A client is receiving packed RBCs and becomes tachypneic. The client's temperature changes from 36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions should the nurse perform first. 1. Give 750 mg acetaminophen orally. 2. Collect blood and urine specimens for analysis. 3. Administer and IV infusion of 0.9% sodium chloride. 4. Stop the infusion and return the blood to the lab.

4. Stop the infusion and return the blood to the lab.

A nurse receives a request from four clients at the same time. Which of the following clients should the nurse address first? A client who 1. Needs to void 1 hr. after removal of an indwelling urinary catheter. 2. Reports restlessness and shortness of breath following surgery for a fractured femur. 3. Asks for a stool softener 2 days following surgery. 4. Demands to take prescribed insulin early the spouse is bringing dinner.

2. Reports restlessness and shortness of breath following surgery for a fractured femur.

After receiving the report, a nurse should plan to access the clients in which priority order? 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally. 2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter. 3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy. 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter.

1st) 2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter. 2nd) 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally. 3rd) 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter. 4th) 3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.

A nurse received the report and should plan to see which of the following client first? 1. A client at 39 weeks of gestation who is having contractions over 5 min lasting45 to 60 seconds. 2. A client who is pregnant and has a blood glucose level of 150mg/dl. 3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV. 4. A client 1 day postpartum who has changed perineal pads twice in the last 7 hr.

3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV.

After receiving the report, which of the following clients should the nurse see first? 1. A client who was admitted with kidney stones and is crying with back pain. 2. A client who had chest discomfort prior to admission and is now requesting coffee. 3. A client who is scheduled for surgery and needs the linen changed. 4. A client who is to receive one unit of packed RBCs today and needs an IV restarted.

1. A client who was admitted with kidney stones and is crying with back pain.

The nurse should triage which of the following clients first? 1. Vomiting, photosensitivity, and stiff neck. 2. Elevated temperature, sore throat, and fatigue. 3. A guarded gait and a bruised, edematous ankle. 4. Cloudy urine with painful urination.

1. Vomiting, photosensitivity, and stiff neck.

5 Rights of Delegation

Right Person Right Task Right Circumstance Right Direction/Communication Right Supervision/Evaluation

Scope of Practice RN - LPN - UAP -

RN - Unstable clients, Assessments, Initiate Care Plans, Initial Teaching, Blood Productions, IV Fluids and IV Push Medications. LPN - Stable clients, Gather data, Contribute to Care Plan, Reinforce Teaching, Monitor IVFs and Blood Transfusions, Administer Piggybacks. UAP - Stable clients, Obtain Vital Signs, Gather specific date, Hygiene care, Bed making, Feeding, Positioning, Ambulation.

A nurse is organizing care for four clients, which of the following tasks should the nurse instruct the UAP to perform? 1. Measure the urine output from a client who was recently admitted with dehydration. 2. Bathe and shampoo hair for a client who was just admitted after a motor vehicle crash. 3. Help a client who is requesting a bedpan after a lumbar puncture. 4. Decrease the oxygen on a nasal cannula for a client who is being discharged with COPD.

1. Measure the urine output from a client who was recently admitted with dehydration.

Which of the following tasks should a nurse assign to the experienced unlicensed assistive personnel (UAP)? (SATA) 1. Completing intake and output measurements. 2. Feeding a client who has early dementia. 3. Explaining oral hygiene to a client receiving chemotherapy. 4. Bathing a client two days after a cerebrovascular accident. 5. Ambulating a client who is one-day post-hysterectomy. 6. Assisting a client who has hypertension select low-sodium snacks.

1. Completing intake and output measurements. 2. Feeding a client who has early dementia 4. Bathing a client two days after a cerebrovascular accident. 5. Ambulating a client who is one-day post-hysterectomy.

A nurse is supervising care delegated to a UAP. The nurse should take corrective action if which of the following is observed? 1. Allowing a client to sit in a bedside chair while discarding bathwater. 2. Pulling the curtain partially around the bed while performing perineal care. 3. Raising the bed and lowing the side rail while repositioning a client. 4. Answering a call that rings the hospital telephone while the client is away.

2. Pulling the curtain partially around the bed while performing perineal care.

A nurse delegates hygiene care for a client hospitalized with COPD to unlicensed assistive personnel. Which of the following is the most appropriate instruction for the nurse to give? 1. Delay hygiene care until one hour after breakfast. 2. Allow the client to nap with the lead of the bed elevated. 3. Encourage the client to participate in hygiene care. 4. Teach the client to breathe slowly and deeply.

1. Delay hygiene care until one hour after breakfast.

An LPN reports the following data to the supervising RN regarding data collection for a client who has congestive heart failure: Pulse oximetry 85%, respirations 48/min and labored. What is the priority action at this time? 1. The LPN will administer IV Furosemide. 2. The respiratory therapist will be notified. 3. The client will be prepared for a chest x-ray. 4. The care of the client will be reassigned to an RN.

