FINAL Qs Flashcards
1
Q
A pt who had gastric bypass surgery 5 weeks ago calls the office to report feelings of nausea, sweating, and diarrhea shortly after eating meals. What response by the nurse is most appropriate? SATA
A
Avoid large meals & limit sweets.
Lie down for about 30 min after eating.
2
Q
At his first postoperative check up appt after a gastrojejunostomy (Billroth II), a pt reports that dizziness, weakness, and palpitations occur about 20 min after each meal. What should the nurse teach the pt to do?
A
Lie down for about 30 min after eating
3
Q
The nurse will be teaching self management to pts after gastric bypass surgery. Which information will the nurse plan to include? SATA
A
Drink fluids between meals but NOT WITH meals
4
Q
A pt admitted with a peptic ulcer disease has a NG tube in place. When the pt develops sudden severe upper abdominal pain, diaphoresis, and a firm abdomen which actions should the nurse take first?
A
Check the vital signs
5
Q
Which information about peptic ulcer disease should the nurse include when teaching a nursing student? SATA
A
A gastric ulcer pain usually starts 1-2 hrs after a meal.
Gastric ulcers are more likely to result in hemorrhage and hematemesis.
Duodenal ulcer pain can be relieved by eating food.
6
Q
The nurse is discussing the impact of cirrhosis on the liver function with the family of a dying pt. The nurse explains that when the damage caused by cirrhosis blocks the blood flow thru the liver, it can lead to which complications? SATA
A
Portal hypertension.
Decrease in clotting factors.
Increase in ascites.
7
Q
Which of the following will the nurse include in the teaching plan for risk factors of colorectal cancer? SATA
A
Personal hx of colorectal polyps.
Family hx of colon cancer.
Ulcerative colitis
8
Q
A 19 yr old pt has a familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care?
A
Schedule the pt for yearly colonoscopy.
9
Q
The nurse is caring for a pt 1 day postoperative after a transverse colostomy. When assessing the stoma, which finding requires the nurses immediate action?
A
A purplish red stoma
10
Q
The nurse is providing discharge teaching for a pt who has undergone colon resection surgery with a colostomy. Which statements by the client indicate that the instruction was understood? SATA
A
I will use warm water & a soft washcloth to clean around the stoma.
I will start bicycling and swimming again once my incision has healed.
I will cut the flange so it fits snugly around the stoma to avoid skin breakdown.
**one answer was changed
11
Q
The nurse is caring for a pt who has been diagnosed with Crohn’s disease. When providing education concerning dietary recommendations, which statement indicates that the nurse’s teaching has been successful? SATA
A
I should not have milk products.
Reducing dietary fat and fiber will be helpful in managing my condition.
I should try to eat foods like white rice and lean poultry.
12
Q
The nurse is planning care for a pt with an acute exacerbation of IBD. Which actions are most important for the nurse to include in the care plan? SATA
A
Assess for internal bleeding.
Encouraging periods of rest.
Auscultate bowel sounds.
Assess number and characteristics of stools.
13
Q
The nurse explains that the most beneficial diet for a person with IBD is a _____ diet.
A
Low fat, low fiber.
14
Q
Which nursing action will be included in the plan of care for a 25 yr old female pt with a new diagnosis of IBS?
A
Encourage the pt to express concerns & ask questions about IBS.
–also look at the notes in the study guide for this one
15
Q
A pt with advanced cirrhosis develops esophageal varices. The nurse anticipates that what complication will be addressed by which type of medications? SATA
A
Vasodilators.
IV vasopressin.
Beta blockers.
16
Q
The nurse is caring for a pt with esophageal varices with a new order for vasopressin (Pitressin). The nurse reviews the pt hx and notes that the pts comorbidities including CAD, DM2, GERD, and fibromyalgia. The nurse should immediately notify the HCP about which component of the pt’s hx?
A
CAD
17
Q
The nurse caring for a pt recently admitted with acute pancreatitis. Which actions should the nurse include in the daily assessments? SATA
A
Monitor for effectiveness of pain control.
Auscultate bowel sounds.
Monitor urine output.
Monitor respiratory function.
