Do walkers need to have rubber caps on all four legs?
Yes- prevents accidents
terbutaline (Brethine) is a drug that ___
is used to delay delivery in preterm labor
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
Limit visiting hours to promote optimal rest.
OR
Arrange for clergy to visit with the client and family as
Arrange for clergy to visit with the client and family as requested. (Kaplan is calling this a crisis... so even though it is psychosocial, it is necessary)
apnea monitor: can the parents "leave our baby for brief periods of time"?
Yes... appropriate because they monitor will alarm if infant stops breathing
Which of the following plans is MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
Show a videotape specifically prepared for children about cardiac catheterization.
OR
Draw a picture of a heart, and explain wher
Draw a picture of a heart, and explain where the tube will go and what the doctor will see.
(The other answer is informative, but not best???)
The nurse cares for a client complaining of moderate pain. Which of the following nursing actions is MOST important to provide the patient with effective pain relief?
1.Teach the patient about the pain.
2.Establish a trusting relationship with the patient
2.Establish a trusting relationship with the patient. (why this is specific to pain, I'm not sure... DUMB question)
Adult in locked psych unit wants to vote. What response is best?
"I'll make the appropriate arrangements for you to vote."
OR
"I'll contact the Election Board to see if you are registered to vote.
I'll make the appropriate arrangements for you to vote."
(The other is not the nurse's responsibility)
The nurse administers sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain. Which of the following observations is MOST important for the nurse to report to the next shift?
Blood pressure has decreased from 140/80 to 90/60.
OR
Respir
Blood pressure has decreased from 140/80 to 90/60.
(Don't be tricked by ABC's...hypotension is a sig SE of nitroglycerin... needs to be monitored closely)
Can someone undergoing a skin biopsy be on aspirin?
Nope... it can increase bleeding
Perforated bowel secondary to a bowel obstruction:
Priority nursing action____
Prepare for emergency surgery
Is thumb sucking ok for a 17 month old?
What to tell concerned mom?
When does malformation of teeth occur?
Yes, it peaks at 18-20 months and it normal behavior.
Negative reinforcement is controversial even for an older child.
Don't discourage... should subside by 24 months.
If persists after 4 years or if teeth are perm
Overweight pt:
What is a good bfast for them?
Applesauce, cream of wheat, toast.
OR
Scrambled eggs and toast, one slice of bacon.
Applesauce, cream of wheat, toast
(I wasn't sure this had enough protein in it. The other has to much fat)
(IM) injections of calcium disodium edetate (Calcium EDTA) and dimercaprol (BAL) are used to tx: ___
Important to ____
High serum lead levels
Rotate injection sites (may cause tissue damage... also promotes absorption of meds)
What kind of drug is tranylcypromine sulfate (Parnate)?
How long does it take to work?
MAOI
3-4 weeks
Most urgent:
A multipara woman at four weeks' gestation reporting unilateral, dull abdominal pain.
OR
A multigravida woman at six weeks' gestation reporting frank, red vaginal bleeding with moderate cramps.
A multipara woman at four weeks' gestation reporting unilateral, dull abdominal pain.
(Possible ectopic prego... more harmful to mom than the spontaneous abortion)
Teaching for someone who is having a spont abortion
Save/count pads
A urinalysis is obtained from a client complaining of dysuria, urinary frequency, and discomfort in the suprapubic area. After evaluating the results, the nurse should order a repeat urinalysis based on which of the following findings?
1.Negative glucose.
3.No WBCs or RBCs
(Basically, when you don't see what you would expect, you will need to repeat the ua. With his s/s, we would expect to see WBCs r/t inflammation of urethra and RBCs d/t irritated bladder mucosa)
Pt puts cooking fat on burn so "it won't blister"... what does the nurse need to do first?
Wash it with soap and water to remove oil (can lead to infection)
Why is it not good to "milk" the finger when checking BG?
Forces interstitial fl out and dilutes sample
nifedipine (Procardia):
Pt has HR of 50, give?
NO
Care for sensitive/sore breasts during prego?
Apply cold compresses to your breasts, and wear a well-fitting, supportive bra.
The nurse cares for a patient diagnosed with hyperparathyroidism. Which symptom is MOST important for the nurse to report to the next shift?
1.Abdominal discomfort.
2.Hematuria.
3.Muscle weakness.
4.Diaphoresis.
2.Hematuria
(All others are s/s of hyperparathyroidism, but doesn't require reporting. Hematuria is a s/s of renal calculi and should be reported)
Do "personal effects" need to be decontaminated for those who are dx with TB?
No
pneumonectomy:
Are breath sounds present?