4. The care of the client will be reassigned to an RN.

A nurse from the adult medical unit is assigned to the pediatric unit. Which of the following would be an appropriate assignment? 1. A toddler admitted with epiglottitis. 2. A school-age child scheduled for excision of a Wilms tumor. 3. An infant who is recovering from repair of a cleft lip and palate. 4. A preschooler who had surgical fixation of a fractured humerus.

4. A preschooler who had surgical fixation of a fractured humerus.

A nurse coordinates care for a client who had a cerebrovascular accident. Which of the following tasks should be addressed by the Physical Therapist? (SATA) 1. Completing self-care. 2. Thickening clear liquids. 3. Using devices for walking. 4. Transferring from chair to bed. 5. Administering Albuterol treatment.

3. Using devices for walking. 4. Transferring from chair to bed.

A client is recovering from a cerebrovascular adducent and has orders to be transferred to a rehabilitation center. Which of the following date should the nurse include in the verbal report? (SATA) 1. The client has been married three times. 2. The client is moving all extremities well. 3. The client is being treated for hypertension. 4. The client has three children who visit daily. 5. The client has an unrepaired aortic aneurism. 6. The client initially received the wrong IV fluids.

2. The client is moving all extremities well. 3. The client is being treated for hypertension. 4. The client has three children who visit daily. 5. The client has an unrepaired aortic aneurism.

A nurse contract the provider and questions the prescription of enoxaparin for a client who is allergic to heparin. The provider directs the nurse to give the medication as prescribed. Which of the following should be the priority action by the nurse? 1. Submit an incident report to the nurse manager. 2. Decline to administer the medication. 3. Document datils of the conversation in the medical record. 4. Immediately report this situation to the charge nurse.

2. Decline to administer the medication.

A client was recently placed in seclusion after exhibiting behaviors of acute mania. What is the appropriate nursing action? 1. Review medical history for potential contraindications of seclusion. 2. Obtain a verbal prescription now and request a medical evaluation with 12 hr. 3. Maintain seclusion if the client continues to exhibit signs of delirium. 4. Administer propofol 80 mg IV and repeat as needed.

1. Review medical history for potential contraindications of seclusion.

A client who is admitted with an epidural hematoma attempts to leave the hospital without a discharge prescription from the provider. After notifying the provider. After notifying the provider, which action should the nurse take? 1. Explain risk to the client. 2. Notify the legal department. 3. Provider discharge instructions. 4. Administer prescribed medications.

1. Explain risk to the client.

A nurse prepares to ask a client to sign a consent for an elective surgical procedure and notes the client received midazolam hydrochloride 1 hr. ago. Which of the following actions should the nurse take? 1. Ask a family member to sign the consent. 2. Obtain the client's signature if alert and oriented. 3. Send the client to the operating room with documentation. 4. Notify the provider ad operating room staff to cancel the procedure.

4. Notify the provider ad operating room staff to cancel the procedure.

A nurse plans care for a client who is pregnant and practices the theory of hot and cold. Which food sections may be served? (SATA) 1. Cereal and milk 2. Yogurt and fruit 3. Steak and potato 4. Chili and crackers 5. Hot tea with ginger

1. Cereal and milk 2. Yogurt and fruit

A nurse provides discharge teaching to an older adult about fall prevention measures in the home. Which instructions should be included? (SATA) 1. Install grab-bars in the shower. 2. Wear shoes inside the house. 3. Use small rigs in the bedroom. 4. Mark stairs-step edges with colored tape. 5. Keep frequently used items within reach.

1. Install grab-bars in the shower. 2. Wear shoes inside the house. 4. Mark stairs-step edges with colored tape. 5. Keep frequently used items within reach.

A nurse provides care to a client who has celiac disease. Which of the following choices would be an appropriate snack? 1. Corn chips and salsa. 2. Pretzels and hummus. 3. Pastrami with rye bread. 4. Cheese spread on crackers.

1. Corn chips and salsa.

A nurse assists an older adult client with selecting kosher foods from the dietary menu. Which options should the nurse expect the client to choose? (SATA) 1. Orange 2. Milkshake 3. Shrimp salad 4. Chili with beef 5. Hardboiled egg

1. Orange 2. Milkshake 4. Chili with beef 5. Hardboiled egg

The school nurse suspects that a junior high student may have anorexia nervosa. This eating disorder is characterized by: 1. A lack of control over overeating patterns. 2. Self-imposed starvation. 3. Binge/purge cycles. 4. Excessive exercise.

2. Self-imposed starvation.

After a surgical procedure, the client is advanced to a full liquid diet. The nurse is able to recommend which one of the following foods for this client? 1. Custard. 2. Pureed meats. 3. Soft fresh fruit. 4. Canned soup.

1. Custard.

The nurse is speaking with parents of a child at a day-care center. The parents ask the nurse about the nutritional needs of their toddler. An appropriate ginger food that is identified by the nurse is: 1. Nuts. 2. Popcorn. 3. Cheerios. 4. Hot dogs.

3. Cheerios.

When introducing a feeding to a client with an indwelling gavage tube for enteral nutrition, the nurse should first: 1. Irrigate the tube with normal saline solution. 2. Check to see that the tube is properly placed. 3. Place the client in a supine position. 4. Introduce some water before giving the liquid nourishment.