18
Q
The nurse is planning care for a pt with acute severe pancreatitis. What is the highest priority patient outcome?
A
Maintaining normal respiratory function.
19
Q
Which action should the nurse take after a pt treated with intramuscular glucagon for hypoglycemia regains consciousness?
A
Give the pt a snack of peanut butter & crackers.
20
Q
Which lab values are consistent with a pt in DKA? SATA
A
Potassium 5.6
BUN 35 mg/dL
21
Q
A pt with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?
A
Lispro
22
Q
A pt with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? SATA
A
Lispro (Humalog)
&
Regular
23
Q
The nurse watches a pt perform an insulin injection. Which observations indicates the pt needs additional instructions? SATA
A
The pt shakes the insulin bottle vigorously before administration.
The pt rubs the injection site after admin of the insulin injection.
The pt draws up the cloudy insulin and then the clear insulin.
24
Q
When discussing exercise programs with the Type 1 diabetic pt, which instructions are important for the nurse to include? SATA
A
Delay exercise until glucose is controlled.
Use the abdominal injection site for insulin.
Keep a quick source of glucose readily available while exercising.
Begin slowly and build up to 30-45 minutes.
25
Which pt action indicates accurate understanding of the nurse's teaching about administration of aspart (Novolog) insulin?
**test my have different answers** refer to study guide
The pt cleans the skin with soap and water before insulin administration.
26
After teaching a client with Type 2 diabetes, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
27
A 26 yr old female who has Type 2 diabetes develops a sore throat and runny nose after caring for her sick toddler. The pt calls the clinic for advice about her symptoms and reports a blood glucose level of 220 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. What should the nurse advise the pt to do?
Monitor blood glucose every 4 hours and contact the clinic if it rises.
28
To monitor for long term complications in a pt with Type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? SATA
Monifilament testing of the foot.
Urine for microalbuminuria.
Retinal exam.
29
A tumor of the pituitary gland has caused the syndrome of SIADH. Which intervention should the nurse plan? SATA
Record accurate urine.
Weigh the pt daily.
Implement seizure precautions.
Assess for changes in level of consciousness.
30
Which pt statement indicates to the nurse that additional instructions is needed for a pt with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?
I need to shop for foods low in sodium and avoid adding salt to food.
31
Which finding indicates to the nurse that demeclocycline is effective for a pt with SIADH?
Urinary output is decreased.
32
An 82 yr old pt in a long term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the HCP before administering the prescribed?
Diazepam (Valium)
33
The nurse is evaluating the lab results of a pt suspected of having hyperparathyroidism. Which findings would be consistent with this condition? SATA
Renal calculi.
Decreased serum phosphate levels.
Increased serum calcium levels.
34
Which information will the nurse teach a pt who has been newly diagnosed with Graves' disease?
Antithyroid medications may take several months for full effect.
35
The nurse is educating a pt who has a new prescription for methimazole. Which instruction is most important for the nurse to include? SATA
Take the medication on a strict schedule.
Report any fever or sore throat.
36
The pt with hyperthyroidism is undergoing ablation therapy with radioactive iodine. Which precaution is most important for that nurse to employ? SATA
Enforce avoiding contact with children for 2 days.
Take radioactive precautions with utensils & bedpans.
Increase fluid intake after the therapy.
37
Which information obtained by the nurse in the endocrine clinic about a pt who has been taking prednisone 40 mg daily for 3 wks is most important to report to the HCP?
Pt stopped taking the medication 2 days ago.
38
A nurse assesses a pt with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? SATA
Administer oxygen to keep saturations greater than 94%.
Administer prescribed albuterol (Proventil) inhaler.
39
The nurse teaches a pt who has asthma about peak flow meter use. Which action by the pt indicates that teaching was successful?
The pt uses albuterol (Ventolin HFA) for peak flows in the yellow zone.
40
The nurse is assessing a pt with COPD. Which assessment finding indicates a potential complication and requires the nurse's immediate attention?
Distended neck veins.
41
A nurse is caring for a pt with COPD. The pts medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status? SATA
Increased expiratory flow rate.
Relief of dyspnea.
