Version 1 Flashcards
1
Q
A resident of a long-term care facility, who has moderate dementia, is having
difficulty eating in the dining room. The client becomes frustrated when dropping
utensils on the floor and then refuses to eat. What action should the nurse
implement?
A
ANSWER- Encourage finger foods, distraction, speak
therapeutically
2
Q
2 days after admission from alcohol withdrawal what should the nurse do?
A
ANSWER- Monitor HR and BP
3
Q
which action should the nurse implement first for a client experiencing alcohol
withdrawal? -
A
ANSWER- prepare the environment to prevent self injury: self
4
Q
A patient won't take oral meds that is going through alcohol withdrawal. The
nurse
starts giving saline lock per alcohol protocol and thiamine. What do you tell them
that
it will help with recovery? -
A
ANSWER- Thiamine will replenish alcohol effects on
the body (something to do with iron)
5
Q
A client comes in after being in a car accident and is experiencing alcohol
withdrawal,
magnesium level of 1.1, cardiac dysrhythmias. What would you give first? -
A
magnesium
6
Q
Patient having to get treated for benzodiazepine and methadone overdose. What do
you use? -
A
narcan
7
Q
When preparing to administer a domestic violence screening tool to a female
client,
which statement should the nurse provide?
A
ANSWER- all clients are screened for
domestic abuse because it is common in our society
8
Q
a mental health care worker caring for a client with escalating aggressive behavior.
What action by the mental healthcare worker wards immediate interventions? -
A
ANSWER- -attempting to physically restrain patient
9
Q
Violence handling
A
ANSWER- - Engage in dialogue to prevent escalation,
intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for meds,
be consistent
10
Q
a 30 year old sales manager tells the nurse "i am thinking about a job change.
i don't feel like i am living
up to my potential." which of maslows developmental stages is the sales
manager attempting to achieve
A
- ANSWER- self actualization:
11
Q
A client is admitted to the mental health unit and reports taking extra anti anxiety
medication because, “I’m so stressed out. I just want to go to sleep.” The RN
should
plan one-on-one observation of the client based on which statement? -
A
“I don’t want to walk. Nothing matters anymore.”
12
Q
What is the most important goal for a client diagnosed with major depression who
has
been receiving an antidepressant medication for two weeks
A
NSWER- not
attempt to commit suicide
13
Q
The nurse is obtaining the medical histories of new clients at a community-based
primary care clinic. Which individual has the highest risk for experiencing elder
abuse? -
A
A 78 year old female on a fixed income who lives with her
relatives
14
Q
Who is most prone to being abused (elder abuse)? -
A
ANSWER- Females over 75
living with their families.
15
Q
While caring for an older client, the RN observes multiple bruises in Over the
client’s legs, arms, back, and gluteal areas. When the RN suspects elder abuse.
What action should the RN take?
A
ANSWER- Measure and document size, shape
and color of the bruised areas.
16
Q
Grief priority
A
Priority should be based on SHOCK!
17
Q
When checking a third grader’s height and weight the school nurse notes that these
measurements have not changed in the last year. The child is currently taking daily
vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder
(ADHD). Which intervention should the nurse implement?
A
ANSWER- Refer
child to the family healthcare provider
18
Q
A middle school male student was recently diagnosed with Attention-Deficit
Hyperactivity Disorder (ADHD) and is having trouble with his grades. He is
referred to the school nurse by the teacher because he continues to have learning
problems. Which action should the school nurse take?
A
ANSWER- * Refer the
child to the school counselor for educational testing
19
Q
A female client with obsessive compulsive personality disorder is admitted to the
hospital for a cardiac catheterization. The afternoon before the procedure, the client
begins to keep detailed notes of the nursing care she is receiving, and reports her
findings to the RN at bedtime. What action should the nurse implement?
A
ANSWER- Encourage the client to express her feelings regarding the upcoming
procedure.
20
Q
When preparing to administer a domestic violence screening tool to a female
client, which statement should the nurse provide
A
ANSWER- all clients are
screened for domestic abuse because it is common in our society
21
Q
A woman is being abused by her husband, the abuse is escalating. What would the
nurse ask first?
A
NSWER- Do you have a plan in place when you are not safe?
(SAFETY!!!)
22
Q
You’re having a one on one session and nurse begins to get angry at patient. -
A
ANSWER- terminate the session before the feelings escalate
23
Q
A nurse is preparing a client for the termination phase of the nurse-client
relationship. The nurse prepares to implement which nursing task appropriate for
this phase?
A
ANSWER- Making appropriate referrals
24
Q
Which action should the nurse implement during the termination phase of the
nurse-client relationship? -
A
ANSWER- Help summarize accomplishments
25
Which features are prominent in anorexia nervosa? -
ANSWER- Amenorrhea for 3
cycles; Perfectionism; Powerlessness; Rigid food rituals
26
After receiving treatment for anorexia, a student asks the school nurse
for permission to work in the school cafeteria as part of the school's
work study program. What action should the nurse take?
ANSWER- Recommend
assignment to the receptionist's office.
27
Bizarre social behavior
assess physical needs, suicide risk, ensure
safety at all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
28
Which assessment finding should indicate to the nurse that a client with arterial
HTN is experiencing a cardiac complication?
ANSWER- Shortness of breath on
exertion
29
When discussing recent onset of feelings of sadness and depression in a client with
hypothyroidism, the nurse should inform the client that these feelings are
ANSWER- Most likely related to low thyroid hormone levels and will improve
with treatment.