2. Check to see that the tube is properly placed.

An older adult client is scheduled for intermittent tube feedings by syringe. To ensure client safety during administration of the feeding, the nurse should take which of the following actions? 1. Unclamp the feeding tube and then connect the syringe to it. 2. Heat the formula before administering the feeding. 3. Verify there is no more than 300 mL residual prior to the feeding. 4. Pour the formula into the syringe, raising or lowering it as needed.

4. Pour the formula into the syringe, raising or lowering it as needed.

ANTIDOATE FOR: Acetaminophen

Acetylcysteine

ANTIDOATE FOR: Benzodiazepine

Flumazenil

ANTIDOATE FOR: Curare

Edrophonium

ANTIDOATE FOR: Cyanide Poisoning

Methylene Blue

ANTIDOATE FOR: Digitalis

Digoxin Immune FAB

ANTIDOATE FOR: Ethylene Poisoning

Fomepizole

ANTIDOATE FOR: Heparin and Enoxaparin

Protamine Sulfate

ANTIDOATE FOR: Iron

Deferoxamine

ANTIDOATE FOR: Lead

Succimer

ANTIDOATE FOR: Magnesium Sulfate

Calcium Gluconate 10%

ANTIDOATE FOR: Narcotics

Naloxone

ANTIDOATE FOR: Warfarin

Phytonadione

Side effects and adverse reactions for: ACE inhibitors

Angioedema

Side effects and adverse reactions for: Benzodiazepines

Anterograde amnesia

Side effects and adverse reactions for: Beta Blockers

Bronchospasm

Side effects and adverse reactions for: Ciprofloxacin

Tendon Rupture

Side effects and adverse reactions for: Digoxin

Yellow tinge to vision

Side effects and adverse reactions for: Docycycline

Tooth discoloration

Side effects and adverse reactions for: Furosemide

Hypokalemia

Side effects and adverse reactions for: Lithium

Tremors

Side effects and adverse reactions for: Tobramycin

Ototoxicity

Side effects and adverse reactions for: Valacyclovir

Thrombotic thrombocytopenic purpura

Therapeutic & Toxic Drug Levels Digoxin

Therapeutic 0.8 to 2.0 ng/mL Toxic > 2.4 ng/mL

Therapeutic & Toxic Drug Levels Lithium

Therapeutic 0.4 to 1.4 mEq/mL Toxic > 2.0 mEq/mL

Therapeutic & Toxic Drug Levels Phenytoin

Therapeutic 10 to 20 mcg/mL Toxic > 30 mcg/mL

Therapeutic & Toxic Drug Levels Magnesium Sulfate

Therapeutic 4 to 8 mg/dL Toxic > 9 mg/dL

Medication Categories "ending" ACE Inhibitors

ACE Inhibitors - PRIL

Medication Categories "ending" Antivirals

Antivirals - VIR

Medication Categories "ending" Antifungals

Antifungals - AZOLE

Medication Categories "ending" Antilipidemic

Antilipidemic - STATIN

Medication Categories "ending" Angiotensin II receptor blockers (ARBs)

Angiotensin II receptor blockers (ARBs) - SARTAN

Medication Categories "ending" Beta-Blockers

Beta-Blockers - OLOL

Medication Categories "ending" Calcium Channel Blockers

Calcium Channel Blockers - DIPINE

Medication Categories "ending" Erectile Dysfunction

Erectile Dysfunction - AFIL

Medication Categories "ending" Histamine receptor antagonists

Histamine receptor antagonists - DINE

Medication Categories "ending" Proton Pump Inhibitors

Proton Pump Inhibitors - PRAZOLE

A nurse prepares to perform a heel stick to evaluate blood glucose for an infant. Which action should be used to minimize pain? 1. Warm the lateral surface to the foot for 5 minutes. 2. Apply a eutectic mixture of location anesthetic (EMLA) 1 hour before the procedure. 3. Allow the skin to dry after cleansing with mild friction. 4. Encourage the mother to breastfeed the infant during the procedure.

4. Encourage the mother to breastfeed the infant during the procedure.

A dietitian instructs a client who has a transdermal fentanyl patch about food choices to minimize constipation. Which of the following should be included? (SATA) 1. Eggs 2. Barley 3. Raisins 4. Oatmeal 5. White rice 6. Fresh celery

2. Barley 3. Raisins 4. Oatmeal 6. Fresh celery

When coordinating home discharge for a client who has a recent spinal cord injury, the nurse plans to promote and maintain health by which of the following actions? (SATA) 1. Reducing fluid intake 2. Assessing food choices 3. Evaluating bowel training 4. Promoting a daily exercise program 5. Recommending annual immunizations

2. Assessing food choices 3. Evaluating bowel training 4. Promoting a daily exercise program 5. Recommending annual immunizations

Eight hours after a vaginal delivery, a client is unable to void. What should the nurse's initial action be? 1. Offer PO medication for pain. 2. Demonstrate use of sitz bath. 3. Assist the woman to the bathroom. 4. Pour warm water for the perineum.