42
A nurse teaches a pt who has COPD. Which statements related to nutrition should the nurse including in this pts teaching? SATA
Avoid drinking fluids just before & during meals.
Rest before meals if you have dyspnea.
Have about 6 small meals a day.
**Some answers may have changed for exam**
43
The nurse is caring for a pt with a closed chest drainage system with chest tubes. Which observation confirms that the system is intact and working?
The water level in the water seal chamber fluctuates.
44
The nurse is caring for a pt with ARDS who is receiving mechanical ventilation and PEEP (positive end expiratory pressure). The alarm sounds, indicating high pressure alarm in the system. What is the nurses best action?
Assess lung sounds.
(Always assess the pt first, the ventilator second)
45
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible PE (pulmonary embolism)? SATA
Exercise on a regular basis.
Maintain a healthy weight.
Stop smoking cigarettes.
46
A pt is admitted with PE. The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?
Teach the client about factor V Leiden testing.
47
The nurse is caring for a pt with heart failure. Which interventions should the nurse include in the plan of care? SATA
Discourage intake of canned soups.
Alternate rest with activity.
48
The home health nurse is caring for a pt with heart failure. Which assessment finding should the nurse report immediately to the physician?
A 6 lb weight gain over the course of a week.
49
The nurse is performing an initial assessment on a new pt with suspected rightsided heart failure. Which findings are consistent with the pts potential diagnosis? SATA
Splenomegaly.
Abdominal distention.
Weight gain.
50
Two days after an acute MI, a pt reports stabbing chest pain that increases with a deep breath. Which action will the nurse take first?
Auscultate the heart sounds.
51
After receiving change of shift report on four pts admitted to a heart failure unit, which pt should the nurse assess first?
A pt who has new onset confusion and restlessness and cool, clammy skin.
52
Which action by a nurse caring for a pt after an implantable cardioverter-defibrillator (ICD) insertion indicates a need for more teaching about the care of pts with ICDs? SATA
The nurse encourages the pt to do active ROM exercises for all extremities.
53
The nurse assesses a friction rub in a pt who is 2 days post MI. The nurse recognizes this finding indicates which problem?
Pericarditis
54
The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? SATA
Pt being treated for infective endocarditis after having prolonged IV therapy.
Pt who has a mitral valve replacement with a mechanical valve.
55
The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?
Have you had dental work done recently?
56
Which pt will need the nurse to plan discharge teaching about prophylactic antibiotics before dental procedures?
*Turned into a SATA for exam.
Pt who had a mitral valve replacement with a mechanical valve.
Maybe: infective endocarditis & mitral valve replavement
57
After receiving a report on the following pts, which pt should the nurse assess first?
Pt with acute aortic regurgitation whose blood pressire is 86/54 mm Hg
58
The nurse is caring for a pt with aortic stenosis. Which assessment data would be most important to report to the HCP?
The pt reports chest pressure when ambulating
59
A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below. What should the nurse do?
Assess airway, breathing, and LOC
60
Which factors are potential causative agents for arrhythmias? SATA
Infarct damage.
Hyperkalemia.
Excess fluid.
Valvular disease.
61
A pt develops the following dysrhythmia and complains of dizziness. Which action should the nurse take first?
Either: apply the transcutaneous pacemaker pads
OR check oxygen saturation
62
The student nurse is planning care for a pt with a recent SCI (spinal cord injury). Which intervention indicated that the student nurse requires further instruction regarding appropriate care for this pt?
Instruct the UAP to turn and reposition the pt every 2 hrs.
63
A pt is admitted to the neurologic ICU with a spinal cord injury. When assessing the pt, the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse expect?
Spinal shock
64
The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?
Prepare for interventions to increase the client's BP.
65
A client with a spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential long term complications one more time. What are the potential complications that should be monitored for this client? SATA
Orthostatic hypotension.
DVT.
Autonomic dysreflexia.
66
A pt who experiences spastic bowel elimination pattern. Which action does the nurse implement to assist in relieving the client's constipation. SATA
High fiber & high fluids intake.
Digital anal simulation.
Implementing a consistent daily time for elimination.