30
Diverticulosis signs and symptoms
ANSWER- LLQ abdominal pain
(descending/sigmoid colon)
Bloating/Gas
Fever
Nausea/Vomiting
Constipation alt. w/ diarrhea
Anorexia
31
A patient is ordered by the physician to take allopurinol (Zyloprim) for treatment
of gout. You've provided education to the patient about this medication. Which
statement by the patient requires you to re-educate them about this medication?
ANSWER- "This medication will help relieve the inflammation and pain during an
acute attack"
32
Allopurinol
ANSWER- -take after meals
- avoid alcohol
- purine-rich foods (red meat/shellfish/fructose drinks)
- increase fluids
- reduce stress
33
DM poor compliance
ANSWER- Check feet
Check visual acuity
Check sensation
34
During discharge teaching, the nurse discusses the parameters for weight
monitoring with a client who was recently diagnosed with heart failure (HF).
Which information is most important for the client to acknowledge -
ANSWERReport
weight gain of 2 pounds (0.9kg) in 24 hours
35
A male pt calls the clinic and complains because he can't tie his shoes? What
should the nurse do next?
ANSWER- Ask if the pt has gained weight in the past
few days
36
Osteoarthritis exercise
ANSWER- Aquatic exercise—improves function,
decreases pain
Remind client that excessive use of the involved joint aggravates pain and may
accelerate degeneration
37
The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis.
Which factor in this client's history is a contributor to osteoarthritis? -
ANSWERLong
distance runner since high school.
38
A client with a small bowel obstruction is experiencing frequent vomiting. Which
instructions are most important for the nurse to provide to the UAP who is
completing morning care for this client?
ANSWER- Maintain a quiet
environment
39
The nurse is caring for a client with a small bowel obstruction. The client is
vomiting foul smelling fecal-like material. Which action should the nurse
implement? -
ANSWER- Give IV fluids with electrolytes.
40
The nurse is assessing a client with a small bowel obstruction who was
hospitalized 24 hours ago. Which assessment finding should the nurse report
immediately to the healthcare provider? -
ANSWER- Rebound tenderness in the
upper quadrants
41
The nurse is developing the plan of care for a client with pneumonia and includes
the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary
secretions." Which intervention is most important for the nurse to include in the
client's plan of care?
ANSWER- Increase fluid intake to 3,000 ml/daily
42
Pneumonia Treatment/Prevention
ANSWER- oxygen therapy, hydration, bed
rest, positioning to facilitate breathing, deep breathing, humidified air, chest
physiotherapy, suctioning prn,
43
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen
with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the
patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and
an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse
observes the patient resting with closed eyes, pink coloration, a respiratory rate of
12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is
correct?
ANSWER- Decrease the oxygen to 2 L/min to improve respiratory rate
44
What are the nutritional needs of this client throughout recovery?
ANSWERAcute
phase: NPO, IV fluids
* Recovery phase: no fiber or foods that irritate the bowel
* Maintenance phase: high-fiber diet with bulk-forming laxatives
45
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis.
Which nursing intervention has the highest priority
- ANSWER- Place the client
on NPO status.
46
A nurse is caring for a client who has heart failure and has been taking digoxin
0.25 mg daily. The client refuses breakfast and reports nausea. Which of the
following actions should the nurse take first?
ANSWER- Check the client's vital
signs.
47
The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with
congestive heart failure. Which intervention should the nurse implement prior to
administering the digoxin? -
ANSWER- Assess the serum potassium level
48
A 77-year-old female client is admitted to the hospital. She is confused and has had
no appetite for several days. She has been nauseated and vomited several times
prior to admission. She is currently complaining of a headache. Her pulse rate is 43
beats/min. The nurse is most concerned about the client's history related to what
medication?
ANSWER- Digitalis (Lanoxin)
49
The nurse is administering a dose of digoxin to a patient with heart failure (HF).
The nurse would become concerned with the possibility of digitalis toxicity if the
patient reported which symptom?
ANSWER- Anorexia, nausea, vomiting,
blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity
50
IV fluids hypertonic
ANSWER- Hypertonic solutions exert an osmotic pressure
greater than that of the ECF.
When normal saline solution or lactated Ringer solution contains 5% dextrose, the
total osmolality exceeds that of the ECF
Saline 3% or 5%
3% NaCl
5% Nacl
D10W
'D20W
D50W
D5LR
51
Rheumatoid arthritis pain
ANSWER- movement causes pain, rather than
relieving pain.
Rheumatoid arthritis occurs bilaterally.
E. Morning stiffness
F. Bilateral inflammation of joints
52
PUD NGT
ANSWER- During surgery stomach contents are drained by NG tube
- Confirmation that obstruction is the cause of pt discomfort us done by assessing
the amount of of fluid aspirated a residual of >400 mL indicated obstruction
53
prostatic hyperplasia
ANSWER- Decreased force in the stream of urine is an
early symptom of benign prostatic hyperplasia
- urgency
- nocturia
- hesitancy
- decreased/intermittent stream
- incomplete emptying
- less than 50-100mL's
Assessment: palpate the bladder
BPH - don't give antihistamines - do not give decongestant, anticholinergics,
antidepressants
54
Type I DM tight control
ANSWER- glucose checks at home
- A1C should be 4-6%
*** LESS THAN 7%
55
Which intervention should the nurse include in a long-term plan of care for a client
with Chronic Obstructive Pulmonary Disease (COPD)?
ANSWER- Reduce risks
factors for infection
56
A 55-year-old male client has been admitted to the hospital with a medical
diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is
the most significant in the development of this client's COPD
ANSWER- The
client smokes 1 to 2 packs of cigarettes per day.