3. Assist the woman to the bathroom.

A nurse cares for a client who speaks a different language. Which of the following are correct statement regarding communication? (SATA) 1. Written material is given in English and primary language. 2. Hospital personnel may interpret if fluent in client's primary language. 3. Communication is directed to the client even if an interpreter is present. 4. Interpretation provided by family member s is strongly discouraged. 5. Language access services are required in all hospitals that receive federal funding.

1. Written material is given in English and primary language. 3. Communication is directed to the client even if an interpreter is present. 4. Interpretation provided by family member s is strongly discouraged. 5. Language access services are required in all hospitals that receive federal funding.

During a facility disaster drill for a mass casualty incident, the nurse should correctly assign a yellow tag to which client? 1. A client reporting severe chest pain and shortness of breath. 2. A client who has superficial chemical burns to both hands and arms. 3. A client who has a traumatic amputation of the left leg above the knee. 4. A client transported via ambulance for asystole nonresponsive to epinephrine.

2. A client who has superficial chemical burns to both hands and arms.

A client reports smoke is coming from a wall socket. in what order should the nurse take the following actions? (put in order) Close all doors Point extinguisher hose to base of fire Squeeze the trigger Remove client from area Initiate emergency response system

1. Remove the client from the area 2. Initiate emergency response system 3. Close all doors 4. Point extinguisher hose to the base of the fire 5. Squeeze the trigger

A nurse initiates emergency protocol on the medical unit during a fire. Which client should be evacuated first? A client who is 1. receiving mechanical ventilation 2. prescribed continuous oxygen therapy 3. recovering from a below the knee amputation 4. schedule for cholecystectomy the following day.

4. schedule for cholecystectomy the following day.

A unit educator evaluates teaching for the staff about the transfer of an obese client who is unable to assist from the bed to ta wheelchair. Which method is best o complete this task? 1. Gait belt 2. Mechanical lift 3. Bear hug technique 4. Two personnel to assist

2. Mechanical lift

A client who lives in a long-term care facility is at high risk for falls. Which actions should the nurse implement? (SATA) 1. Place the client's walker at the foot of the bed. 2. Keep all four side rails up throughout the night. 3. Maintain a clear bath from bed to the bathroom. 4. Put items on the beside table within easy reach. 5. Check the client every four hours to ensure safety. 6. Ask the client o use the call light before getting up.

3. Maintain a clear bath from bed to the bathroom. 4. Put items on the beside table within easy reach. 6. Ask the client o use the call light before getting up.

A unit manager provides an update from the quality improvement report. Which standards of care should be followed for a client who requires mechanical restraints? (SATA) 1. Vital signs 2. Toileting needs 3. Range of motion 4. Behavior changes 5. Neurovascular checks

- ALL - 1. Vital signs 2. Toileting needs 3. Range of motion 4. Behavior changes 5. Neurovascular checks

A client who has a latex allergy is admitted to a medical-surgical unit for elective surgery. Which action should the nurse implement? (SATA) 1. Verify surgery is schedule last. 2. Bring a latex-free cart to the room 3. Use of stopcocks to inject IV medications 4. Alert the perioperative team of allergy 5. Place monitor devices in a stockinet

2. Bring a latex-free cart to the room 3. Use of stopcocks to inject IV medications 4. Alert the perioperative team of allergy 5. Place monitor devices in a stockinet

A nurse reviews the following admission prescriptions for a client who has pneumonia. Which action should be implemented? (SATA) - Vital Signs every 4 hrs. - Regular Diet - Ceftriaxone 500 mg IV BID - Continue regimen for insulin 1. Determine any known allergies 2. Ensure an identification bracelet is in place. 3. Verify all medications currently being taken. 4. Store home medications at the bedside. 5. Validate the client's understanding related to the purpose of each medicine.

1. Determine any known allergies 2. Ensure an identification bracelet is in place. 3. Verify all medications currently being taken. 5. Validate the client's understanding related to the purpose of each medicine.

A client has a sealed radiation implant. Which action should the nurse implement? (SATA) 1. Save linens in the client room. 2. Assign client to a private room 3. Limit each visitor to 30 minutes a day. 4. instruct friends to stand 3 feet from client. 5. Place a "Caution: Radioactive Material" sign on door.

1. Save linens in the client room. 2. Assign client to a private room 3. Limit each visitor to 30 minutes a day. 5. Place a "Caution: Radioactive Material" sign on door.

Ten days after chemotherapy, a client's WBC is 1000/mm3. Which discharge instructions should the nurse provide? (SATA) 1. Sanitize your personal toothbrush daily. 2. Avoid cleaning cages of household pets. 3. Wear a mask when around other people. 4. Increase intake of raw fruits and vegetables. 5. Avoid using the public transportation system.

1. Sanitize your personal toothbrush daily. 2. Avoid cleaning cages of household pets. 3. Wear a mask when around other people. 5. Avoid using the public transportation system.

Four clients enter the emergency department and require immediate admission. Only one private room is available. Which client should the nurse place in the private room. 1. A client who has a steel rod protruding from the chest. 2. A client who is coughing up coffee ground color emesis. 3. A client who has a low-grade fever and dry cough. 4. A client who is referred for admission due to sever viral conjunctivitis.

