ATI comprehensive predictor STUDY THIS ONE

A 23-year-old woman at 32-weeks gestation is seen in the outpatient
clinic. Which of the following findings, if assessed by the nurse, would
indicate a possible complication?
1. The client's urine test is positive for glucose and acetone.
2. The client ha

1

After abdominal surgery, a client has a nasogastric tube attached to low
suctioning. The client becomes nauseated, and the nurse observes a
decrease in the flow of gastric secretions. Which of the following nursing
interventions would be MOST appropriate?

2

After sustaining a closed head injury and numerous lacerations and
abrasions to the face and neck, a five-year-old child is admitted to the
emergency room. The client is unconscious and has minimal response to
noxious stimuli. Which of the following asses

2

The nurse is caring for a manic client in the seclusion room, and it is
time for lunch. It is MOST appropriate for the nurse to take which of the
following actions?
1. Take the client to the dining room with 1:1 supervision.
2. Inform the client he may go

4

A client is given morphine 6 mg IV push for postoperative pain.
Following administration of this drug, the nurse observes the following:
pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the
following nursing actions is MOST appropria

3

What type of infectious diseases are required to be reported to the health department?

- severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA)

What is the process of taking a telephone order from a provider?

Patient name, drug, dose, route, frequency
read back for accuracy

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA
a) Place the client in a negative pressure room
b) wear gloves when assisting the client with oral care
c) limit each visitor to 2 hr increment

A
B
E

A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching?
a) Assign the client to a room with a negative air-flow system
b) Use alcohol-b

D

A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?
a) place a warm compress over

A

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client?
a) use a bed exit alarm system
b) raise 4 side rails while client is in bed
c) apply one soft wris

A

A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?
a) implement a regular toileting schedule
b) encourage the client to wear athletic socks when ambulating
c) place all 4

A

Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?
a) insert the suction catheter while the client is swallowing
b) apply intermittent suction when withdrawing the catheter
c) place the catheter in

B

A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's indepe

C

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?
a) serum albumin level of 3 g/dL
b) HDL level of 90 mg/dL
c) Norton scale score of 18
d) Braden scale score of 20

A

A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
a) "I had a bowel movement, but I was able to save the urine"
b) "I have a specimen in the b

C

A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance?
a) tap water
b) sterile water
c) 0.9% sodium chloride
d) 0

C

A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching?
a) use the cane on the weak side of the body
b) advance the cane and the atrong leg simulta

C

Which of the following should indicate to a nurse the need to suction a client's tracheostomy?
a) irritability
b) hypotension
c) flushing
d) bradycardia

A

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
a) wear sterile gloves when removing the old dressing
b) warm the irrigation solution to 40.5C (105F)
c) cleanse the wound fr

C

A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid?
a) lemon-lime sports drinks
b) ginger ale
c) black coffee
d) orange sherbet

D

A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take?
a) assess for bladder distention after 6 hr
b) encourage the client to use

D

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?
1. Cancer of any kind.
2. Impaired hearing.
3. Prescription drug intoxication.
4. Heart failure.

3

Which of the following is essential when caring for a client who is experiencing delirium?
1. Controlling behavioral symptoms with low-dose psychotropics.
2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to inc

2

Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?
1. Explain the experience of having delirium.
2. Resume a normal sleep-wake cycle.
3. Regain orientation to time and place.
4. Establish no

3

A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?
1. Administer PRN haloperidol (Haldol) to decrease the need

2

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Whic

2
3
4

The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?
1. Sleep disturbances.
2. Concomitant depression.
3. Agitation and a

3

The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruc

1

When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?
1. Allow the client to go to bed four to five times during the day.
2. Test the cognitive

4

What are some ways to identify a patient before giving a medication?

The Joint Commission requires 2 client identifiers be used when administering medications.
- clients name
- assigned identification number
- telephone number
- birth date or other personal-specific identifiers. Bar code scanners may be used to identify cl

What are some things to teach about home safety with elderly patients?

- Removing items that could cause the client to trip, such as throw rugs and loose carpets
- Placing electrical cords and extension cords that against a wall behind furniture
- Making sure that steps and sidewalks are in good repair
- Placing grab bars ne

A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in
his home. Which of the following should the nurse teach the client about using oxygen safely in his
home? (Select all that apply.)
A. Family members wh

B
C
E

A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk
with the appropriate instruction.
____ Passive smoking
____ Carbon monoxide poisoning
____ Food poisoning
A. Have water heaters inspected on an annual
b

C
A
B

When performing nasotracheal suctioning what technique should be used?