57
IBD - peritonitis
ANSWER- - Fluid, colloid, and electrolyte replacement is the
major focus
- Antibiotic therapy
58
The mother of a child recently diagnosed with asthma asks the nurse how to help
protect her child from having asthmatic attacks. To avoid triggers for asthmatic
attacks, which instructions should the nurse provide the mother? (Select all that
apply)
ANSWER- Close car windows and use air conditioner
Avoid sudden changes in temperature
Keep away from pets with long hair
Stay indoors when grass is being cut
59
Ulcerative colitis bloody diarrhea
ANSWER- Patients with ulcerative colitis may
experience as many as 10-20 liquid, bloody stools per day
60
Arterial insufficiency diabetic
ANSWER- arterial insufficiency symptoms
-weak pedal pulses
-shiny and cool skin
-intermittent claudication
- aching/cramping
- induced fatigue
61
Which of the following instructions should the nurse include in the teaching plan
for a client who is experiencing gastroesophageal reflux disease (GERD)? -
ANSWER- The nurse should instruct the client to not lie down for about 2 hours
after eating to prevent reflux
Minimize symptoms by wearing loose and comfortable clothes
62
Pre op labs which is abnormal
ANSWER- WBC count higher than 5,000-
10,000/mm3 = possible infection
63
Seizure unconscious pat
ANSWER- Make sure suction is available
64
While monitoring a client during a seizure, which interventions should the nurse
implement? (Select all that apply)
ANSWER- a. Move obstacle away from client
b. Monitor physical movements
d. Observe for a patent airway
e. Record the duration of the seizure
65
A pt is preparing for discharge after lithotripsy. Which intervention should
the nurse include in the client's postoperative discharge instructions?
ANSWERmonitor
urinary stream for decrease in urinary output
66
A patient returns to the medical-surgical unit after having extracorporeal shock
wave lithotripsy (ESWL). What is an appropriate nursing intervention for the
postprocedural care of this patient?
ANSWER- Strain the urine to monitor the
passage of stone fragments
67
General anesthesia - post anesthesia car
ANSWER- systolic under 90 =
immediately reportable unless baseline!!
68
Thrombocytopenia labs -
ANSWER- under 50,000 /LOW PLATELET COUNT
normal PT/PTT
prolonged Bleeding time
Thrombocytopenia: Low platelet count
Bleeding and petechiae usually do not occur with platelet counts greater than
50,000/mm3, although excessive bleeding can follow surgery or other trauma.
When the platelet count drops to less than 20,000/mm3, petechiae can appear,
along with nasal and gingival bleeding, excessive menstrual bleeding, and
excessive bleeding after surgery or dental extractions. When the platelet count is
less than 5000/mm3, spontaneous, potentially fatal central nervous system or GI
hemorrhage can occur
69
Sickle cell first sign of crisis
ANSWER- pain
- fatigue
- swollen hands and feet
- dehydration
**give oxygen, fluids, pain med, infection prevention
70
A child with possible Duchenne muscular dystrophy ( MD) undergoes an
electromyogram (EMG). Following the procedure, the child's parents tell the nurse
that the child is complaining of sore muscle. How should the nurse respond?
ANSWER- Offer reassurance that muscle soreness following this procedures is
temporary and does not indicate a problem
71
The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, "How
can our son have this disease? We are wondering if we should have any more
children." What information should the nurse provide to parents?
ANSWERThis
is an inherited X-linked recessive disorder, which primarily affects male
children in the family
72
A 4-year-old boy was recently diagnosed with Duchenne muscular dystrophy
(DMD). Which characteristic of the disease is most important for the nurse to
focus on during the initial teaching?
ANSWER- Lower legs become
progressively weaker, causing waddling, unsteady gait
73
Duchenne muscular dystrophy
- ANSWER- Duchenne muscular dystrophy appears
in early childhood (ages 3 to 5 years) (children appear normal at birth until signs
and symptoms of the disease manifest).
By the age of 9 to 11 years old, the child loses the ability to walk independently.
Life expectancy generally in the third decade
74
Febrile seizures teaching
ANSWER- febrile seizures: reassure parents febrile
seizures will go away
use seizure precautions, call 911 if lasts more than 5 minutes
75
The nurse is caring for an infant who was recently diagnosed with a congenital
heart defect. Which assessment finding is most important for the nurse to report to
the healthcare provide
ANSWER- Weight gain of 2.2 lbs (1kg) in last 48 hours
76
Which of the following should the nurse expect to note as a frequent complication
for a child with congenital heart disease?
ANSWER- Susceptibility to respiratory
infection
77
In making the initial assessment of a 2-hour-old infant, which finding should lead
the nurse to suspect a congenital heart defect?
ANSWER- Diminished femoral
pulses
78
RSV distress
ANSWER- RSV: Private room, not airborne - transferred via hand
(no mask is needed) - Standard precautions. Cool mist via tent.
Do not expose other children to RSV, it is very contagious even without direct
contact
Look for nasal flaring
79
Pyloric stenosis symptoms
ANSWER- olive shaped mass may be visible
Mass in the upper right abdominal quadrant, shaped like an olive.
S/s:- RUQ sausage shaped mass
- vomiting/ Note Degree of forcefulness of vomiting episodes
- bloody mucus stool
fever
weight loss
80
The 6-week-old infant diagnosed with pyloric stenosis has recently developed
projectile vomiting. Which assessment finding indicates to the nurse that the infant
is becoming dehydrated?