4. A client who is referred for admission due to sever viral conjunctivitis.

A child who has a rash and fluid-filled blisters across the face and chest is confirmed to have varicella. Which action should the nurse take? 1. Administer amoxicillin P.O. TID 2. Give one dose of the varicella vaccine. 3. Implement airborne and contact precautions. 4. Place the client in a private room and provide positive airflow.

3. Implement airborne and contact precautions.

A nurse provides care for a client who has a WBC of 900mm3. Which actions increase the risk for harm? (SATA) 1. Bathe client every other day. 2. Use plastic cup kept at the bedside. 3. Wash hands with antimicrobial soap. 4. Place fresh plants at least 3 feet from client. 5. Dispose of any beverage serviced to client after 8 hours. 6. Limit number of personnel who may enter the room.

1. Bathe client every other day. 2. Use plastic cup kept at the bedside. 4. Place fresh plants at least 3 feet from client. 5. Dispose of any beverage serviced to client after 8 hours.

A woman who has a premature rupture of membranes is admitted for observation. Which finding should concern the nurse? 1. Cloudy amniotic fluid 2. Fetal heart rate 160/min 3. Irregular uterine contractions 4. Maternal temperature 37.2*C(99*F)

1. Cloudy amniotic fluid

A client remains in the intensive care unit 48 hr. post-intubation. The nurse recognizes which interventions are needed to assist in prevention of ventilator-associated pneumonia? (SATA) 1. Turn ever 2 hrs. 2. Wearing a face mask. 3. Frequent hand hygiene. 4. Client positioned supine. 5. Clean oral suction device. 6. Oral care with disinfectant.

1. Turn ever 2 hrs. 3. Frequent hand hygiene. 5. Clean oral suction device. 6. Oral care with disinfectant.

A nurse provides teaching about preventing sudden infant death syndrome to the parent of a newborn. Which statement indicates understand? 1. I will offer the baby a pacifier at sleep time. 2. Only one stuffed animal should be kept in the crib. 3. The baby's head should be covered while napping. 4. A pillow can be used to maintain a side-lying position.

1. I will offer the baby a pacifier at sleep time.

The client is to apply a topical corticosteroid to an area of atopic dermatitis. When teaching the client about his drug the nurse should tell the client to 1. Apply the medication often during the day 2. Avoid stopping the medication abruptly 3. Use gloves for application 4. Expect that the problem will worsen before it improves

2. Avoid stopping the medication abruptly

The client is going to the beach. Which of the following suggestions regarding protection form the sun is accurate? 1. Use a sunscreen with the lowest SPF number. 2. Use a sunscreen, even on overcast days. 3. Sitting in the shade will protect you from sun exposure. 4. Wear light-colored, loosely woven clothes.

2. Use a sunscreen, even on overcast days.

The client developed herpes simplex. The nurse documents that the client has which of the following types of skin lesions? 1. Vesicle 2. Pustule 3. Nodule 4. Wheal

1. Vesicle

If an area of skin is indurated, it means that it is? 1. reddened 2. hardened 3. inflamed 4. draining

2. hardened

A client has iron-deficiency anemia. The nurse anticipates that which of the following abnormalities will be present during the inspection of the nailbeds? 1. Pint color 2. cyanosis 3. jaundice 4. pallor

4. pallor.

The nurse is bathing a client. When the nurse lifts the client's foot to clean it, the nurse notices that is is cool to the touch. Which of the following action would be most appropriate for the nurse to take first? 1. Document the finding on the client's chart. 2. Place the extremity under a blanket and continue the bath. 3. Inspect hair distribution on the lower half of the leg. 4. Compare the temperature of the foot with the client's other foot.

4. Compare the temperature of the foot with the client's other foot.

The client is to undergo a surgical excisional biopsy of a skin lesion o his arm. Which of the following should the nurse include in preoperative teaching? 1. Discussion of general anesthesia 2. Remaining NPO after midnight 3. Avoidance of aspirin 48 hours prior to surgery 4. Need for postoperative antibiotics.

3. Avoidance of aspirin 48 hours prior to surgery

A nurse initiates IV therapy for an older adult. Which of the following actions should be implemented? 1. Slap the extremity gently to visualize veins. 2. Ensure that the tourniquet is applied tightly for a brief time. 3. Use an inflated blood pressure cuff in place of a tourniquets. 4. Insert the IV catheter at higher angle to help avoid rolling veins.

3. Use an inflated blood pressure cuff in place of a tourniquets.

After insertion is completed a nurse should perform which of the following assessments prior to infusing antibiotics through a client's tunneled central venous catheter. (SATA) 1. Observe the antecubital fossa for edema 2. Aspirate the IV port for a brisk blood return 3. Validate there is no resistance when flushing the line with normal saline. 4. Evaluate the client's discomfort level at the insertion site when the infusion begins. 5. Review the radiology report to confirm the catheter tip rests in the superior vena cava.

2. Aspirate the IV port for a brisk blood return 3. Validate there is no resistance when flushing the line with normal saline. 5. Review the radiology report to confirm the catheter tip rests in the superior vena cava.