67
After teaching a male pt with a spinal cord injury at the T4 level about sexual dysfunction, the nurse assesses the pt's understanding. Which client statement indicates the correct understanding of the teaching related effects of his injury? SATA
"I may feel orgasm, but may be different than before"
"I should be able to have an erection with stimulation"
"Ejaculation may not be as predictable as before"
68
The nurse is caring for a pt with autonomic dysreflexia (AD). The nurse should assess the pt for which conditions or situations? SATA.
Constipation.
Abrupt environmental temperature changes.
Wrinkled bed linens.
Distended bladder.
69
What should the nurse explain to the pt who has a T2 spinal cord transection injury? SATA (maybe T5)
Function of both arms should be maintained.
(Good upper extremities muscle strength)
70
A pt with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information is most important for the nurse to communicate to the HCP before the procedure?
The pt has an allergy to shellfish.
71
The pt is scheduled for a PET scan of the brain asks if there is any special preparation for the test. The nurse correctly responds with which statement? SATA.
You should avoid any tranquilizers or sedatives the night before and the day of the test.
You will need to sign a consent form for this test to be performed.
72
Following a craniotomy to relieve increased ICP which implementations should the nurse implement?
Elevate the HOB to 20-30 degrees.
73
To help prevent aspiration while feeding a pt who has a right sided paralysis, the nurse should implement which interventions? SATA
Place the pt in high fowlers position.
Place food in the left side of the mouth.
Avoid mixing foods with different textures.
74
When taking care of a pt who had a left hemisphere stroke, which nursing diagnosis can the nurse establish for the pt? SATA
Ineffective coping related to depression and distress about disability.
Impaired physical mobility related to right sided hemiplegia.
Impaired verbal communication related to speech language deficits.
75
The nurse is writing the care plan for a CVA pt who has a partial left sided paralysis and is experiencing ataxia. Which intervention is most beneficial for this pt?
Place the pts call light on the right side of the pt and remind her to call for assistance before getting up.
76
A nurse obtains a health hx on a pt prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the HCP?
Prinzmetals angina
77
The nurse should determine that teaching about migraine headaches has been effective when the pt says which of the following?
I will lie down someplace dark and quiet when the headaches begin.
78
The HCP is considering the use of sumatriptan (Imitrex) for a 54 yr old male pt with migraine headaches. Which information obtained by the nurse is most important to report to the HCP?
The pt had a recent acute myocardial infarction.
79
The nurse is caring for a pt with bacterial meningitis. What interventions should the nurse include in the plan of care? SATA
Maintain a quiet environment with minimal stimulation.
Protect the pt from injury.
Manage fever vigorously.
80
Aphasia pt question. SATA
Stand in front of pt.
Allow pt to take time speaking.
81
A pt with Alzheimer's disease who is being admitted to a long term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? SATA
Place the pt in a room close to the nurses station.
Keep the facility doors closed at all times.
Place a large plant in front of the elevator to block it from view.
82
A pt who has severe Alzheimer's disease is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care?
Maintain a consistent daily routine for the pts care.
83
Which intervention will the nurse include in the plan of care for a pt with multiple sclerosis? SATA
Offer soft diet in a sitting position.
Teach the pt how to use the Crede method.
Remove throw/scatter rugs.
84
The nurse caring for a pt with Guillain-Barre syndrome has identified the priority client problem of decreased mobility for the the client. What actions by the nurse are best? SATA
Ask occupational therapy to help the client with activities of daily living.
Consult with the HCP about a physical therapy consult.
Work with speech therapy to design a high protein diet.
85
An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? SATA
Needle decompression.
Initiating IV fluids.
Endotracheal intubation.
Removing wet clothing.
86
The nurse caring for hospitalized clients includes which action on their care plans to reduce the possibility of the client's developing shock? SATA
Removing invasive lines as soon as possible.
Using aseptic technique during a procedure.
Performing proper hand hygiene.
Assessing and identifying client's at risk.
87
The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? SATA.
Anaerobic metabolism.
Hypotension.
88
The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a high risk for shock. For what factors would the nurse assess? SATA
Altered mobility/immobility.
Decreased thirst response.
Diminished immune response.
Malnutrition.