ANSWER- Weak cry without any tears.
81
The nurse is assessing an infant with pyloric stenosis. Which pathophysiological
mechanism is the most likely consequence of this infant's clinical picture
ANSWER- metabolic alkalosis (from the forceful vomiting
82
The nurse is preparing a child with an intussusception for a prescribed barium
enema. What is the main purpose of conducting this procedure prior to surgical
intervention?
ANSWER- Reduce the invaginated bowel segment
83
The nurse is caring for an infant scheduled for reduction of intussusceptions. The
day before the scheduled procedure the infant passes a soft-formed brown stool.
Which intervention should the nurse implement?
ANSWER- Notify the
healthcare provider of the passage of brown stool
84
A healthcare provider informs the charge nurse of a labor and delivery unit that a
client is coming to the unit suspected abruptio placentae. What findings should the
charge nurse expect the client to demonstrate?
ANSWER- A. dark,red vaginal
bleeding
D. increased uterine irritability
F. Rigid abdomen
85
placenta abruption s/s -
ANSWER- severe abdominal and back pain
uterine rigidity
bright red or dark vaginal bleeding
maternal hypovolemia
86
A client who is at 32 wks calls the HCP b/c she is experiencing dark red vag
bleeding. She is admitted to the ED, where the nurse determines the FHR to be
100bpm. The client's abd is rigid & boardlike, & she is complaining of severe pain.
What action does the nurse take first?
ANSWER- -Use their knowledge base to
differentiate b/w abruption & previa
-IMMEDIATELY NOTIFY HCP, & NO ABD OR VAG MANIPULATION OR
EXAMS
-ADMIN O2 BY FACEMASK
-MONITOR FOR BLEEDING AT IV SITE & GUMS B/C OF ↑ RISK FOR DIC
-EMERGENCY C-SECTION REQUIRED b/c uteroplacental perfusion to the
fetus is being compromised by early sep. of the placenta from the uterus
87
While in labor at 39 weeks' gestation, a primigravida develops a temperature of
38.2°C (100.7°F), and fetal tachycardia is noted at 170 beats per minute. The
student nurse asks the experienced nurse what this could indicate. How should the
experienced nurse respond?
ANSWER- A temperature of 38.2°C (100.7°F) may
indicate an infection such as chorioamnionitis, and the practitioner should be
notified.
88
Prolapsed Cord: Care
Care Includes: Knee to Chest position OR
Trendelenburg
89
PATIENT IS IN DELIVERY, NURSE NOTICES PRESENCE OF UMBILICAL
CORD PROTRUDING THROUGH VAGINA. WHAT WOULD YOU DO? -
ANSWER- Knee-to-chest position or Trendelenburg's, oxygen, call physician
90
A primipara with a breech presentation is in the transition phase of labor. The
nurse visualizes the perineum and sees the umbilical cord extruding from the
introitus. In which position should the nurse place the client?
ANSWER- supine
with the foot of the bed elevated.
need to aleviate pressure on the prolapsed cord.
91
Shoulder dystocia actions
ANSWER- McRoberts' maneuver and suprapubic
pressure (need step stool)
92
Variable deceleration actions
ANSWER- Change maternal position.
2. Stimulate fetus if indicated.
3. Discontinue oxytocin (Pitocin) if infusing.
4. Administer oxygen (O2) at 10 L by tight facemask.
5. Perform a vaginal examination to check for cord prolapse.
6. Report findings to physician and document.
93
Pt has variable deceleration. What is nursing action?
ANSWER- Turn her on her
side
94
Nurse discovers the postpartum client has a boggy uterus and is on the left side
ANSWER- fundal massage and administer uterotonic to increase uterine
contraction.
- give oxytocin
95
A hospitalized child stiffens and starts to seize as the nurse enters the room. What
actions should the nurse take? (Select all apply)
ANSWER- * Turn client to the
side if possible
* Pad side rails with available pillows and blankets* Monitor duration and progress
of the seizure
96
Mother brings infant complaining of vomiting and diarrhea to ER that's been
breastfeeding and introducing formula
ANSWER- Ask what kind of water are
you mixing with formula
97
How is symmetric IUGR diagnosed
ANSWER- By serial ultrasound, which is the
reason for 1st trimester ultrasound
98
Engorgement Teaching
ANSWER- Avoid nipple stimulation
Do not express milk
Place ice packs for 15 minute
Tight fitting bra or binder
99
A new mother reports breast engorgement and nipple pain on day 2 after the
delivery of a healthy newborn. The mother tells the nurse, "I'm not sure that
breastfeeding the baby is for me." What should the nurse advise the mother to do to
help relieve discomfort and encourage persevering with breastfeeding? -
ANSWER- Inform the mother that breastfeeding the newborn more frequently will
help treat these symptoms
100
A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce
breast engorgement. Which instruction should the nurse provide?
ANSWERBreastfeed
the infant every 2 hours
101
The nurse is teaching the parents of a 5-year-old child with cystic fibrosis about
respiratory treatments. Which statement indicates to the nurse that the parents
understand? -
Administer aerosol therapy followed by postural
drainage before meals.
102
A 17-year-old male student with cystic fibrosis talks with the school nurse about
his disease and wonders how it will affect getting married and having children.
Which relevant information would the nurse include in this discussion? -
ANSWER- He is likely to have infertility problems and further evaluation
103
The nurse is caring for a 6-month-old infant who has been diagnosed with
hydrocephalus.
Which of the following signs best indicates ↑ ICP in this child?