A client is receiving total parental nutrition (TPN) and lipids. The nurse should recognize which of the following measures should be implemented? (SATA) 1. Change TPN infusion tubing every 24 hrs. 2. Discontinue infusion of lipids after 12 hrs. 3. Clean the IV injection port before and after each time it is used. 4. Increase the rate if the infusion falls behind schedule. 5. Monitor blood glucose levels before meals and at bedtime.

1. Change TPN infusion tubing every 24 hrs. 2. Discontinue infusion of lipids after 12 hrs. 3. Clean the IV injection port before and after each time it is used.

A client develops swelling of the eyes, face, tongue, and lips after administration of intravenous penicillin. Which action should the nurse perform first? 1. Give diphenhydramine 25 mg IV 2. Administer epinephrine 0.2 mL IM 3. Raise dead of bed to 45* or higher 4. Prepare to administer a 1-liter fluid bolus.

2. Administer epinephrine 0.2 mL IM

A provider prescribes amoxicillin 500 mg orally every 12 hrs. for a client. The nurse should be concerned if the client reports a history of an allergic reaction to which of the following classification of medication? 1. Macrolides 2. Quinolones 3. Sulfonamides 4. Cephalosporins

4. Cephalosporins

A client diagnosed with pneumonia received ceftriaxone 1g IV every 12 hrs. for 4 days. Which of the following statement should be of most concern to the nurse? 1. My IV site is a little tender 2. I still have a productive cough 3. I feel nauseated ever time I eat 4. I have had runny diarrhea all day

4. I have had runny diarrhea all day

A nurse reviews discharge documentation written by the provider for a client who takes clopidogrel daily. Which of the following information should be clarified before speaking with the client? (SATA) 1. Schedule INR each moth. 2. Use saline nasal spray as needed. 3. take 81 mg aspirin each morning. 4. Instruct client to report any usually bleeding or bruising. 5. Rotate self-injection sites to include abdomen and deltoid area.

1. Schedule INR each moth. 5. Rotate self-injection sites to include abdomen and deltoid area.

A nurse cares for a client who is prescribed alteplase. The concurrent us of which medication should be of concern? 1. Warfarin 2. Metoprolol 3. Furosemide 4. Levothyroxine

1. Warfarin

A nurse is providing discharge teaching to a client prescribed ferrous sulfate. Which client statement indicates a need for additional teaching? 1. I will dilute the medicine in juice or water 2. I will eat more food high in fiber every day 3. I will take the medicine before eating breakfast 4. I will call the doctor if my stools are dark green or black

4. I will call the doctor if my stools are dark green or black

A nurse provides discharge teaching to a client who has a diagnosis of chronic kidney disease and a new prescription for metoprolol. Which action is most important for the client to accomplish? 1. Identify symptoms of uremia 2. Verbalize how to obtain a daily weight 3. Create a list of low sodium food options. 4. Demonstrate ability to check heart rate.

4. Demonstrate ability to check heart rate.

A nurse should advise a client to discontinue lisinopril and see the provider immediately if which of the following manifestations occur? 1. A persistent dry cough 2. Dizziness when standing 3. A rash on the torso and neck 4. Swelling of the tongue and lips

4. Swelling of the tongue and lips

A client is newly prescribed isosorbide mononitrate. Upon review of the client's admission history, which of the following findings should concern the nurse most? 1. Use of vardenafil 2. Administration of metoprolol 3. Report of frequent headaches 4. History of myocardial infarction

1. Use of vardenafil

A client is receiving digoxin. The nurse should instruct the client to notify the provider of which of the following finding? (SATA) 1. Blurred vision 2. Muscle weakness 3. Nausea and vomiting 4. Irregular heart rhythm 5. Increased urine output

1. Blurred vision 2. Muscle weakness 3. Nausea and vomiting 4. Irregular heart rhythm

A nurse provides discharge instruction to a client receiving simvastatin. Which of the following symptoms should the client immediately report to the provider? 1. Headaches 2. Dyspepsia 3. Sore throat 4. Weakness

4. Weakness

A nurse provides teaching to a client prescribed furosemide. Which of the following client statements indicates effective teaching? 1. I will take one pill every day at bedtime 2. I will avoid eating high-potassium foods 3. I will skip the next dose if my feet tingle 4. I will call the doctor if my legs feel weak

4. I will call the doctor if my legs feel weak

A nurse cares for a client who takes insulin lispro for the management of type 1 diabetes mellitus. Which of the following instructions would be a priority for teaching? 1. Schedule eye examinations at least once each year. 2. Medication can be administered immediately after eating. 3. A medical alert bracelet should be worn where it can be easily identified. 4. Rotate injection sites systematically within the designated region.

2. Medication can be administer immediately after eating.

A client is prescribed levothyroxine. Which of the following symptoms should concern the nurse most? 1. Weight loss 2. Palpitations 3. Heat intolerance 4. Increased appetite

2. Palpitations

A nurse provides care to a client receiving methylprednisolone sodium succinate for status asthmaticus. The nurse should monitor for which of the following adverse effects? 1. Blurred vision 2. Loss of energy 3. Hyperglycemia 4. Compression factures

3. Hyperglycemia

A client is receiving magnesium sulfate 1 g per hr. The nurse is unable to elicit a patellar deep tendon reflex and respirations are 10/min. Which of the following is the priority nursing action? 1. Review previous laboratory results. 2. Verify infusion rate of medication. 3. Prepare to administer calcium gluconate. 4. Arrange for an emergency cesarean birth.