Sterile asepsis bc the trachea is considered sterile and prevents infections

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?

A

What do you do when a client has a seizure

- lower to bed/floor
- protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury
-in event of seizure, stay with client and call for help
-admin meds as ordered
-note dur

seclusion and restraints

-must be ordered
-should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient
-a client may voluntarily request temp seclusion
-restraints can be physical or chemical
-if used, frequency of client assessm

What position is good to use for a patient who is at high risk for a pressure ulcer

30 degree lateral position is recommended for clients at risk for pressure ulcers

health promotion (injury prevention-suffocation): infant (birth-1 yr)

-avoid plastic bags
-keep balloons out of reach
-ensure crib mattress fits snugly
-ensure crib slats are no more than 6 cm (2.4 in) apart
-remove crib mobiles and gyms by 4-5 months
-do not use pillows in crib
-place infant on back for sleep
-keep toys wi

hypotension is classified with a reading below normal;

systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation

What temperature should pork be cooked at

160 degrees

What is the safest way to thaw out frozen foods

In the refrigerator

What are the precautions for vancomycin resistant enterococcus

Standard precautions including hand washing and gloving should be followed

What does a newborns poop look like

If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency

What is appropriate for an adolescent in the hospital?

Puzzles and books

What is the proper nutrition during pregnancy

- Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida
- green leafy vegetables and brown rice

What should be avoided during pregnancy

Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby

What is the most appropriate method for contraception for an adolescent

IUD or implant

What can be delegated to Assistive personnel (AP)?

- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients

A nurse on a med surge unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP?
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B. Reinforcing te

C

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP?
Select all:
A. the roommate is up independently
B. The client ambulates with his slippers on ov

B
C
D

An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
A. Assisting a client who is 24 hr postop to use an incentive spirometer
B. Collecting a clean catch urine spe

D

A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all:
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Rig

B
C
E

A nurse manager of a med surge unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client?
A. Charge nurs

B

What is the study of conduct and character?

Ethics

What are the values and beliefs that guide behavior and decision making?

Morals

What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest

Autonomy

What are positive actions to help others

Beneficience

What is an agreement to keep promises

Fidelity

What is fairness in care delivery and use of resources

Justice

What is avoidance of harm or injury

Non-maleficence

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificience

A

A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficience

D

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should

C

A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificence

D

Which of the following situations can be identified as an ethical dilemma?
A. A nurse on a med surge unit demonstrates signs of chemical impairment
B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will re

C

Most managers can be categorized as

authoritative, democratic, and laissez faire

makes decisions of the group
motivates by coercion
communication occurs down the chain of command
Work output by the staff is usually high-good for crisis situations and bureaucratic settings

Authoritative

includes the group when decisions are made
Motivates by supporting star achievements
Communication occurs up and down the chain of command
Work output by staff is usually of good quality-good when cooperation and collaboration is necessary

Democratic

makes very few decisions and does little planning
motivation is largely the responsibility of individuals staff members
Communication occurs up and down the chain of command and between group members
Work output is low unless an informal leader evolves fr

Laissez faire

The nurse should consider the hierarchy of human needs when prioritizing interventions, which are?

- Physiological needs first (oxygen, shelter, food)
- Safety & security needs (physical safety)
- Love and belonging
- Self esteem
- Self actualization

The ABC framework identifies, in order, the three basic needs for sustaining life

Airway
Breathing
Circulation

Nurses must follow what code of standards in delegating and assigning tasks

ANA codes of standards

What values would a nurse possess to be a client advocate?

- caring
- autonomy
- respect
- empowerment

What do the nurse need to keep in mind about the client when being their advocate?

Client's religion & culture

When should planning discharge process begin?
a. at time of admission
b. 2 days after client is admitted
c. whenever the nurse has the time to do planning
d. when the physician has the discharge order

A

What is an interdisciplinary team?

A group of health care professionals from different disciplines

Fill in the blank:
1. _______ is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. ________, which may take place at team meetings, allows the achievement of results that the participants would be incapa

1 & 2 = collaboration

What is the nurse's contribution to an interdisciplinary team?