ANSWER- high
pitched cry
104
Which information is most important for the nurse to provide parents about longterm
care for their child with hydrocephalus and a VP shunt? -
ANSWER- Shunt
malfunction or infection requires immediate treatment.
105
A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped
femoral capital epiphysis (SFCE). What focus should the nurse include in this
child's plan of care?
- ANSWER- Pin and incisional care after surgery
106
The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace
that her health care provider has prescribed. Which instruction should the nurse
provide to this client?
ANSWER- Remove the brace 1 hour each day for bathing
only.
107
post-op interventions for scoliosis
ANSWER- neuro assess
-log roll 5 days
-iv fluids and pain meds
-NPO, mouth care
-NG tube, bowel sounds
-assist with ambulation
-body jacket for bone fusion
108
A postpartum client who is Rh-negative refuses to receive Rho(D) immune
globulin (RhoGAM) after delivery of an infant who is Rh-positive. Which
information should the nurse provide this client?
ANSWER- RhoGam prevents
maternal antibody formation for future Rh-positive
109
A one-day-old neonate develops a cephalhematoma. The nurse should closely
assess the neonate for which common complication?
ANSWER- Jaundice
110
A client with hemophilia has a very swollen knee after falling from bicycle riding.
Which of the following is the first nursing action?
ANSWER- apply ice pack and
compression dressings to the knee
111
A toddler with hemophilia is being discharged from the hospital. Which teaching
should the nurse include in the discharge instructions to the mother?
ANSWERapply
padding to sharp edges
112
A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing
around when a blood specimen is obtained.The child's color becomes blue and
respiratory rate increases to 44 bpm.Which of the following actions would the
nurse do first?
ANSWER- place the child in knee-to-chest position
113
During a follow up clinical visit a mother tells the nurse that her 5 month old son
who had surgical correction for tetralogy of fallot has rapid breathing, often takes a
long time to eat, and requires frequent rest periods. The infant is not crying while
being held and his growth is in the expected range. Which intervention should the
nurse implement?
ANSWER- Auscultate heart and lungs while infant is held
114
Chronic kidney disease & metabolic acidosis -
ANSWER- kidneys fail, no longer
reabsorb HCO3 (bicarb), serum bicarbonate decrease = acidosis occurs
** sodium bicarb administration
115
Pulmonary edema first action - getting out of bed
ANSWER- high fowlers, dangle the legs
116
RN is caring for client w DX of HF who suddenly experiences dyspnea & RN
suspects pulmonary edema. RN immediately:
ANSWER- Answer: Places client
in high fowlers
feet hanging over edge of bed
117
The nurse is caring for several clients on a telemetry unit. Which client should the
nurse assess first? The client who is demonstrating? -
ANSWER- Normal sinus
rhythm and complaining of chest pain
118
normal sinus rhythm
ANSWER- 60-100 bpm
P wave always in front
P:QRS ratio 1:1
119
Diabetes insipidus -
ANSWER- Dry Inside
diabetes insipidus (DI) = makes you want to SIP water
Diabetes insipidus - dysuria, dysphagia, low urine specifity gravity, wgt loss, NA+
is high, high blood sugar
-Caused by a deficiency of production of ADH or a decreased renal response to
ADH.
-Clinical Manifestations: Polydipsia and Polyuria.
-Diagnostic Studies: Water deprivation test (pt deprived of water for 8-12 hrs and
then given desmopressin acetate subcut or nasally), Measure level of ADH after an
analog of ADH is given
120
PE report findings
ANSWER- INCREASE D-DIMER!!!
121
Glaucoma signs and symptoms
ANSWER- loss of peripheral vision
halo around lights
reddened sclera
mild aching
headache
** tonometry diagnose between the two (open and closed angle)
IOP pressure - 30mmhg is glaucoma
122
Guillain barre assess
ANSWER- watch for shallow/rapid breathing, ask if
cold/stomach flu in last month
123
CVA expressive aphasia
ANSWER- sg assessment: inability to speak/understand
language
(Left Side = Language)
A patient is admitted to the ER with expressive aphasia. To further assess the
patient, the nurse should include which of the following techniques:
Give them picture charts to communicate
124
Cardiomyopathy care plan -
ANSWER- A. Monitor vital signs at least every 4
hours for changes.
B. Monitor apical HR with vital signs to detect dysrhythmias, or abnormal heart
sounds such as S3 or S4.
C. Assess for hypoxia.
1. Restlessness
2. Tachycardia
3. Angina
F. Elevate head of bed to assist with breathing.
G. Observe for signs of edema.
1. Weigh daily.
2. Monitor I&O.
3. Measure abdominal girth; observe ankles and fingers
125
A client sustains a complex comminuted fracture of the tibia with soft tissue
injuries after being hit by a car while riding a bicycle. Surgical placement of an
external fixator is performed to maintain the bone in alignment. Postoperatively it
is most essential for the nurse to?
ANSWER- Perform a neurovascular
assessment of both lower extremities
126
One day following an open reduction and internal fixation of a compound fracture
of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse
determines the client's left pedal pulses are diminished. Based on these findings,
what is the client's greatest risk? -
ANSWER- Neurovascular and circulation
compromise related to compartment syndrome
127
The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention
ANSWERDeep
unrelenting pain in the right arm
128
Stroke broca's area
ANSWER- Stroke in Broca's area of left cerebral cortex
Answer: Listen patiently
- expressive aphasia usually occurs
-paralyzed on right side
129
A patient has Broca's aphasia. Which lobe of the brain does the nurse anticipate to
have been affected by a stroke?
