed • dose must be tapered over 7-10 days • another corticosteroid should be used to DC prednisone for COPD. What instructions to give? • • lifelong treatment tis common for chronic disease drug should be stopped immediately if no longer needed • dose must be tapered over 7-10 days • another corticosteroid should be used to Serious SE for high dose prednisone • alopecia • anorexia • n/v • susceptibility to infection Serious SE for high dose prednisone • alopecia • anorexia • n/v • susceptibility to infection Nurse is preparing to administer Albuterol (Proventil). Assess what before? • n/v • lung sounds and presence of dyspnea • HA and LOC • UO and BUN Nurse is preparing to administer Albuterol (Proventil). Assess what before? • n/v • lung sounds and presence of dyspnea • HA and LOC • UO and BUN Order to give Metaproterenol sulfate (Alupent) and Beclomethasone (QVAR) • beclomethasone first • metaproterenol first • alternating beginning with beclomethasone • alternating beginning with metaproterenol Order to give Metaproterenol sulfate (Alupent) and Beclomethasone (QVAR) • beclomethasone first • metaproterenol first • alternating beginning with beclomethasone • alternating beginning with metaproterenol Upon admission to ED, an adult client with acute status asthmaticus is prescribed a series of meds, which order? • prednisone (deltasone) orally • gentamicin (Garamycin) IM • albuterol (Proventil) nebulizer • aminophylline (Truphyline) IV Upon admission to ED, an adult client with acute status asthmaticus is prescribed a series of meds, which order? • prednisone (deltasone) orally (1) • gentamicin (Garamycin) IM • albuterol (Proventil) nebulizer (3) • aminophylline (Truphyline) IV (4) (2) Nurse teaches patient taking tetracycline to do what? • regular PT and INR • long sleeves, sunglasses • • take with milk or food to minimize GI disturbances change positions slowly to avoid orthostatic hypotension Nurse teaches patient taking tetracycline to do what? • regular PT and INR • long sleeves, sunglasses • • take with milk or food to minimize GI disturbances change positions slowly to avoid orthostatic hypotension Allergy to penicillin. What related allergy? • aminoglycosides • cephalospoins • sulfonamides • tetracyclines Allergy to penicillin. What related allergy? • aminoglycosides • cephalospoins • sulfonamides • tetracyclines Trichomonis vaginalis prescription for metronidazole (Flagyl) • do not ingest with dairy • notify clinic with urine color change • TP/TPP q3months • avoid OTC antitussives Trichomonis vaginalis prescription for metronidazole (Flagyl) • do not ingest with dairy • notify clinic with urine color change • TP/TPP q3months • avoid OTC antitussives Phenytoin (Dilantin) capsules prescribed for tonic-clonic seizures. What instructions? • perform good oral hygiene and gum massage • CBC monthly • report rashes • contact physician if a red-brown discoloration of the urine occurs Phenytoin (Dilantin) capsules prescribed for tonic-clonic seizures. What instructions? • perform good oral hygiene and gum massage • CBC monthly • report rashes • contact physician if a red-brown discoloration of the urine occurs Levodopa PO TID for Parkinson's. New script for sustained levodopa/carbidopa PO BID. Took levodopa at 8am, what now? • • • take first dose of sinemet today, as soon as prescription is filled since you took levodopa, wait until tomorrow for sinemet take both for the first week, then switch to only sinemet Levodopa PO TID for Parkinson's. New script for sustained levodopa/carbidopa PO BID. Took levodopa at 8am, what now? • • • take first dose of sinemet today, as soon as prescription is filled since you took levodopa, wait until tomorrow for sinemet take both for the first week, then switch to only sinemet What client is highest risk for opioid complications • older client with type 2 DM • chronic RA • open compound fracture • young adult with inflammatory bowel disease What client is highest risk for opioid complications • older client with type 2 DM • chronic RA • open compound fracture • young adult with inflammatory bowel disease When assessing acetaminophen OD. Most important assessment for pain? • flank • abdomen • chest • head When assessing acetaminophen OD. Most important assessment for pain? • flank • abdomen • chest • head Teaching about antiinflammatories. Education with aspirin, acetominophen, or NSAIDS? • • • radial pulse and temp prior to admin consult provider before OTC meds because of combinations that may have more of the med than is safe cholesterol levels measures before treatment Teaching about antiinflammatories. Education with aspirin, acetominophen, or NSAIDS? • • • radial pulse and temp prior to admin consult provider before OTC meds because of combinations that may have more of the med than is safe cholesterol levels measures before treatment Child from ED with acetominophen OD. Which for OD? • protamine • epoeitin alfa (Epogen) • acetylcysteine (Mucomyst) • ethylenediaminetetraacetic acid (EDTA) Child from ED with acetominophen OD. Which for OD? • protamine • epoeitin alfa (Epogen) • acetylcysteine (Mucomyst) • ethylenediaminetetraacetic acid (EDTA) Dx with glaucoma has miotic medication prescription. Teaching effects: • reshape the lens to eliminate blurred vision • dilate pupil to reduce intraocular pressure • • interrupt the drainage of aqueous humor from the eye lower intraocular pressure and enhance blood flow to the retina Dx with glaucoma has miotic medication prescription. Teaching effects: • reshape the lens to eliminate blurred vision • dilate pupil to reduce intraocular pressure • • interrupt the drainage of aqueous humor from the eye lower intraocular pressure and enhance blood flow to the retina Allopurinol (Zyloprim) administered knowing that what is accurate • used for lysis of thrombi obstructing coronary arteries • decreases sympathetic outflow from CNS • prevents calcium absorption • decreases uric acid Allopurinol (Zyloprim) administered knowing that what is accurate • used for lysis of thrombi obstructing coronary arteries • decreases sympathetic outflow from CNS • prevents calcium absorption • decreases uric acid Tamoxifen (Nolvadex) is prescribed for metastatic breast carcinoma. • increase DNA and RNA synthesis • promote biosynthesis of nucleic acids • • increase estrogen concentration an estrogen response compete with estradiol for binding to estrogen in tissues containing high Tamoxifen (Nolvadex) is prescribed for metastatic breast carcinoma. • increase DNA and RNA synthesis • promote biosynthesis of nucleic acids • • increase estrogen concentration an estrogen response compete with estradiol for binding to estrogen in tissues containing high