3. Prepare to administer calcium gluconate.

A client has excessive bleeding during the third stage of labor. Which of the following pre-existing medical conditions should cause the nurse to question a prescription for methylergonovine? 1. Chronic depression 2. Transfusion reaction 3. Migraine headaches 4. Gestational hypertension

4. Gestational hypertension

The following pattern is observed on the fetal monitor for a client who is receiving oxytocin: multiple contractions with short resting period, duration of contractions is 100 to 115 seconds and the fetal heart rate baseline is at 100 beats/min. Which of the following actions should the nurse perform first? 1. Notify the provider 2. Administer oxygen by face mask 3. Discontinue the oxytocin infusion 4. Prepare to administer terbutaline

3. Discontinue the oxytocin infusion

Twenty four hours ago, a client who is Rh-negative delivered and infant which is Rh-positive. Which medication should the nurse prepare to administer to the mother. 1. Vitamin K 2. Rubella vaccine 3. Methylergonovine 4. RHo(D) immune globin

4. RHo(D) immune globin

A nurse provides teaching to an older adult prescribed patient-controlled analgesia (PCA). Which of the following should the nurse include? 1. Press the button 15 minutes prior to physical therapy. 2. Allow at least 60 minutes between doses. 3. Maintain regular time interval for using pump. 4. Large doses of the medication will be infused on a preset cycle.

1. Press the button 15 minutes prior to physical therapy.

A nurse provides care for a client who has received an epidural analgesia. Which of the following finding requires immediate intervention? 1. Inability to urinate 2. Reports of a headache 3. Bilateral upper extremity itching 4. Decrease level of consciousness

4. Decrease level of consciousness

A client who has Parkinson's disease is prescribed selegiline. The nurse should provide dietary teaching that includes avoiding which foods? (SATA) 1. Red wine 2. Soy sauce 3. Watermelon 4. Aged cheese 5. Cured sausage

1. Red wine 2. Soy sauce 4. Aged cheese 5. Cured sausage

A nurse reviews the medication record of several clients. Which of the following clients should be of most concern if taking sertraline? A client who 1. takes phenelzine daily. 2. has a decline in sexual libido. 3. is prescribed furosemide daily. 4. reports a 20-pound weight gain this month.

1. takes phenelzine daily. Sertraline = SSRI Phenelzine = MAOI

A nurse provides discharge teaching to a a client prescribed clozapine. Which of the following instructions should the nurse include? 1. Schedule weekly lab tests. 2. Decrease fiber in the diet. 3. Monitor blood pressure for hypertension. 4. Avoid consuming aged cheeses and win.

1. Schedule weekly lab tests.

ANEMIA Aplastic

Low RBC production - Renal failure - Chemotherapy

ANEMIA Hemolytic

Autoimmune Sickle Cell Thalassemia

ANEMIA Pernicious

B12 deficiency - Malnutrition - Lack intrinsic factor

ANEMIA Iron Deficiency

Blood loss Pregnancy Gastric Bypass

Hemophilia What should a nurse monitor, teach, and assess?

Monitor for epistaxis or bleeding gums Avoid injections and NSAIDs Assess joint bleeding

Sickle Cell Anemia What should a nurse avoid, manage, and assess?

Teach self-care, causes, and prevention of crisis Manage pain Assess for S/S of infection

A child who has hemophilia is being discharge home. The nurse should teach the parents to use which measures if a child sustains an injury? (SATA) 1. Pace ice over the injured tissue 2. Provide passive range of motion 3. Apply pressure directly if bleeding 4. Soak the affected area in warm water 5. Keep injured extremity above the heart 6. Administer replacement clotting factors

1. Pace ice over the injured tissue 3. Apply pressure directly if bleeding 5. Keep injured extremity above the heart 6. Administer replacement clotting factors

An older adult client who has heart failure reports feeling short of breath two hours after a blood transfusion is started. The nurse should suspect fluid overload based on which assessment finding? 1. Bilateral crackles in the lungs 2. Jugular venous distention is absent 3. BP decreased from 135/79 to 110/62 mmHg 4. Potassium level changes from 4.8 to 3.7 mEq/L

1. Bilateral crackles in the lungs

A nurse recognizes which client statements demonstrate effective teaching regarding stomatitis after radiation therapy? (SATA) 1. I should try to ignore the sores 2. Food choices do not make a difference 3. My toothbrush should be replaced often 4. Alcohol-based mouth rinses should be avoided 5. My provider may prescribe medicine if sores develop

3. My toothbrush should be replaced often 4. Alcohol-based mouth rinses should be avoided 5. My provider may prescribe medicine if sores develop