ANSWER- The frontal lobe of the brain is related
to reasoning, planning, parts of speech, movement, emotions, and problem solving
130
Acute pancreatitis assessment
ANSWER- rigid board like abdomen
131
A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test
result is most indicative of acute pancreatitis
ANSWER- Serum amylase
132
Cirrhosis ascites dyspnea
- ANSWER- As the ascites increases, the client is likely
to experience dyspnea because the fluid build-up puts pressure on the diaphragm
133
A female pt was in an MVC and admitted with a fractured L femur. Nurse
assessment include diminished pulses. What should the nurse do next? SATA
ANSWER- Verify pedal pulses with a Doppler
Monitor L leg for pain, pulselessness, pallor,paralysis
Evaluate the app of the splint to the L leg
134
Pt with Addison's has started taking hydrocortisone in a divided dose. What should
the nurse do next?
ANSWER- Monitor pt's glucose
135
If Hypoglycemia occurs during Addison's crisis, what should the nurse do?
ANSWER- Administer IV glucose
136
Chemo side effects
ANSWER- * Nausea and vomiting
* Bone marrow suppression
* Alopecia
* Weight gain or loss
* Anorexia
* Fatigue
* Decline infunctional status
* Mucositis
* "Chemo" Brain
137
The nurse formulates the nursing diagnosis of Urinary retention related to
sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention
should the nurse implement?
ANSWER- Teach the client techniques of
intermittent self-catheterization.
138
Meningitis first step
ANSWER- Antibiotics - penicillin (ampicillin) AND
cephalosporin
o Corticosteroids
After the diagnosis of meningitis is confirmed, isolation is required for 24 to 72
hours after the institution of antibiotic therapy
139
The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse
would plan which of the following as a priority action?
ANSWER- place the
client on a cardiac monitor
140
The client hemodialyzed suddenly becomes short of breath and complains of chest
pain. The client is tachycardic, pale and anxious. The nurse suspects air embolism.
The priority action for the nurse is to -
ANSWER- discontinue dialysis and notify
the physician
141
End of life plan of care -
ANSWER- Pain management is a priority in end-of-life
care because untreated or undertreated pain consumes energy; interferes with
function; affects quality of life and social interactions; and contributes to sleep
142
A nurse is caring for a client who has Cushing's syndrome. Which of the following
clinical manifestations should the nurse expect to observe? (Select all that apply.)
ANSWER- 1) Buffalo hump
2) Purple striations
3) Moon face
143
The nurse is developing a plan of care for a client with Cushing's syndrome. The
nurse documents a client problem of excess fluid volume. Which nursing actions
should be included in the care plan for this client? Select all that apply.
ANSWER- Answer: Monitor daily weight.
Monitor intake and output.
Assess extremities for edema
144
When conducting discharge teaching for a client who has had a mechanical valve
replacement, which information should the nurse plan to include?
ANSWERThe
client will need to take an antibiotic before dental procedures.
ANTIBIOTIC PROPHYLAXIS FOR DENTAL PROCEDURES!!
145
The home health care nurse is caring for a client with cancer who is complaining of
acute pain. The most appropriate determination of the client's pain should include
which assessment?
ANSWER- The client's pain rating
146
A female client who has breast cancer with metastasis to the liver and spine is
admitted with constant, severe pain despite around-the-clock use of oxycodone
(Percodan) and amitriptyline (Elavil) for pain control at home. During the
admission assessment, which information is most important for the nurse to
obtain?
ANSWER- Sensory pattern, area, intensity, and nature of the pain
147
A client is admitted to the hospital with intractable pain. What instruction should
the nurse provide the UAP who is assisting with a bed bath? -
ANSWER- Take
measures to promote as much comfort as possible
148
A client with GERD is being treated with dietary management. The client states, "I
like to have a glass of juice everyday." Which juice will the nurse recommend?
Answer: Apple Juice
149
A primary healthcare provider prescribes a low-sodium, high-potassium diet for
client with Cushing Syndrome. Which explanation should the nurse provide to the
client about the need to follow this diet?
Answer: "Excessive aldosterone and cortisone cause retention of sodium and loss
of potassium."
150
Two clients with polydipsia and polyuria arrived at the hospital. Both were having
similar symptoms but were diagnosed with different types of diabetes insipidus.
Which assessment finding helped to differentiate the diagnosis?
Answer: Urine Osmolarity
151
A client has a history of GERD. Why should the nurse monitor the client for
clinical manifestation of heart disease?
Esophageal pain may imitate the symptoms of a heart attack
152
A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes
about self-care. What is the primary long-term goal this nurse and client should
agree on?
Maintaining normoglycemia
153
The nurse is caring for a client before, during and immediately after surgery.
Which type of care is provided to the client?
Care that supports homeostatic regulation
154
A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection.
The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and
is in the 10th percentile for both height and weight. What is the priority nursing
intervention?
Performing postural drainage
155
A nurse is planning to teach a school-aged child with newly diagnosed type 1
diabetes about self-care. After an assessment of what the child knows about
diabetes, what is the next nursing intervention?
Developing a sequence of goals with the child and parent
156
The nurse concludes that a client with glaucoma needs education when the client
makes which statement?
"It is dangerous for me to use sedatives."
Sedatives have no effect on intraocular pressure
157
A mother reports feeding her infant immediately before arriving in the emergency
department. After completing the assessment, the nurse reports which finding
immediately to the primary healthcare provider because it likely indicated pyloric
stenosis?
Peristaltic waves that transverse the epigastrium.