What is the most important assessment?
No, not on the surgical side
Position of the trachea in the sternal notch
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 ml/hour. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 ml. The nurse is MOST concerned by which of
Rales and tachycardia.
(I thought it was the other d/t ABC's... but those s/s aren't relevant to fl overload)
The nurse answers the psychiatric unit's desk phone. The caller identifies himself as the spouse of a patient and inquires about the patient's condition. Which of the following responses by the nurse is MOST appropriate?
1. "I cannot deny or confirm any p
2."Patients are not allowed to use this phone. Please call the patient's phone number directly."
So apparently no. 1 doesn't break confidentiality
2-gm sodium diet:
Which meal is best?
1.Scrambled egg, orange slices, and milk.
2.Instant oatmeal, toast, and orange juice.
3.Poached egg, bacon, and milk.
4.Biscuit, fruit cup, and sausage.
1.Scrambled egg, orange slices, and milk.
(But I thought that milk was high in sodium!)
A client at 39 weeks' gestation in active labor screams, "I have to push, I have to push." The nurse notes that the client is 8 cm dilated. The nurse should take which of the following actions?
1.Instruct the client to take a deep breath and bear down.
2.
4.Tell the client to pant with pursed lips. (this helps control pain and urge to push as well as provide o2 for fetus)
calcium gluconate 10% 500 mg IV stat:
Priority assessment before giving?
Vein patency d/t fact that it can cause severe chem burn if in the extravascular tissue
A child admitted with failure to thrive has just had a positive sweat test. What to anticipate?
Admin of enzymes... pos sweat test indicates cf
Sengstaken-Blakemore tube:
Priority equip at bedside?
If in resp distress... do what?
Scissors
Cut balloon ports and remove the tube (it goes all the way down to a balloon in the stomach)
Best way to take prenatal vitamins?
At night with oj
risperidone (Risperdal) teaching:
____ wt
_____ temp
_____ sun
_____ bp
May cause increase in wt
Avoid extreme temps (impairs bods regulation)
Wear sunscreen (photosensitivity)
Orthostatic hypotension may occur
To promote safety in the environment of a client with a marked depression of T cells, the nurse should take which of the following actions?
1.Keep a linen hamper immediately outside the room.
2.Restrict eating utensils to spoons made of plastic.
3.Provide
4.Remove any standing water left in containers or equipment.
(I thought that it was to provide masks...but it's not)
A client develops severe, crushing chest pain radiating to the left shoulder and arm. Which of the following PRN medications should the nurse administer?
Morphine sulfate IV.
OR
Nitroglycerine (Nitrostat) SL.
Morphine
(The nitroglycerine will be given via IV by the nurse although they may have it SL for at home)
When would a nurse wear a lead apron while caring for a pt with internal radiation?
When the nurse has to spend any length of time at a close distance, not just for routine care
The nurse cares for a client diagnosed with dementia in a long-term care facility. Which of the following actions by the nurse is BEST?
Orient the client to the present time and assist the client to be alert and oriented when the family comes to visit.
OR
Direct conversation toward assisting the client to reminisce and talk about important past events in life.
("even w/ orientation, the pt soon forgets... encourage reminiscing)
Which of the following is the FIRST nursing action that should be implemented for a client after a vaginal delivery?
Lochia or fundus?
Lochia... ok????
Buck's traction... pt keeps sliding down in bed... what to do?
Elevate the foot of the bed on blocks.
(Keeps leg strait and counters the pull of the weights)
What meds to give someone experimenting EPSE's: __ or __
Cogentin or trihexyphenidyl (Artane)
What is a common SE of soniazid (INH) that would concern the nurse?
My hands and feet tingle." (peripheral neuropathy)
Nausea
child has frequent bouts of gastroenteritis. Priority question for parents ___
Does the child attend a day care center?"
Kids are likely to get in daycare
What is the normal range for CVP?
What does a normal value indicate?
3-12 cm water pressure
Desired response to fl replacement
Post lp, lying in bed for 8 hours does what?
Prevents post lp HA (csf leak)
Early s/s of hepatic encephalopathy:
Impaired thought process... (can't describe what they do at work for example)
Sign of therapeutic response to therapy for edema?
Weight loss of 5 lb over last two days.
OR
Serum potassium 4.0 mEq/L.
Weight loss of 5 lb over last two days.
(Potassium has not relation to edema)
Tx for Kaposi's sarcoma
Clean the area carefully with soap and warm water every day, and cover them with a sterile dressing.
*Need to find out which is right... there was another question that said to have it air dry
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM 1 hour ago?
1.The child states that his pain has gone away.
