Nursing Case Studies: Neurological and Respiratory Compromised Clients, Exams of Nursing

Download Nursing Case Studies: Neurological and Respiratory Compromised Clients and more Exams Nursing in PDF only on Docsity! RN 2024 EXIT EXAM Questions with 100% Correct Answers. When preparing to administer a prescribed medication to a homeless client at a community psychiatric clinic. The client tells the nurse that the usual dosage taken is different from the dose the nurse is giving. Which action should the nurse take? A) Inform the client that he may refuse the medication and document whether or not the client takes it. B) Withhold the medication until the dosage can be confirmed. C) Explain to the client that the dosage has been changed. D) Tell the client to take the medication then verify the dosage at the next healthcare team meeting. - Correct answer B) Withhold the medication until the dosage can be confirmed. The charge nurse is making assignments for one practical nurse and three registered nurses who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN? A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60. B) Viral meningitis whose temperature change from 101 S to 102F. C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7. D) Myxedema, whose blood pressure change from 80/50 to 70/40. - Correct answer B) Viral meningitis whose temperature change from 101 S to 102F. The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care? A) Maintain strict intake and output. B) Keep head of bed raised 45°. C) Excess warmth of extremities. D) Monitor blood glucose level. - Correct answer A) Maintain strict intake and output. And adolescent client is admitted to the hospital because of writing a suicide note to a teacher at school. On the second day of hospitalization, the nurse asked the client to meet with the treatment team. After the team meeting, the client leaves in tears and goes to their room. Which nursing intervention is best? A) Let the client rest quietly in their room for a while. B) Explore the clients goals and desire for treatment. C) Ask the treatment team about the clients behavior. D) Go to the clients room and ask what happened. - Correct answer D) Go to the clients room and ask what happened. The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a client who weighs 154 pounds. The medication is available and 25,000 units per milliliter vial. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest 10th.) - Correct answer 0.6 NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency department last night when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. Which two orders should the nurse complete first? A) Sputum culture. B) Start oxygen 3 L per minute via nasal cannula. C) Place the client on a cardio respiratory monitor. D) Chest x-ray. E) Acetominophen 350 mg PO every six hours for temperature control. F) Run 0.9% sodium chloride IV infusion at 150 mL per hour. G) Start peripheral IV. H) NPO. - Correct answer B) Start oxygen 3 L per minute via nasal cannula. C) Place the client on a cardio respiratory monitor. seconds. Heart rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89, temperature 100.2 F, respiratory rate 28 BPM. 0500: Placedthe client in semi-Fowlers position. No improvement in oxygen saturation on 3L nasal cannula... (Which are the three most important goals?) A) The client will remain free of skin breakdown. B) The client will have quit smoking. C) The client will be afebrile for 24 hours. D) The client will maintain oxygen saturation of 96% without supplemental oxygen. E) The client will report pain less than 3/10. - Correct answer B) The client will have quit smoking. C) The client will be afebrile for 24 hours. E) The client will report pain less than 3/10. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch toys by the client indicates that the teaching was effective? A) A peanut butter sandwich with soda and cookies. B) Vegetable soup, crackers, and milk. C) A tuna fish sandwich with chips and ice cream. D) A salad with three kinds of lettuce and fruit. - Correct answer C) A tuna fish sandwich with chips and ice cream. A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected MRSA. Which nursing intervention should the nurse include in the plan of care? SATA. A) Institute contact precautions for staff and visitors. B) Use standard precautions and wear a mask. C) Send wound drainage for culture and sensitivity. D) Monitor the clients white blood cell count. E) Explain the purpose of a low bacteria diet. - Correct answer A) Institute contact precautions for staff and visitors. C) Send wound drainage for culture and sensitivity. D) Monitor the clients white blood cell count. An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? A) Weight loss of 10 pounds in the past month. B) Six hours of sleep in the past three days. C) Blood alcohol level of 0.09%. D) Serum lithium level of 1.6. - Correct answer D) Serum lithium level of 1.6. When conducting diet teaching for a client who is on a post operative full liquid diet, which foods should the nurse encouraged the client to eat? SATA. A) Clear beef broth. B) Vanilla frozen yogurt. C) Vegetable juice. D) Creamy peanut butter. E) Canned fruit cocktail. - Correct answer A) Clear