158
The registered nurse is teaching a student nurse the points to be included while
educating a client on cortisol replacement therapy about self-management. Which
statement provided by the student nurse indicates the need for further teaching
"I will advise the client to take the medication before meals."
159
Two clients with polydipsia and polyuria arrived at the hospital. Both were having
similar symptoms but were diagnosed with different types of diabetes insipidus.
Which assessment finding helped to differentiate the diagnosis?
Urine osmolarity
160
A client with stage 3 Alzheimer's disease is living with his son and daughter-inlaw.
The visiting nurse is educating the family about the progression of the illness,
including "sundown syndrome," and is assisting with care planning and comfort
measures. Which statement by the daughter-in-law reflects that the teaching has
been effective?
"We will have locks placed at the top of all the outside doors."
Rationale:
Placing locks at the top of the doors is an important safety intervention. The term
"sundown syndrome" refers to behaviors that become more pronounced in the
evening. Clients with late stage dementia are prone to wandering, especially at
night.
161
A student nurse working as an aide in a memory care facility asks the charge nurse
if there is a neurobiological basis for the deterioration in cognitive function in
Alzheimer's disease. Which explanation by the nurse is correct regarding the
etiology of neurocognitive decline?
"Decreases in neurotransmitters affect parts of the brain responsible for memory."
Rationale:
Neurocognitive decline is associated with changes in neurotransmitter
concentration. Alzheimer's disease has been linked with a decrease in the
production and function of acetylcholine (ACh). Alzheimer's disease affects an
area of the brain called the nucleus basalis, which contains cholinergic neurons.
These neurons provide ACh to areas of the brain responsible for memory and
learning.
162
A client with long-term alcohol addiction is admitted to the emergency department.
Which medications should the nurse anticipate the healthcare provider will
prescribe for this client?
Diazepam.
Multivitamins.
Thiamine (vitamin B1).
Rationale:
Alcohol withdrawal delirium usually peaks 48-72 hours since last consumption of
alcohol. The diazepam has sedative and anticonvulsant properties. Thiamine and
multivitamins are usually given to help with nutritional and malabsorption
deficiencies common in clients with alcohol addiction
163
A client with stage 2 Alzheimer's disease is being cared for at home by the spouse.
The client's spouse tells the nurse about the emotional difficulties involved in
providing fulltime care at home. Which self-care activity is most important for the
nurse to recommend to the spouse?
Periodic times of respite from caregiving.
Rationale:
Caregiver role strain may be attributed to many different factors. The nurse must
become familiar with this diagnosis in order to accurately assess the caregiver and
offer effective interventions. One important recommendation is to have the
caregiver incorporate periodic breaks as part of the daily routine to relieve stress.
The nurse should contact the client's manager and provide the client's caregiver a
list of agencies offering "Respite Care".
164
The nurse is counseling a client who is dealing with complicated grief over the
death of a spouse. Which statement reflects the most desirable outcome for the
client?
The client will attend a surviving spousal support groups.
Rationale:
A major outcome of grief counseling is to assist the client in sharing their loss and
to accept support from others. It is critical for the spouse to share the feelings of
loss and grief in a supportive interpersonal environment. Complicated grief is a
consistent state of sadness associated with a great loss. It is suspected that there
may be a relationship between complicated grief and adjustment disorder. Most
people go through the stages of grief at their own pace. Individuals dealing with
complicated grief have difficulty progressing through the stages and it may take
over a year or more to resolve their sense of lost.
165
The nurse and the treatment team establish a weekly weight gain goal for a client
with anorexia nervosa. The client agrees to the goal, but continues to engage in
vigorous exercise before the weight gain goal has been met. Which statement by
the nurse is most effective in this situation?
"According to our agreement, no exercising is permitted until you have reached
your goal."
Rationale:
Clients must be held accountable for behaviors that are not consistent with
treatment plan goals. The nurse is correct to remind client about the previously
established weight gain goals and to state that exercise should be limited (or not
permitted) until the weekly goal has been achieved.
166
Which behaviors indicate that the treatment plan for a client in alcohol
rehabilitation has been effective?
Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has
spoken with employer about returning to work.
Rationale: The statement "one day at a time" reflects the Alcoholics Anonymous
(AA) philosophy. AA promotes a 12-step program that has been successful in
helping individuals who desire to stop drinking and abusing substances.
Individuals learn about sobriety and responsibility through the support of other
members.
167
A client is admitted due to alcohol intoxication and injuries sustained in a fall. The
client appears anxious, agitated, and diaphoretic. Vital signs include a pulse of 140
and a blood pressure of 170/98. Delirium is suspected due to the client's claim that
bugs are crawling on the bed. Which medication should the nurse expect will be
administered to the client?
Chlordiazepoxide (Librium).
Rationale: The information provided indicates that the client is experiencing
alcohol withdrawal, and is therefore at an increased risk for seizures.
Chlordiazepoxide (Librium) raises the seizure threshold to reduce the risk of
convulsions.
168
A newly admitted client diagnosed with schizophrenia who is physically healthy
believes that they are in the process of dying and their body is actively decaying
and falling apart. Which intervention for this client should the nurse implement?
Discuss what they are feeling and acknowledge their fear and anxiety.
Rationale: The client's delusion of dying and their body decaying is their reality.
The nurse should identify and focus on the client's feelings and discuss those and
try to divert the client's preoccupation of the delusion.
169
A client is undergoing treatment for schizophrenia. Which outcome provides
evidence that the client's negative symptoms are improving?
Participates in music therapy and states that he enjoys playing the drums.