- knowledge of nursing care & its management
- a holistic understanding of the client, her/his healthcare needs & healthcare systems.

A four-month-old infant is admitted to the pediatric intensive care unit
with a temperature of 105�F (40.5 �C). The infant is irritable, and the nurse
observes nuchal rigidity. Which assessment finding would indicate an
increase in intracranial pressure?

2

A client is receiving total parenteral nutrition (TPN). To determine the
client's tolerance of this treatment, the nurse should assess for which of the
following?
1. A significant increase in pulse rate.
2. A decrease in diastolic blood pressure.
3. Tempe

4

The client is exhibiting symptoms of myxedema. The nursing
assessment should reveal
1. increased pulse rate.
2. decreased temperature.
3. fine tremors.
4. increased radioactive iodine uptake level.

2

A nonstress test is scheduled for a client at 34-weeks gestation who
developed hypertension, periorbital edema, and proteinuria. Which of the
following nursing actions should be included in the care plan in order to
BEST prepare the client for the diagnos

3

Which of the following nursing interventions is MOST important for a
45-year-old woman with rheumatoid arthritis?
1. Provide support to flexed joints with pillows and pads.
2. Position her on her abdomen several times a day.
3. Massage the inflamed joints

4

The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient
1. with his neck in a midline position and the head of the bed elevated 30�.
2. side-lying with his head extended and the bed f

1

The nurse is teaching a 40-year-old man diagnosed with a lower motor
neuron disorder to perform intermittent self-catheterization at home. The
nurse should instruct the client to
1. use a new sterile catheter each time he performs a catheterization.
2. pe

2

A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
1. take the medication five minutes after the pain has started.
2. stop taking the medication if a stinging sensation is absent.
3. take

4

A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if
found by the nurse at the patient's bedside, is nonessential?
1. Potassium chloride for IV administration.
2. Calcium g

1

A nurse recognizes that an initial positive outcome of treatment for a
victim of sexual abuse by one parent would be that the client
1. acknowledges willing participation in an incestuous relationship.
2. reestablishes a trusting relationship with his/her

3

An adolescent client is ordered to take tetracycline HCL (Achromycin)
250 mg PO bid. Which of the following instructions should be given to this
client by the nurse?
1. "Take the medication on a full stomach, or with a glass of milk."
2. "Wear sunscreen a

2

After a client develops left-sided hemiparesis from a cerebral vascular
accident (CVA), there is a decrease in muscle tone. Which of the following
nursing diagnoses would be a priority to include in his care plan?
1. Alteration in mobility related to para

2

A client has a history of oliguria, hypertension, and peripheral edema.
Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be
restricted in the client's diet?
1. Protein.
2. Fats.
3. Carbohydrates.
4. Magnesium.

1

An extremely agitated client is receiving haloperidol (Haldol) IM every
30 minutes while in the psychiatric emergency room. The MOST important
nursing intervention is to
1. monitor vital signs, especially blood pressure, every 30 minutes.
2. remain at the

1

The nurse is caring for clients in the skilled nursing facility. Which of the
following clients require the nurse's IMMEDIATE attention?
1. A client admitted for a cerebral vascular accident (CVA) whose prescription for
warfarin (Coumadin) expired two day

1

The nurse is observing care given to a client experiencing severe to
panic levels of anxiety. The nurse would intervene in which of the following
situations?
1. The staff maintains a calm manner when interacting with the client.
2. The staff attends to cl

3

A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse?
1. The client complains of pain during the inflow of the dialysate.
2. The client complain

3

The clinic nurse is performing diet teaching with a 67-year-old client
with acute gout. The nurse should teach the client to limit his intake of
1. red meat and shellfish.
2. cottage cheese and ice cream.
3. fruit juices and milk.
4. fresh fruits and unco

1

A client is scheduled for a left lower lobectomy. The physician has
ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine
that the medication is appropriate if the client displays which of the
following symptoms?
1. Agitation and decrea

3

A 59-year-old woman with bipolar disorder is receiving haloperidol
(Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my
breasts." Which of the following responses by the nurse is BEST?
1. "You are seeing things that aren't real."
2. "Why d

3

The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for
a client. The nurse should advise the client the BEST time to take this
medication is
1. before breakfast.
2. with dinner.
3. with food.
4. at hs.