beef broth. B) Vanilla frozen yogurt. C) Vegetable juice. An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for internal feedings after corrective surgery. To promote normal growth and development of the infant, which action should the nurse include in the plan of care? - Correct answer Offer a pacifier for non-Nutritive sucking The nurse is preparing a four year-old client with a serum bilirubin level of 19 for discharge from the hospital. When teaching the parents about home photo therapy, which instruction should the nurse include in the discharge teaching plan? A) Cover with a receiving blanket. B) Perform diaper changes under the light. C) Feed the infant every four hours. D) Reposition the infant every two hours. - Correct answer D) Reposition the infant every two hours. The nurse initiate the procedure to remove a clients peripherally inserted central catheter when a code blue is called for another client in the unit who collapse in the hallway while ambulating with the unlicensed assistive personnel. Which action should the nurse take? A) Close the room door. B) Finish the procedure. C) Respond to the code. D) Call for an assistant. - Correct answer B) Finish the procedure. Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium? A) Maintain a quiet, non-stimulating environment. B) Confront the clients denial of substance abuse. C) Force oral fluids and provide frequent small meals. D) Encourage attendance and group participation. - Correct answer A) Maintain a quiet, non-stimulating environment. A client arrives at the emergency department describing chest pain that began three hours earlier which has not subsided. To assess the quality of the clients chest pain. Which approach for the nurse use? A) Provide a numeric pain scale. B) Ask the client to describe the pain. C) Identify effective pain relief measures. D) Observe body language and movement. - Correct answer B) Ask the client to describe the pain. An adolescent who was diagnosed with type one diabetes Molite us at the age of nine, is admitted to the hospital in diabetic keto acidosis. Which occurrence is the most likely cause of the keto acidosis? A) Ate an extra peanut butter sandwich before gym class. B) Incorrectly administered too much insulin. C) Had a cold and ear infection for the past two days. D) Skipped eating lunch while at school. - Correct answer C) Had a cold and ear infection for the past two days. C) Help the client unless the help of friends and family. F) Refer the client for cognitive behavioral therapy. The client is a 26 year old female who was in a car accident six months ago that killed her mother, husband, and two year old son. She and her father were the only survivors of the crash. She is seeking care for depression. (which findings are effective or ineffective) -The client states she feels less jumpy and more relaxed. -The client states she feels numb when thinking about the crash. -The client talks to her father and her best friend when she starts to feel sad. -The client reports sleeping 6 to 7 hours per night. -The client states that she avoids driving altogether and takes the bus. - Correct answer -The client states she feels less jumpy and more relaxed. (EFFECTIVE) -The client states she feels numb when thinking about the crash. (INEFFECTIVE) -The client talks to her father and her best friend when she starts to feel sad. (EFFECTIVE) -The client reports sleeping 6 to 7 hours per night. (EFFECTIVE) -The client states that she avoids driving altogether and takes the bus. (INEFFECTIVE) The healthcare provider prescribes acarbose, an alpha-glucosidase inhibitor, for a client with type two diabetes. Which information provides the best indicator of the drugs effectiveness? A) Body mass index between 20 and 24. B) Blood pressure readings less than 120/80. C) Self-reported glucose levels 120 to 150. D) Hemoglobin A1c readings less than 7%. - Correct answer D) Hemoglobin A1c readings less than 7%. After receiving report on an inpatient acute care unit which client should the nurse assess first? A) The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. B) The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. C) The client with an obstruction of the large intestine who is experiencing abdominal distention. D) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. - Correct answer D) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. Client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone and a low T3 and T4 levels. After the client is admitted to the telemetary unit, which intervention is most appropriate for the nurse to implement? A) administer prescribed dose of level thyroxine. B) Note clients most recent hemoglobin level. C) Offer additional blankets and a warm drink. D) Assess for the presence of nonpitting edema. - Correct answer A) administer prescribed dose of level thyroxine. While caring for a client post operative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take? A) Determine if the drainage has an unpleasant odor. B) Cleanse the wound with a sterile saline solution. C) Monitor the clients white blood cell count. D) Request a culture and sensitivity of the wound. - Correct answer D) Request a culture and sensitivity of the