Rationale: An inability to experience pleasure and a desire to remain isolated are
examples of negative symptoms exhibited by clients with schizophrenia. By
participating in therapy and expressing enjoyment, the client shows a decrease in
negative symptoms and evidence that the treatment is being effective
170
During a meeting with the interdisciplinary treatment team, a client in the acute
phase of schizophrenia states that she cannot return to live with her parents because
they are trying to kill her. Which statement by the team leader represents a correct
therapeutic response?
"That must be very frightening; tell us why you believe you are in danger."
Rationale: The acute phase of illness is characterized by reality impairment and
paranoia; it is not useful to debate or contradict a delusion while a client is in the
acute phase. Attempting to see things from the client's perspective will build trust,
which is the basis for an effective therapeutic relationship.
171
The emergency department nurse is providing care for a rape victim. Which action
represents an essential element of care for this client?
Providing nonjudgmental care.
Rationale: The nurse's attitude can have an important therapeutic effect on the
victim of rape. Displays of shock, horror, disgust, or disbelief can increase anxiety
and shame. When providing care for a rape victim, it is essential to maintain a
nonjudgemental attitude, and to let the client talk while listening attentively
172
A newborn yellow abdomen and chest
Assess bilirubin level
173
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal
bleeding after the IV Pitocin is infused. When notifying the healthcare provider of
the condition, what information is most important for the nurse to provide?
Maternal blood pressure
174
A 36-week primigravida is admitted to labor and delivery with severe abdominal
pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch.
The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120
beats/minute. What action should the nurse implement first?
obtain written consent for an emergency cesarean section
175
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration.
The nurse determines that the increased respiratory rate is a compensatory
mechanism for wich acid base alteration?
Metabolic acidosis
176
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after
spontaneous rupture of the membranes, the nurse notes several sudden decreases in
the fetal heart rate with quick return to baseline, with and without contractions.
Based on this fetal heart rate pattern, which intervention is best for the nurse to
implement?
Place the client in a slight Trendelenburg position.
The goal is to relieve pressure on the umbilical cord, and placing the client in a
slight Trendelenburg position is most likely to relieve that pressure. The FHR
pattern is indicative of a variable fetal heart rate deceleration, which is typically
caused by cord compression and can occur with or without contractions.
177
The nurse calls a client who is 4 days postpartum to follow up about her transition
with her newborn son at home. The woman tells the nurse, "I don't know what is
wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which
adjustment phase should the nurse determine the client is experiencing
Postpartum blues
During the postpartum period, when serum hormone levels fall, women are
emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth postpartum day.
The taking-in phase is the period following birth when the mother focuses on her
own psychological needs; typically, this period lasts for 24 hours. Crying is not a
maladaptive attachment response. It indicates a normal physical and emotional
response. The letting-go phase is when the mother sees the child as a separate
individual.
178
The Total bilirubin of a 36-hour, breastfeeding newborn is 14mg/dL. Based on this
finding, Which intervention should the nurse implement?
Encourage the mother to breastfeed frequently.
179
A multigravida client arrives at the labor and delivery unit and tell the nurse that
her "bag of water" has broken. The nurse identifies the presence of meconium fluid
on the perineum and determines the fetal heart rate is between 140 to 150 bpm.
What action should the nurse implement next?
Complete a sterile vaginal exam.
A vaginal exam should be preformed after the rupture of membranes to determine
the presence of a prolapsed cord.
180
A HCP informs the charge nurse of a labor and delivery unit that a client is coming
to the unit with suspected abruption placentae. What findings should the nurse
expect the client to demonstrate?
Dark, red vaginal bleeding.
Increased uterine irritability.
A rigid abdomen.
181
A woman who gave birth 48 hours ago is bottle feeding her infant. During
assessment, the nurse determines that both breasts are swollen, warm, and tender
upon palpation. What action should the nurse take?
Apply cold compress to both breast for comfort
182
When explaining "postpartum blues" to a client who is one day postpartum, which
symptoms should the nurse include in the teaching plan?(Select all that apply)
-Mood swings
-Tearfulness
183
risk factor for abruptio placentae
HTN
184
A client with obsessive-compulsive personality disorder is admitted for
laparascopic surgery of the gallbladder. What is the nurse likely to observe in the
client prior to surgery?
Client keeps detailed notes of everything that is said by the nurse about the
procedure and the postoperative instructions.
Rationale: OCD is characterized by an occupation with control. Patients are very
perfectionistic and rigid in their behavior and thought patterns. Taking detailed
notes of everything being said is an attempt to regain control in a stressful
situation.
185
A client is experiencing symptoms of alcohol withdrawal. During which interval is
the client most likely to develop a seizure?
12 to 48 hours after the last drink.
Rationale: The risk for seizures is highest 12 to 48 hours after the last drink.
186
A client with schizophrenia suddenly becomes very anxious and says that an evil
alien is trying to get him. What should the nurse do at this time?
Relocate the client to the assigned room and suggest doing a puzzle together.
Rationale: the nurse should distract an anxious client with a non-threatening
activity in a low stimuli environment. Solving a puzzle together in the client's room
will help reduce anxiety
187
A client with an anxiety disorder is having trouble completing work because
emails need to be reread several times before sending to ensure nothing
inappropriate is written. Which disorder is this client most likely experiencing?
Obsessive-compulsive disorder (OCD).
Rationale: client with OCD present with a combination of repetitive thoughts and
specific fears (obsession), as well as stereotyped, ritualized behavior (compulsions)
that are used to reduce that fear