4

. If a client develops cor pulmonale (right-sided heart failure), the nurse
would expect to observe
1. increasing respiratory difficulty seen with exertion.
2. cough productive of a large amount of thick, yellow mucus.
3. peripheral edema and anorexia.
4.

3

The nurse is performing triage on a group of clients in the emergency
department. Which of the following clients should the nurse see FIRST?
1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a
rusty metal can.
2. A 19-year-ol

2

The nurse in the outpatient clinic teaches a client with a sprained right
ankle to walk with a cane. What behavior, if demonstrated by the client,
would indicate that teaching was effective?
1. The client advances the cane 18 inches in front of her foot w

2

A client returns to his room following a myelogram. The nursing care
plan should include which of the following?
1. Encourage oral fluid intake.
2. Maintain the prone position for 12 hours.
3. Encourage the client to ambulate after the procedure.
4. Evalu

1

The nurse is caring for a patient following an appendectomy. The patient
takes a deep breath, coughs, and then winces in pain. Which of the
following statements, if made by the nurse to the patient, is BEST?
1. "Take three deep breaths, hold your incision

1

A young woman is transferred to a psychiatric crisis unit with a
diagnosis of a dissociative disorder. The nurse knows which of the following
comments by the client is MOST indicative of this disorder?
1. "I keep having recurring nightmares."
2. "I have a

4

A 23-year-old man is admitted with a subdural hematoma and cerebral
edema after a motorcycle accident. Which of the following symptoms should
the nurse expect to see INITIALLY?
1. Unequal and dilated pupils.
2. Decerebrate posturing.
3. Grand mal seizures

4

. The nursing team includes two RNs, one LPN/LVN, and one nursing
assistant. The nurse should consider the assignments appropriate if the
nursing assistant is assigned to care for
1. a client with Alzheimer's requiring assistance with feeding.
2. a client

1

An elderly client is returned to her room after an open reduction and
internal fixation of the left femoral head after a fracture. It is MOST
important for the nursing care plan to include that the client
1. eat a high-protein, low-residue diet.
2. lie on

4

Which of the following is a correctly stated nursing diagnosis for a client
with abruptio placentae?
1. Infection related to obstetrical trauma.
2. Potential for fetal injury related to abruptio placentae.
3. Potential alteration in tissue perfusion relat

4

An 8-year-old client is returned to the recovery room after a
bronchoscopy. The nurse should position the client
1. in semi-Fowler's position.
2. prone, with the head turned to the side.
3. with the head of the bed elevated 45� and the neck extended.
4. s

1

Which of the following assessment findings would indicate to the nurse
the need for more sedation in a client who is withdrawing from alcohol
dependence?
1. Steadily increasing vital signs.
2. Mild tremors and irritability.
3. Decreased respirations and d

1

The home care nurse is instructing a client recently diagnosed with
tuberculosis. It is MOST important for the nurse to include which of the
following as a part of the teaching plan?
1. During the first two weeks of treatment, the client should cover his

4

The nurse's INITIAL priority when managing a physically assaultive
client is to
1. restrict the client to the room.
2. place the client under one-to-one supervision.
3. restore the client's self-control and prevent further loss of control.
4. clear the im

3

A client with newly diagnosed type I diabetes mellitus is being seen by
the home health nurse. The physician orders include: 1,200-calorie ADA
diet, 15 units of NPH insulin before breakfast, and check blood sugar qid.
When the nurse visits the client at 5

1

The nurse is supervising the staff providing care for an 18-month-old
hospitalized with hepatitis A. The nurse determines that the staff's care is
appropriate if which of the following is observed?
1. The child is placed in a private room.
2. The staff re

1

When using restraints for an agitated/aggressive patient, which of the
following statements should NOT influence the nurse's actions during this
intervention?
1. The restraints/seclusion policies set forth by the institution.
2. The patient's competence.