2.The child's heart rate has changed from
4.Results from the incentive spirometer have improved.
Will be able to breath deeper if pain is decreased.
Kids won't always tell the truth about pain d/t fear of getting injection
Sleeping except when receiving care indicates need to decrease amount of m
What two conditions commonly cause ARF?
Hypovolemia and HF
*they cause renal ischemia
Discharge teaching after treatment for dehydration:
___ flds
___ intake
Drink lots throughout the day
Measure with a measuring cup
*Daily wts is not part of teaching because it only indicates OVERhydration, not DEhydration.
The nurse assesses an infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which of the following nursing actions is MOST appropriate?
1.Elevat
3.Position the infant on one side.
(Suctioning is contraindicated because of pt's op site)
Post cardiac cath pt complains that hand is numb... what to do?
Notify Dr.
(May need anticoagulant s and vasodilators)
The nurse plans care for a patient hospitalized with bipolar disorder. While the patient is in the manic phase, nursing interventions should involve ____
Distract the patient, and redirect behaviors.
(isolation not required, would increase anxiety and hostility)
wearing a gown, gloves, and a mask:
Which dx warrants this?
RSV, S.aureus, TSS, Rubella
Just Rubella
(Droplet... all others do not require mask)
metronidazole (Flagyl):
Which is true about this med?
You should avoid alcohol
OR
You should avoid sunlight
Alcohol (causes Antabuse-like reaction)
Sickle cell anemia should not take which meds?
Aspirin (can cause hemorrhage during sickle crisis)
Minor head injury...
no strenuous activity for how long?
How long to check LOC and orientation?
Avoid what meds?
48 hrs
q 3-4 hrs
Sedatives, sleeping pills, alcohol
Kaopectate and other meds ordered. What to do?
Wait an hour before taking the other meds if Kao is taken
What is the purpose of a Salem sump tube (nasogastric)?
How do you know that it is functioning effectively?
To provide continuous steady suction without pulling gastric mucosa
It will have a hissing sound from the blue lumen tube.
indicative that air is freely exiting the airway,
Mag sulfate is a ____ and may cause ___
CNS depressant
Oliguria
A postoperative client is returned to the assigned room from the surgical recovery area. The client is sleeping, and the nurse notes that the client is disoriented when aroused. Which of the following actions, if taken by the nurse, is BEST?
Stay with the
Elevate the side rails until the client is fully awake.
Side rails should always be elevated for any disoriented client
What is an ileus?
Partial or complete blockage of intestine
Throat culture:
Must ____
swab the area of throat to be tested... a sputum sample would not reflect throat bacteria.
Butorphanol tartrate (Stadol) is a ____.
Must assess ___ after admin.
opioid
VS (decreases rate and depth of respirations is the serious SE... not fl change)
Which of the following plans would be a priority for an infant with a positive PKU blood test?
Give them Lofenalac formula. It is low in phenylalanine but contains minerals and vitamins to provide balanced nutrition.
Total laryngectomy teaching:
Initial communication ___
Then by ___
Eating___
Will require ___
Common finding after surgery ___
Rules on tracheoesophageal puncture ____
Should you encourage to cough and deep breath after surgery?____
In writing.
Artificial larynx or esophageal speech.
Nutritional support for 10 days
then gradually resumes oral intake
laryngectomy tube to prevent scar tissue contracture
Difficulty with taste/smell
No singing, whistling, or laughing
Yes
What are two notable s/s of Type 1 diabetes?
Excessive thirst and wt loss
A physician writes an order for an HIV-positive infant to receive IPV immunization. Which of the following nursing actions is MOST appropriate?
Wear gloves and a gown when administering the immunization.
or
Administer the immunization.
Administer the immunization.
(Only need to to take standard precautions)
Staff member's kid has lice. What should the nurse do?
Inspect their head for louse and nits. (REALLY... we don't have them go to the dr. first, huh? OK)
A client who attends an outpatient clinic is taking chlorpromazine hydrochloride (Thorazine) 100 mg tid. The client reports to the nurse that he is sleeping through the day. Which of the following actions by the nurse is MOST appropriate?
1.Contact the ph
2.Change the time of the medication to 100 mg in the morning, 100 mg after dinner, and 100 mg at hs.
The physician orders an arterial blood gas (ABG) for a client receiving oxygen at 6 L/minute. What information concerning the patient is MOST important for the nurse to document on the lab slip that accompanies the blood sample?
1.The patient's position i
3.The use of supplemental oxygen. (for accurate test results)
How often to chance an ostomy bag?