wound. The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student screening record? A) Lateral curvature that creates a symmetry of the shoulders. B) Posterior curvature that is convex in the thoracic area. C) Excessive concave curvature of the lumbar spine. D) Rounded spine from head to hips without concave curbs. - Correct answer C) Excessive concave curvature of the lumbar spine. The nurse is assigned to care for for surgical clients. After receiving report, which client should the nurse see first? A) An older client who is receiving packed red blood cells on the third day post operative for colon resection. B) An older client with continuous bladder irrigation who is two days post operative for bladder surgery. C) An adult who is in bucks traction, and scheduled for hip arthroplasty within the just 12 hours. D) An adult one day post operative laparoscopic cholecystectomy requesting pain medication. - Correct answer A) An older client who is receiving packed red blood cells on the third day post operative for colon resection. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situation and perceived stress. In addition to information about prescribe medication and administration, which instruction should the nurse include in the teaching? A) Think about reasons the episodes occur. B) Center attention on positive upbeat music. C) Practice using muscle relaxation techniques. D) Find outlets for more social interaction. - Correct answer C) Practice using muscle relaxation techniques. The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendations should the nurse provide this client? SATA. A) Use a residual limb shrinker. B) Inspect skin for redness. C) Apply alcohol to the residual limb after bathing. D) Wash the residual limb with soap and water. E) Avoid range of motion exercises. - Correct answer A) Use a residual limb shrinker. B) Inspect skin for redness. D) Wash the residual limb with soap and water. G) Echocardiogram. - Correct answer B) Blood gases. D) Complete blood count. F) Chest radiograph. NGN: Nurses Notes, saturation is low. Noted cyanosis in the clients lips. Healthcare provider made aware. 1310: pain rating for on a pain scale of 0 to 10. Temperature elevation noted. The client is anxious and using accessory muscles to breathe. Alerted the surgeon about the client status. New orders noted. (what does the nurse need to document at 1330? SATA) A) urine output. B) Respiratory rate. C) Blood pressure. D) Pain. E) Temperature. F) Flow rate of oxygen. G) Oxygen saturation. - Correct answer B) Respiratory rate. C) Blood pressure. D) Pain. E) Temperature. G) Oxygen saturation. NGN: Match the activity with the most appropriate person to do the activity. -Provide mouth care. -Document changes in respiratory status. -Set up the oxygen administration system. -Change the gauze under the nasal cannula. - Correct answer -Provide mouth care. (UAP) -Document changes in respiratory status. (RN/RT) -Set up the oxygen administration system. (RN/RT) -Change the gauze under the nasal cannula. (UAP) A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare? A) IV administration of benztropine. B) IV administration of isotonic crystalloid fluid. C) PO administration of lorazepam. D) PO administration of divalproex. - Correct answer A) IV administration of benztropine. A client with heart failure become short of breath, anxious, and has audible reasoning with pink frothy sputum. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one time dose of morphine sulfate IV. Which action should the nurse take? A) Administer the dose of morphine sulfate as prescribed. B) Consult with the charge nurse regarding the morphine prescription. C) Review the need for the prescription with the healthcare provider. D) Withhold the morphine until the clients dyspnea resolves. - Correct answer A) Administer the dose of morphine sulfate as prescribed. A client with acute asthma exacerbation is manifesting inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which prescribed drug class should the nurse administer first to the client? A) Inhaled short acting beta two agonists. B) Inhaled corticosteroids. C) Anti-cholinergics. D) Leukotriene modifiers. - Correct answer B) Inhaled corticosteroids. The nurse enters a clients room to administer oral medication's and find an unlicensed assistive personnel providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action? A) Determine why the UAP did not notify the nurse of the change in the clients condition. B) Advised the UAP to stop providing care so the nurse can assess the clients condition. C) Explain to the UAP that changes in a clients condition should be reported immediately. D) Ask for UAP to position the client so the oral medication's can be administered. - Correct answer B) Advised the UAP to stop providing care so the nurse can assess the clients condition. The client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge IV catheter with 0.9% sodium chloride is infusing at a rate of 150 mL per hour. Which intervention should the nurse implement first? A) Discontinue the 24 gauge IV. B) Establish a second IV site. C) Stop the 0.9% sodium chloride infusion. D) Assess the IV for blood return. - Correct answer C) Stop the 0.9% sodium chloride infusion. Client should the nurse