3

The nurse is caring for an 80-year-old client with Parkinson's disease.
Which of the following nursing goals is MOST realistic and appropriate in
planning care for this client?
1. Return the client to usual activities of daily living.
2. Maintain optimal

2

A client with a peptic ulcer had a partial gastrectomy and vagotomy
(Billroth I). In planning the discharge teaching, the client should be
cautioned by the nurse about which of the following?
1. Sit up for at least 30 minutes after eating.
2. Avoid fluids

4

A nurse is caring for a 37-year-old woman with metastatic ovarian
cancer admitted for nausea and vomiting. The physician orders total
parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of
the following is the BEST indication that th

3

If a patient has anorexia nervosa and works out constantly

Allow them to workout and continue their regimen

What medications can be taken to help with smoking cessation

Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban�, Wellbutrin�, Wellbutrin SR� and Wellbutrin XL� but this medication is also available as a generic. Varenicline (chantix)

What are the five stages of grief

denial
anger
bargaining
depression
acceptance

discrete and applies the letting go of an object or person before the loss as in the case of terminal illness
individuals have the opportunity to greet before the actual loss

anticipatory grief

involves difficult progression through the expected stages of the grieving process
grief work is prolonged and manifestations more severe
client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem
somatic complaints persist fo

dysfunctional grief

Signs for meningococcemia

Vomiting, febrile, petechial rash
(unstable)

Levothyroxine effects

Used to restore client's metabolic rate
* Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension

Multiple Sclerosis Patient

Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug)
* Report Sore Throat
(greatest risk for client is severe infection due to myelosuppression from mitoxantrone)
* Vomiting = causes dehydration
* Hair Loss = emotional distress
* Amenorrhea = emo

Malnourished COPD patients

(1) Limit liquid intake at meal times
(2) Consume foods w/ protein (like eggs)
(3) Maintain an upright position (High Fowler's position) to promote ventilation
(4) Use milk instead of water when making soup

Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others
"I don't deserve to die, this isn't fair

Anger stage

Which Grief Process when Client acknowledges the impending loss while remaining hopeful
"If I could just make it through this, I'd never smoke again

Bargaining Stage

How should you respond when client wants to discontinue dialysis

What has changed to make you decide this?"
= Seek clarification from client to establish mutual understanding while staying therapeutic

What should the nurse do when one member of a support group expresses anger repeatedly?

Focus more on the group members who have a positive outlook
(Speak to group member privately to uncover source of anger)

What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given?

Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella)
Should give = TDaP (Tetanus, Diphtheria, Pertussis)

Long term effects of NSAIDS (Ibuprofen)

Gastric Ulcerations, perforations, hemorrhage, hypertension

Alcohol Use Manifestations of Withdrawal

Body burns 0.5 oz of alcohol per hour
* Withdrawal appears within 4-12 hours
* Irritability + Tremors + Anxiety
* Nausea + Vomiting + HA
* Diaphoresis
* Sleep Disturbances
* TACHYCARDIA + HTN
Use Benzodiazepines = tx
Diazepam (Valium), lorazepam (Ativan),

When does Discharge planning begin?

At Admission

Case Management nursing involves:

*Decreasing cost by improving client outcomes
* Providing education to optimize health participation
* Advocating for services + client's rights

What is bipolar disorder?

Bipolar disorder is a mood disorder with recurrent episodes of depression and mania.

What comorbidities may be observed with a patient who is bipolar?

Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD.

What therapy will be useful for patients with bipolar?

Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior.

What kind of medications are indicated for abstinence maintenance of alcohol?

Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)

Teaching points for naltrexone (Vivitrol)?

Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen.

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
a) restrict fluid intake to 1 qt (1,000 ml)/day.
b) drink liquids only between meals.
c) don't drink liquids 2 hours be

B

A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient?
a) Instruct the patient to keep a record of food intake
b) Instruct the patient to avoid prune or

C

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?
a) Left lower quadrant
b) Left upper quadrant
c) Right upper quadrant
d) Right lower quadrant

D

Which outcome indicates effective client teaching to prevent constipation?
a) The client reports engaging in a regular exercise regimen.
b) The client limits water intake to three glasses per day.
c) The client verbalizes consumption of low-fiber foods.
d

A

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia?
a) Hypotension
b) Bradycardia
c) Warm moist skin
d) Polyuria

A

The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find?
a) Green color and texture
b) Black and tarry appearance
c) Clay-like quality

B

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly bei

C

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
a) Skim milk
b) Nothing by mouth
c) Regular diet
d) Clear liquids

B

Bladder retraining for the treatment of urge incontinence:

� Use timed voidings to increase intervals between voidings/decrease voiding frequency.
� Perform pelvic floor (Kegel) exercises.
� Perform relaxation techniques.
� Offer undergarments while the client is retraining.
� Teach the client not to ignore the u

what are normal creatinine levels?
what are normal BUN levels?