89
A student nurse is assisting with the care for a 50 yr old man who is being treated in the ED for hypothermia. The student asks the charge nurse why the pt is having his heart monitored. How should the nurse best respond?
Lactic acid from pooled blood in the extremities shunts back to the heart.
90
The ED nurse is attempting to revive an unconscious, shivering person with extreme hypothermia (rectal temp of 94F). The nurse should be most alarmed with which change?
The pt stops shivering.
91
A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? SATA
Wear synthetic clothing instead of cotton to keep your skin dry.
Wear sunglasses to protect skin and eyes from harmful rays.
Know your physical limits. Come in out of the cold when limits are reached.
92
The nurse is participating in an educational program concerning nuclear disasters. Which factors determines a victims level of exposure to radiation? SATA
Shielding of the victims from the nuclear source.
Distance of the victim from the nuclear source.
Length of exposure.
93
A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility. SATA.
Client who had open reduction and internal fixation of a femur fracture 3 days ago.
Client on the medical unit for wound care.
94
A wing of a hospital is on fire. Which actions by the nurse promotes safe evacuation of the clients? SATA
Use ambulatory clients to help push clients in wheelchairs.
Direct ambulatory clients on where to go to be safe.
Drag clients on blankets if not ambulatory.
Manually ventilate clients who are on ventilators.
95
A pt arrives in the ED after exposure to radioactive dust. Which action should the nurse take first?
Place the pt in a shower.
96
While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first?
Deliver rescue breaths.
97
A provider prescribes a rewarming bath for a client who presents with partial thickness frostbite. Which action should the nurse take prior to starting this treatment?
Administer IV morphine.
98
The nurse counsels a group of young track athletes about heat stroke prevention. Which information should the nurse include? SATA
Rest frequently in cool places.
Practice in the early morning.
Wear lightweight, loose clothing.
99
An ED nurse moves to a new city, where heat related illnesses are common. Which clients should anticipate as at higher risk for heat related illness. SATA
Illicit drug users.
Homeless.
Older adults.
100
The nurse is working at a first aid booth for spring training game on a hot day. A spectator comes in reporting that he is not feeling well. Vital signs are temp 104.1F (40.1C), pulse 132 bpm, RR 26, and BP 106/66. He trips over his feet as the nurse leads him to a cot. What is the priority action of the nurse?
Sponge the victim with cool water and remove his shirt.
101
An ED nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this client's plan of care? SATA
Administer oxygen via mask or nasal cannula.
Infuse 0.9% sodium chloride via a large bore IV cannula.
Obtain baseline serum electrolytes and cardiac enzymes.
102
Which of the following statements is true about biological warfare agents? SATA
Surgical mask & gown are required when taking care of a pt with pneumonic plague.
Smallpox pt is placed in a negative pressure room.
Botulism can spread thru improperly canned food.
Inhaled anthrax can be fatal if untreated.
103
Gastric lavage and administration of activated charcoal are ordered for an unconscious pt who has been admitted to the ED after ingesting 30 Ativan. Which should the nurse plan to do first?
Assist with intubation of the client.
104
The nurse is caring for a client who had a near drowning incident in a lake. Which action will the nurse take to monitor for possible complications?
Assess the client's temp Q 4 hours.
105
A pt who has a deep human bite wound on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?
Teach the pt the reason for the use of prophylactic antibiotics.
106
A female pt who had a stroke 24 hrs ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. Which nursing intervention is appropriate to help the pt communicate?
The nurse should allow time for the pt to respond.
Ask questions that can be answered in yes or no.
Allow pt to use gesture and a picture board.
107
A pregnant pt with bell's palsy refuses to eat while others are present because of embarrassment about drooling. What is the best response by the nurse?
Respect the pts feelings and arrange for privacy at meal times.
108
When taking care of a pt with MG, which clinical manifestations will the nurse anticipate? SATA
Dyasarthria & hoarsness.
Diplopia ptosis.
Fatigue.
109
The nurse is taking health hx of a client suspected of having bacterial meningitis. What question is most important to ask?
Do you live in a crowded residence?
110
The nurse is caring for a client experiencing migraine headaches who is receiving a beta blocker to help manage this disorder. When prepping a teaching plan, which instructions does the nurse provide?