assess frequently because of the risk for overflow incontinence? A) a client with hematuria and decreasing hemoglobin and hematocrit levels. B) A client who has been fast, with increased serum creatinine levels. C) A client who is confused and frequently forgets to go to the bathroom. D) A client who has a history of frequent urinary tract infections. - Correct answer C) A client who is confused and frequently forgets to go to the bathroom. After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? SATA. A) Location of the initial IV site. B) Swollen lymph nodes in the groin. C) Red blood cell count. D) White blood cell count. E) Core body temperature. - Correct answer B) Swollen lymph nodes in the groin. D) White blood cell count. E) Core body temperature. A client develops your to Caria on the trunk and neck shortly after a secondary infusion of pepper Sillen is initiated. In which order should the nurse implement these interventions? Document reaction of the drug. During discharge teaching, and overweight client with heart failure is asked to make a grocery list for the nurse to review. Which food choices include it on the clients list should the nurse encouraged? SATA. A) Cheddar cheese cubes. B) Canned fruit in heavy syrup. C) Lightly salted potato chips. D) Plain, air-popped popcorn. E) Natural whole almonds. - Correct answer D) Plain, air-popped popcorn. E) Natural whole almonds. A client is receiving IV fluids by gravity infusion and exhibit signs of fluid volume overload. When assessing the clients IV delivery system, where should the nurse assess first? - Correct answer A I can't see all the pics. Use the clamp on the IV tubing. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? SATA. A) Widen stance while working near the sink. B) Leans forward to pull a pan from a high shelf. C) Tenths from the waist to pick trash off the floor. D) Brings a heavy can close to body before lifting. E) Lots knees while preparing food on the counter. - Correct answer A) Widen stance while working near the sink. D) Brings a heavy can close to body before lifting. A client is receiving methylamine 800 mg PO three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication? A) Bowel patterns. B) Pupillary response. C) Peripheral pulses. D) Oxygen saturation. - Correct answer A) Bowel patterns. Ulcerative colitis medication that helps reduce inflammation in the G.I.. Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspect the client may have had a pulmonary embolus. Which action should the nurse take first? A) Provide supplemental oxygen. B) Prepare a continuous heparin infusion per protocol. C) Bring the emergency craft cart to the bedside. D) Notify the healthcare provider. - Correct answer A) Provide supplemental oxygen. The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take? A) Monitor daily sodium intake. B) Auscultate for a regular heart rate. C) Document abdominal girth. D) Measure ankle circumference. - Correct answer B) Auscultate for a regular heart rate. The older adult client who has difficulty hearing is being discharged from the day surgeries following a cataract extraction and lens in plantation. Which intervention is most important for the nurse to implement to help ensure the client compliant with self-care? A) Ensure that someone will stay with the client for 24 hours. B) Have a client vocalize the instructions provided. C) Speak clearly and face the client for lip reading. D) Provide written instructions for eyedrop administration. - Correct answer B) Have a client vocalize the instructions provided. NO QUESTION 68 - Correct answer Well making rounds, the charge nurse notices that a young adult client with asthma who has admitted yesterday is sitting on the side of the bed and leaning over the side table. The client is currently receiving oxygen at 2 L per minute via nasal cannula. The client is wheezing and is using per slip breathing. Which intervention should the nurse implement? A) Increase oxygen to 6 L per minute. B) Call for an Ambu resuscitation bag. C) This is the client to lie back in bed. D) Administer a nebulizer treatment. - Correct answer D) Administer a nebulizer treatment. An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which non-pharmacological intervention should the nurse implement? A) Clarify reality with the client about delusional thoughts. B) Use distraction and therapeutic communication skills. C) Reduce the clients interaction with others during the day. D) Awakening the client for reality checks every four hours at night. - Correct answer B) Use distraction and therapeutic communication skills. Four hours after surgery, a client reports nausea and begins to vomit. The nurse knows that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take? A) Reposition the transdermal patch to the clients trunk. B) Remove the transdermal patch until the vomiting subsides. C) Notify the clients healthcare provider of the vomiting. D) Explain that this is a side effect of the medication in the patch. - Correct answer C) Notify the clients healthcare provider of the vomiting. This medication is used for nausea and the provider should be made aware if the medication is not effective. The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. Which