0.8-1.4 mg/dL
8-25 mg/dL

What are total serum protein values (normals)

6-8 g/dL

Describe pre-albumin

this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks)

what is normal pre-albumin values?
what are normal serum levels of magnesium ?
what is a normal potassium serum level?

17-40 mg/dL
1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia)
3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia)

what are good sources of folic acid?

Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils.

Sources of potassium

beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas

what is important about the diet of someone taking ACE inhibitors?

can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas)

Taking Coumadin. Which foods should the client limit?

Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes

what is a normal hematocrit level in a female?
What are normal Hgb values (female)?
what are normal values for WBCs?

37-48% (male is 42-52%)
12-16 g/dL (male 13-17)
4500-11,000 / uL

what foods should you avoid if you have diverticulitis?

avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber)

When taking MAOI's, limit your consumption of

thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl,

At what age does bone loss begin with osteoporotis
what are normal Calcium levels?

at age 35 (women)
8.6-10 mg/dL

A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of

calcium gluconate (because hypocalcemia causes Chvostek's sign)

What are the S/S of lithium toxicity?
(depakote for bipolar disorder)

fine hand tremors, mild GI upset, slurred speech and muscle weakness

a nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin) . which of the following over the counter medication should the nurse instruct the client to avoid

Aspirin

a nurse responsible for a client receiving a antihypertensive medication is to

teach the client to change position slowly to avoid dizziness or fainting

a client should receive a dose of flumazenil ( romazicon) to treat symptoms of

benzodiazepine overdose

a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teaching

I will tell my doctor before I stop taking the medication

a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include

1. change position slowly to minimize dizziness
2. chewing sugarless gum to prevent dry mouth

a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid ibuprofen. why or why not ?

what , if any is the appropriate action for the nurse to take NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should notif

a client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medication

thrombocytes, amylase count and liver function test

alcohol withdrawal
heroin withdrawal
nicotine withdrawal
alcohol abstinence
opioid over dose

chlordiazeproxide( Librium)
methadone( dolophine)
bupropion ( wellbutrin)
disulfiram ( antabuse)
naloxone (narcan)

a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for which of the following should the nurse monitor this client

orthostatic hypotension

a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV) . for what adverse effect should the nurse monitor this client

the nurse should monitor the client respiratory depression

a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider

serum potassium 5.2

a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at risk

Toxic level of digoxin

a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching

i should decrease the amount of calcium in my diet while taking the medication

A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity?

* Verapamil (Calan)

Adverse effect of Verapamil

Avoid grapefruit juice

Interaction of diuretics and ACE inhibitors

excessive reduction in blood pressure and symptomatic hypotension or hyperkalemia

What can prevent MI, stroke, or death in high-risk patients

Ramipril

What to monitor for when taking enoxaparin (lovenox)

Hyperkalemia
Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported

What are the therapeutic effects of protamine

Antidote to severe heparin overdose + Reversal of heparin administered during procedures

How to prevent adverse effects of oxycodone

can cause respiratory depression.
What is the nursing intervention and/or client education ? Monitor vital signs.
� Stop opioids for respiratory rate less than 12/min, and notify the provider.
� Have naloxone and resuscitation equipment available.
� Avoid

opioid agonists can cause Constipation
What is the nursing intervention and/or client education ?

Advise the client to increase fluid/fiber intake and physical activity.
� Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract
decreased bowel motility, or a stool softener such as docusate sodium (Colace)
to prevent constipation.

Adverse effects of ferrous sulfate

constipation;
upset stomach;
black or dark-colored stools; or.
temporary staining of the teeth.

Baclofen (Lioresal) therapeutic outcome:

Decrease the frequency and severity of muscle spasms (MS).

What is the difference between respiratory acidosis and respiratory alkalosis?

Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45.

Bowel elimination how to get a specimen collection

Collect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine.

Identifying manifestations of transient ischemic attacks

symptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke.

Musculoskeletal congenital disorders

Monitor skin for breakdown areas and prevent pressure sores.

The nurse caring for a child in Buck's skin traction will keep the:

Child pulled up in bed

Where should the cath bag be placed when urinary catheterization

Make sure the catheter bag/system is at a level below the client's bladder to avoid reflux.

What are the signs and symptoms of fluid volume deficit

loss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension.

What is the nursing action for dehiscence

Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's .