Once per week or if leaking/loose seal (good time time to inspect stoma)
An 8 month old will indicate that they are in pain by ___
rubbing a body part and crying
cephalexin monohydrate (Keflex) teaching:
Eat ___
Yogurt and acidophilus milk to maintain normal intestinal flora
How is subcutaneous emphysema described?
Crackling under the skin...like rice crispies
(Indication of pneumothorax)
Normal head circ of newborn ___
Chest circ ___
32-36 cm (so 40 would be of concern)
32 is normal
Can a minor request birth control without parental consent?
Yes
Is this considered neglect?
The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide (Prostigmin) PO at 7:45 AM.
Yes... may cause difficulty in swallowing
The nurse cares for an elderly patient following a right total hip replacement. The nurse's notes indicate that since the surgery, the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patie
I notice you're laughing."
(The other is "confrontational" and would block communication)
Should diabetics (type 1) bathe feet daily in warm water?
yes, that it proper care
Tx for DKA:
NS and Reg insulin
A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client receives 80 mg of furosemide (Lasix). Which of the following nursing observations is MOST important to report to th
2.Urine output of 200 ml in two hours.
(UOP is reported because the pt is on a diuretic... even though it is a normal output?! N and V are further s/s of RHF and are "not a priority")
Hep A is communicable ___ before ___ and ___ after ___
2-3 weeks
onset of jaundice
about 1 week
onset of jaundice
Diabetes insipidus:
Tx ___
desmopressin (DDAVP) nasally or SQ required for remainder of life
What does the bulge test confirm?
How is it done?
Presence of fl in the knee
Pt lies down and extends legs with legs supported on bed
The nurse performs a routine IV tubing change on a patient with a central line. Fifteen minutes later, the nurse re-enters the patient's room to find the patient cyanotic, short of breath, and complaining of pain. The patient's vital signs are BP 84/62, p
2.Lower the head of the bed and place the patient on the left side.
(Will cause air to rise to R atrium, minimizes chance of air bubbles entering cerebral circulation)
What precautions is a pt with Haemophilus influenzae meningitis on?
Droplet (for at least 24 hours after abx therapy started)
How often is a defibrillator checked?
Should it be plugged in or unplugged?
Every 8 hrs
Plugged in (at all times)
When are imaginary friends normal?
4-6 years of age
hyperthyroidism:
Pt will need this regularly ___
Artificial tears d/t exophthalmos
Pt with increased ICP:
HOB should be ___
15-30 degrees to promote venous drainage
evisceration is treated immediately by ___
applying sterile gauze soaked in normal saline.
Umbilical cord care:
Clean several times a day (Uh... not sure with what) and expose to air frequently.
The nurse cares for a client diagnosed with pneumonia. Which of the following nursing observations indicates a therapeutic response to the treatment?
1.Oral temperature of 101�F (38.3�C), increased chest pain with nonproductive cough.
2.Cough, productive
3.Respirations at 20 with moderate amount of thin, white sputum, denies dyspnea.
albuterol (Proventil) may give one a SE ____ which should diminish after they take it for a week or longer.
pounding" heart
(So assess how long pt has been taking if they complain of this)
Drug abuser....The nursing diagnosis is ineffective individual coping:
Goal for the "working stage" of the nurse/pt relationship would be to ____
Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Pt with stage III pressure ulcer of the sacrum with foul-smelling, purulent drainage:
Will be on ___ precautions
Food ___
Repositioning ___
Contact (so they DON'T need a mask)
Give high protein (so milkshake would be good)
Lift to prevent shearing force
cromolyn sodium (Intal):
Tx for ___
Should be taken when?
Preventing asthma attacks (not as a rescue inhalor)
Before pt begins any vigorous exercise
The nurse cares for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It is MOST important for the nurse to take which of the following actions?
1.Utilize an organized team to place the client
4.Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
(He is too pissed off to do a quiet activity.... having him try to id and express feelings should be done before seclusion)
Guaiac stool samples:
___ container.
How to get the sample ___
Order is for guaiac x 3, how is this done?
What can cause a false pos?
Clean ok... sterile not needed
Use a tongue blade to collect a sm amount
Once sample each day (So no more than one each day)
Recent ingestion of red meat
Good outcome from Synthroid tx?
Increased UOP
How to palpate uterine contractions?
Place one hand on the abdomen over the fundus, and with the FINGERTIPS, presses gently.
The nurse knows that for a client to manage at home alone following discharge from the hospital, the client diagnosed with rheumatoid arthritis must be able to perform which of the following tasks?
1.Climb up and down stairs.
2.Lace and tie his/her shoes.
3.Comb his/her hair and brush his/her teeth
(Everything else can be modified)