action should the nurse take? SATA. A) Instruct the adult child to check the clients temperature. B) Encourage increased intake of high protein foods. C) Determine if the client has recently experienced a fall. D) Reviewed the clients current food and medication allergies. E) Ask if the client is experiencing any pain with urination. - Correct answer A) Instruct the adult child to check the clients temperature. C) Observe for signs of respiratory distress and monitor oxygen. D) Tell the mother that she will need to discuss any concerns. E) Explain to the mother that the babies respiratory rate needs. F) Monitor temperature. G) Informed the mother that the baby is stable enough to take. - Correct answer B) Continue to monitor glucose levels. C) Observe for signs of respiratory distress and monitor oxygen. F) Monitor temperature. NGN - Correct answer NGN: day 2. 0630: Vitals have remained stable throughout the night. Oxygen 98% on 0.25 L per minute oxygen via nasal cannula. Mother to breast-feed in nursery on demand. Able to tolerate breastmilk. Glucose after feeding was 60, temp 97.8 F axillary when you return to warmer and Billy Rubin light. Chest x-ray and echocardiogram results were normal. Calcium and magnesium within normal limits. Direct bilirubin five. Discharge teaching initiated, with goal of discharging infant and mother on day three. Highlight notes that demonstrate improvement. - Correct answer -Vitals have remained stable -Oxygen 98% on 0.25 L per minute oxygen via nasal cannula -Able to tolerate breastmilk. -Glucose after feeding was 60, temp 97.8 F axillary -Calcium and magnesium within normal limits. -Direct bilirubin five The nurse discovers that an older adult client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, which information is most important for the nurse to obtain from the clients medical history? A) length and frequency of the clients tobacco use. B) Genetically inherited disorders of family members. C) Frequency of laxative use for chronic constipation. D) Ingestion of shellfish or fish oil capsules daily. - Correct answer D) Ingestion of shellfish or fish oil capsules daily. Client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client? A) To food slowly and thoroughly before attempting to swallow. B) Plan volume controlled, evenly space meals throughout the day. C) Sip fluids Chloe with each meal and between meals. D) Eliminate or reduce intake a fatty and gas forming foods. - Correct answer B) Plan volume controlled, evenly space meals throughout the day. A client with an acute myocardial infarction is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response? A) Activated partial thromboplastin (aPTT) time is two times the control value. B) Cardiac tracing shows 1.2 MM wide Q waves half the height of the complex. C) Guiac test of the stools is positive. D) S3 heart sounds are present with auscultation - Correct answer A) Activated partial thromboplastin (aPTT) time is two times the control value. An adolescent client who has been treated in the past for a seizure disorder is admitted to the hospital immediately after admission the client begins to have a grand mal seizure. Which action should the nurse implement? A) Place a padded tongue blade between the clients teeth. B) Observe the client carefully. C) Obtain assistance in holding the client to prevent injury. D) Call a rapid response team. - Correct answer B) Observe the client carefully. Client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000. Which intervention is most important for the nurse to include in the clients plan of care? A) Obtain a clients temperature every four hours. B) Assess urine and stool for occult blood. C) Require visitors to wear respiratory masks. D) Monitor for signs of activity intolerance. - Correct answer B) Assess urine and stool for occult blood. A client with diabetes insipidus has an average urinary output of 500 ML of dilute urine every hour for the past four hours. Which laboratory test is most important for the nurse to monitor? A) Urine specific gravity. B) Capillary glucose. C) Serum sodium. D) White blood count. - Correct answer C) Serum sodium. The nurse is managing the care of a client with Cushing syndrome. Which intervention should the nurse delegate to be unlicensed assistive personnel? SATA. A) Weigh the client and report any weight gain. B) Note and report the clients food and liquid intake during meals and snacks. C) Assess the client for weakness and fatigue. D) Evaluate the client for sleep disturbances. E) Report any client mention of pain or discomfort. - Correct answer A) Weigh the client and report any weight gain. B) Note and report the clients food and liquid intake during meals and snacks. E) Report any client mention of pain or discomfort. A client with persistent low back pain has received a prescription for an electronic stimulator tens unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? A) Check the amount of gel coating on the electrodes. B) Decrease the strength of the electrical signals. C) Remove electrodes and observe for skin redness. D) Determine if the sensation feels uncomfortable. - Correct answer D) Determine if the sensation feels uncomfortable. Before leaving the room of a confuse client, the