Take this drug as ordered, even when feeling well to prevent vascular changes associated with migraine headaches.
111
The nurse is caring for a pt who is being treated for extensive burns. The nurse notes the presence of coffee ground material in the Salem sump catheter. The nurse correctly recognizes which factor as the likely cause?
Physiologic stress ulcer.
112
A pt who had gastric bypass surgery 5 wks ago calls the office to report feelings of nausea, sweating, and diarrhea shortly after eating meals. What response by the nurse is most appropriate? SATA
Avoid large meals and limit sweets.
Lie down for about 30 minutes after eating.
113
Conservative treatment of diverticulosis includes which management? SATA
Increase physical activities.
Taking bulk laxatives.
114
The nurse explains which advantage benefits pts with a Kock Pouch ileostomy?
The pt does not have to wear a collection device.
115
The nurse is speaking with a pt who has concerns about the development of choleithiasis. The nurse correctly includes which risk factors for this condition? SATA
Physical inactivity.
Obesity.
Multiparity
116
The nurse is caring for a pt with a 4 day old ileostomy. The pt complains of cramping, the nurse notes only a drop in the effluent for the ileostomy and the bowel sounds are rapid with a tinkling sounds. What action should the nurse take?
Notify the charge nurse immediately.
117
A nurse is caring for a pt who is 4 hrs post op after a laparoscopic cholecystectomy. The pt reports abdominal fullness and mild discomfort. After verifying that the pts vital signs are stable, what action is most important for the nurse to take next?
Ambulate the pt.
118
The nurse is planning skin care for the pt with ascites. Which actions should the nurse include? SATA.
Closely trim the pts fingernails.
Apply emollients to decrease itching.
Change the pts position every 1-2 hrs.
119
The nurse is caring for a pt who underwent a cholecystectomy 3 days ago. Which assessment finding best indicated to the nurse that the bile flow is no longer obstructed from entering the bowel?
Dark brown stool.
120
A 20 yr old college student who has not been immunized against Hep B comes to the clinic and reports that he has been exposed. The nurse anticipates that the HCP will likely recommend what treatment?
An injection of Hepatitis B immune globulin (HBIG)
121
The nurse is caring for a pt with cirrhosis. Which assessment finding warrants the nurses immediate attention?
Confusion.
122
Which finding indicates to the nurse that the pts transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
Fewer episodes of bleeding varices.
123
The nurse is planning post op instructions for the pt who will undergo a transsphenoidal hypophysectomy. Which info is most important for the nurse to include?
Breathe thru your mouth.
Avoid brushing your teeth.
Avoid blowing your nose.
124
The nurse is planning care for a pt with DI. Which interventions are important for the nurse to include? SATA
Assess for hypotension.
Conserve energy.
Maintain fluid therapy.
125
What are the s/s of hyperthyroidism? SATA
Tremors
Scanty menstruation.
Hypertension.
126
The nurse is caring for a pt who reports abruptly discontinuing his prescribed levothyroxine. The nurse should carefully monitor for which complication?
Respiratory distress.
127
Which interventions are indicated for the immediate post op care of a person after a thyroidectomy? SATA
Asses for bleeding.
Assess pts ability to swallow.
Supporting the head with pillows. (or sandbags?)
128
A nurse is teaching a pt with Addison disease who has a prescription for corticosteroids. Which statement is most important for the nurse to include in the teaching plan?
Take the medication every day.
129
On the first post op day following a total throidectomy, which findings would lead the nurse to suspect that the pt may be developing a thyroid storm? SATA
Temp of 101.8F
Short attention span.
Apprehension and restlessness.
130
The pt with Addison disease is receiving IV fluids for rehydration. The nurse should carefully monitor the pt for which potential problem? SATA
Hypotension.
Hypercalcemia.
131
The nurse is caring for a pt with suspected bacterial PNA. Which finding supports the potential diagnosis w/ consolidation? SATA
Dullness on percussion.
Elevated WBC.
Fever & chills.
132
A 79 yr old pt with bacterial pneumonia becomes increasingly restless, confused, and agitated. The pts temp is 100F and his pulse, BP and RR are elevated since the last assessment 6 hrs ago. What action should the nurse take first?