nurse notes that a half bow not was used to attach the clients wrist restraints to the movable portion of A) History of vomiting at home for three days prior to surgery. B) Peripheral pulse is present with full range of motion of both legs. C) Soft abdomen, absent bowel sounds, no bleeding on dressing. D) Declining to take ice chips for complaints of dry mouth. - Correct answer C) Soft abdomen, absent bowel sounds, no bleeding on dressing. Entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse? A) Low intermittent suction prescribe for the nasal gastric tube is turned off. B) The urinary catheter drainage bag is almost completely full of amber urine. C) A Hemovac drain is partially full of serious drainage and he's not impressed. D) Oxygen has been administered via nasal cannula at 4 L per minute without humidification. - Correct answer C) A Hemovac drain is partially full of serious drainage and he's not impressed. An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods? A) Turn on overhead lights while giving instructions. B) Stand behind the client to avoid intimidation. C) Use background music to promote relaxation. D) Provide handouts written at a 12th grade reading level. - Correct answer A) Turn on overhead lights while giving instructions. The nurse leading the care team on a medical surgical unit is assigning client care to a practical nurse and an unlicensed assistive personnel. Which activity should the nurse assigned to the UAP? A) Change the hydrocolloid dressing to a clients venous ulcer. B) Start an adverse event report related to a clients fall incident. C) Empty and measure drainage from closed will containers. D) Introduced client teaching forecast care and crutch walking. - Correct answer C) Empty and measure drainage from closed will containers. Older adult client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident. Which intervention should the nurse include in the plan of care during convalescence and rehabilitation.? Select all that apply. A) Place a bedside commode next to bed. B) Measure neurological bagel signs every four hours. C) Play classical music in room while client is awake. D) Section oral cavity every four hours. E) Encourage family to participate in the clients care. - Correct answer A) Place a bedside commode next to bed. E) Encourage family to participate in the clients care. The nurse enters the room of a client with Parkinson's disease who is taking carbidopa levodopa. The client is a rising slowly from the chair while the unlicensed assistive personnel stands next to the chair. Which action should the nurse take? A) Offer a PRN analgesic to reduce painful movement. B) Tell the UAP to assess the quiet and moving more quickly. C) Affirm that the client should arise slowly from the chair. D) Demonstrate how to help the client move more efficiently. - Correct answer C) Affirm that the client should arise slowly from the chair. The healthcare provider prescribes 500 mL IV bolus of 0.9% normal saline to be infused over 30 minutes. How many milliliters per hour should the nurse at the infusion pump? (Enter numerical value only.) - Correct answer 1000 The nurse observes an unlicensed assistive personnel begin to remove exam gloves after emptying a bedpan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off which action should the nurse implement? A) Advise the UAP that the technique being used will result in hand contamination. B) Suggest that the UAP row both of the gloves off and inside out at the same time. C) Instructor UAP to use two pairs of gloves when fecal contamination is likely. D) Remind the UAP to discard the gloves in the biohazard container after removal. - Correct answer A) Advise the UAP that the technique being used will result in hand contamination. Healthcare provider to move a client medication prescription from IV to PO administration and doubles the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first pass effect and reduce bio availability. Which action should the nurse implement? A) Consult with the pharmacist regarding the error in prescription. B) Give half the prescribed oral dose until the provider is consulted. C) Administer the medication via the oral route as prescribed. D) Continue to administer the medication via the IV route. - Correct answer C) Administer the medication via the oral route as prescribed. Three hours after birth, a newborn becomes jittery and tacky piña. Which action should the nurse do first? A) Feed 30 mL of 10% dextrose in water. B) Obtain a capillary glucose level. C) Wrapped tightly in a warm blanket. D) Encourage the mother to breastfeed. - Correct answer B) Obtain a capillary glucose level. Unlicensed assistive personnel is assigned to a client with flu like symptoms who has been placed on a droplet precaution. The UAP request a change in assignment because the UAP has not yet been fitted for a particulate filter mask. Which action should the nurse take? A) Before changing assignments, determine which staff members have fitted particulate filter masks. B) Advise the UAP to wear a standard facemask to obtain vital signs, and then get fitted for a filter mask before providing care. C) Instruct the UAP that a standard facemask is sufficient to be able to provide care for the assigned client. D) Send the UAP to be fitted for a particular filter mask immediately to be able to provide care to this client. - Correct answer B) Advise the UAP to wear a standard facemask to obtain vital signs, and then get fitted for a filter mask before providing care. B) Provide her nails skin barrier cream. C) Encourage intake of high potassium foods. D) Monitor for signs of anemia - Correct answer A) Initiate toileting schedule. ???? Client who is having G.I. difficulties is undergoing diagnostic procedures. The client asked the nurse about the difference between ulcerative colitis and Crohn's disease. Which information should the nurse offer? A) Anal abscess and fistula rarely occur in Crohn's disease. B) Constipation is more common in Crohn's disease. C) Rectal bleeding is a predominant symptom and ulcerative colitis. D) Both disorders are distributed along the entire G.I. tract. - Correct answer C) Rectal bleeding is a predominant symptom and ulcerative colitis. The nurse assesses a child in 90-90s skeletal traction. Where should the nurse assess for signs of compartment syndrome? Click on correct location. - Correct answer Click the lower calf area above the ankle, for the leg in traction. The nurse receives shift report about a client with obsessive-compulsive disorder. The nurse completes morning rounds and approaches the client who is repeatedly washing the top of the same table. Which intervention should the nurse implement? A) Teach the client thought stopping techniques and ways to refocus behaviors. B) Assist the client to identify stimuli that precipitate the activity. C) Encourage the client to be calm and relax for a little while. D) Allow time for the behavior and then redirect the client to other activities. - Correct answer D) Allow time for the behavior and then redirect the client to other activities. Following morning care, a client with a C5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first? A) Assess the clients blood pressures every 15 minutes. B) Relieve any kinks or obstruction in the clients Foley tubing. C) Teach the client to recognize symptoms of dysreflexia. D) Administer a prescribed PRN dose of hydralazine. - Correct answer A) Assess the clients blood pressures every 15 minutes. This likely dysreflexia but the BP needs to be monitored first. Dysreflexia is an abnormal overreaction of the involuntary her nervous system. EXP, change in heart rate, blood pressure, diaphoretic, skin flushing, throbbing HA, confusion/anxiety In evaluating the effectiveness of a postoperative client intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A) Observe both lower extremities for redness and swelling. B) Monitor the amount of drainage from the clients incision. C) Palpate all peripheral pulse points for volume and strength. D) Evaluate the clients ability to use an incentive spirometer. - Correct answer C) Palpate all peripheral pulse points for volume and strength. Puzzler absent all week I can enter key compromise circulation, due to clock formation. A client with a history of hypertension and diabetes mellitus is admitted with uncontrolled a fib. The healthcare provider prefers synchronized cardioversion and prescribed a stat dose of dronedarone 400 mg PO. Which assessment finding warrants immediate intervention by the nurse? A) Proximal a fib. B) Third-degree heart block. C) Elevated mean arterial pressure. D) Premature ventricular beats. - Correct answer B) Third-degree heart block. A home health nurse makes a home visit to a client with Amy trophic lateral sclerosis. The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement? A) Assess the client to lay down and turn to the side. B) Demonstrate use of a tucked chin position while eating. C) Recommend the use of supplemental liquid feedings. D) Encourage the use of assistive feeding devices. - Correct answer B) Demonstrate use of a tucked chin position while eating. Which assessment showed the home health nurse include during a routine home visit for a client who was discharged home with a super pubic catheter? A) Palpate flank area. B) Measure abdominal girth. C) Assessed perineal area. D) Observe insertion site. - Correct answer D) Observe insertion site. Which is the best approach for the nurse to use when interviewing a client about sexual abuse? A) Ask questions in a way, nonspecific format. B) Get the most difficult questions over with first. C) Begin with questions that are less sensitive in nature. D) Share personal values to put the client at ease. - Correct answer C) Begin with questions that are less sensitive in nature. *** Photo of quiet injecting insulin into outter thigh. A) Demonstrate correct selection of the injection site. B) Advise the client to change the angle of the needle. C) Observe the injection site for signs of lipodystrophy. D) Provide a pair of exam gloves for the client to wear. - Correct answer A) Demonstrate correct selection of the injection site. The nurse is assessing a one day postpartum client. Which finding is most indicative of a postpartum infection? A) Moderate amount of foul smelling lochia. B) Blood pressure of 122/74. C) White blood count of 19,000. D) Oral temperature of 100.2. - Correct answer A) Moderate amount of foul smelling lochia.