Assess the pts oxygen saturation.
133
The home health nurse is making an initial call on a newly diagnosed TB pt. The pt lives with his wife and child. Which infection control instructions should the nurse include in the teaching plan? SATA
Take medications exactly as directed.
Wash hands frequently.
Place contaminated tissue in sealable plastic bag.
Wear a mask when in crowds.
134
The nurse is caring for a pt with advanced emphysema. Which signs are manifestations of this disorder? SATA
Hyperresonance
Barrel chest
Productive cough
135
The home health nurse is educating a 60 yr old pt with emphysema with a nutritional deficit. Which instructions should the nurse include in the teaching plan to address this problem? SATA.
Eat 4 to 6 meals instead of 3 large meals.
Rest before eating.
Take small bites & chew slowly.
Avoid gas producing foods.
136
After using a nasal cannula delivery system at 3L/min a pt with chronic airflow limitation changes to a simple face mask. The nasal equipment oxygen was set at 3L/min. How should the nurse adjust the oxygen flow for the new delivery system?
Increase it to 6L
137
The nurse is caring for a pt immediately post op after left pneumonectomy. How should the nurse position the pt?
In a left side lying position.
138
The nurse assesses a pt who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse?
Notify the HCP and prepare for intubation.
139
Which teaching point will the nurse include when providing discharge instructions to the pt with a new permanent pacemaker? SATA
You should be able to resume your sexual activities in 6 weks.
Airport screening devices may cause your pacemaker to fire incorrectly.
Avoid lifting heavy objects as long as your MD prescribes
140
The nurse is caring for a male pt w/ angina who has a new prescription for sublingual nitroglycerin. What information is most important for the nurse to include in the teaching plan?
Store nitroglycerin tablets in a cool, dark location.
141
A pt who presented to the ER with a MI becomes pale, diaphoretic, and hypotensive. What action should the nurse take first?
Notify the physician immediately.
142
The nurse in a SNF is caring for a 80 yr old pt who develops a productive cough with pink, frothy sputum. Which independent interventions should the nurse implement immediately?
Place the pt in high fowlers.
143
During the acute phase following a MI the nurse anticipates that the pt may require a temporary pacemaker in what situation? SATA
Pts pulse rate remains below 40.
Pts experiences complete heart block.
144
When caring for a pt with ACS who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicates the need for immediate action by the nurse?
Chest pain level 7 on a 1 to 10 point scale
145
The nurse documents with s/s of basilar skull fracture in a pt with a closed head injury? SATA
Headache
Periorbital ecchymosis
Battle sign
146
The nurse is caring for a pt with complete transection of the cord at C7. The pt asks the nurse what functions he will be able to perform. SATA.
Transferring himself.
Using a wheelchair w/ standard hand rims.
Feeding himself.
Dressing himself.
147
The nurse is caring for a pt admitted with a TIA. A carotid ultrasound reveals a 10% obstruction. The nurse anticipates that the treatment will likely consist of which factors? SATA
Lifestyle alteration.
Aspirin for antiplatelet aggregation.
Diet modification.
148
The nursing is completing the care plan for a stroke pt who is at risk for impaired physical mobility. Which intervention should the nurse include in the care plan? SATA.
Reinforce the use of a walker or cane.
Ensure that the call light is within reach.
Coach the pt in active ROM.
Assist the pt to stand.
149
Following a spinal cord injury a pt is placed in a halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
Notify the neurosurgeon
150
The first responder to an automobile accident finds a victim with a sucking chest wound. What action should the responder take first?
Place a plastic sandwich bag over the wound and tape on three sides to make a flutter (vent) dressing.
151
In the memory prompt for emergency care, ABCDE, what does "E" represent?
Expose
152
The nurse is preparing a presentation that highlights the benefits of annual flu vaccine. The nurse correctly targets which groups? SATA
Pregnant women.
Diabetics 50 yrs old.
Home health aids.
CNAs who work in long term care facilites.
153
The nurse is teaching community members about precautions related to a pandemic occurrence. Which info is most important for the nurse to include in the teaching plan?
Avoid shaking hands.
154