After radiation treatment, a client reports dryness, redness, and scaling within the designated radiation markings. how should the nurse respond? 1. Leve it alone because the area should not be touched 2. Wash the area with mild soap and water, and pat dry 3. Powders, ointment or creams can be used as needed 4. A heating pad will improve blood flow and help the area heal

2. Wash the area with mild soap and water, and pat dry

M. O. N. A. This stands for?

M - Morphine: treats pain and decreases preload and afterload O - Oxygen: treats ischemic myocardium N - Nitroglycerin: Improves coronary perfusion A - Aspirin: decreases clot formation

A nurse provides care to a client who underwent an aortic femoral bypass yesterday. Which finding should the nurse immediately repot to the surgeon? 1. Limited range of motion of the affected extremity 2. Manual brachial BP of 160/88 mmHg 3. Serosanguineous drainage on the abdominal dressing 4. Lower extremity pulse 1+ with warmth, redness, and edema

2. Manual brachial BP of 160/88 mmHg

One hour after a client has a cardiac catheterization and stent placement using an approach via the left femoral artery, the nurse should be most concerned about which findings? 1. Left pedal pulse 1+, right pedal pulse 2+, left leg slightly cooler than the right 2. Client rates discomfort of 3, on a scale of 0 - 10, in the left groin area 3. Cardiac monitor shows 1 to 2 premature ventricular contractions (PVCs) per minute 4. Vital signs include pulse rate 120 bpm, BP 90/60, respirations 22, and temperature 99*F

4. Vital signs include pulse rate 120 bpm, BP 90/60, respirations 22, and temperature 99*F

What heart rhythm?

1. Yes (see P waves) 2. Yes (QRS after P wave) 3. Rate is too fast 4. Irregular 5. SINUS TACHYCARDIA

What heart rhythm?

1. Yes (see P waves) 2. Yes (QRS after P wave) 3. Rate is slow 4. Regular 5. SINUS BRADYCARDIA ** Give ATROPINE **

What heart rhythm?

ATRIAL FIBULATION (A-FIB) - ANTICOAGULANTS - CARIDO VERSION

What heart rhythm?

SINUS RYTHEM WITH MULIFOCUAL PVC'S - NITROGLYCERIN - HYPOLKALEMIA

What heart rhythm?

Complete (3rd degree) Heart Block - Need PACEMAKER

What heart rhythm?

VENTRICULAR TACHYCARDIA - CPR if no Pulse

What heart rhythm?

VENTRICULAR FIBRILLATION - Defibrillate

A client reports a "racing" heart, restlessness, and anxiety. The blood pressure is 140/68 mmHg and respirations 32/min. The nurse should recognize which finding may explain the cardiac rhythm? 1. Anemia 2. Carotid massage 3. Diabetes Mellitus 4. Valsalva maneuvers

1. Anemia

A client is alert and oriented, but anxious and short of breath. After vagal maneuvers and medication administration the cardiac rhythm has not changed. The nurse should prepare to assist with which procedure? 1. Defibrillation 2. Cardioversion 3. Echocardiogram 4. Pacemaker insertion

2. Cardioversion

A nurse provides discharge teaching to a client about management of an implantable cardioverter/defibrillator (ICD). Which statement requires clarification? 1. Strenuous exercises should be avoided 2. The ICD identification card is in my wallet 3. Exposure to a metal detector will active the device 4. I can talk on my cell phone using the ear opposite of the ICD

3. Exposure to a metal detector will active the device

A nurse prepares to insert a peripheral intravenous catheter. Which actions will be included? (SATA) 1. Done sterile gloves for the procedure 2. Prime tubing after the catheter is inserted 3. Insert catheter with the bevel up at 10* to 30* angle (*=degrees) 4. Use chlorhexidine to cleanse the skin before insertion 5. Apply a tourniquet 4 to 6 inches above the selected insertion site

3. Insert catheter with the bevel up at 10* to 30* angle 4. Use chlorhexidine to cleanse the skin before insertion 5. Apply a tourniquet 4 to 6 inches above the selected insertion site

A nurse in the PACU admits a client who had gastric surgery. Which sign indicates postoperative hypovolemia? 1. Dyspnea 2. S3 gallop 3. Confusion 4. Tachycardia

4. Tachycardia

A child who has a rash and fluid-filled blisters across the face and chest is confirmed to have varicella. Which action should the nurse take? 1. Administer amoxicillin P.O. TID 2. Give one doe of the varicella vaccine 3. Implement airborne and contact precautions 4. Place the client in a private room and provide positive airflow

3. Implement airborne and contact precautions

Nagele's Rule

1st day of last period + 7 days - 3 months

Name this drug? Anti-platelet Uses: Prevent MI & CVA SE: Bleeding, Hemorrhage

Clopidogrel

Name this drug? Mood Stabilizer uses: BPD SE: Tremors, polyuria, toxicity: GI upset, CNS changes, convulsions, coma, death.

Lithium

Name this drug? Antipsychotic Uses: Schizophrenia, acute psychosis, Tourette's SE: Neutropenia, high risk of EPS

Haloperidol

Name this drug? Sedative-Hypnotic Uses: Insomnia SE: Changes in behavior and mental health, sleep walking.

Zolpidem

Name this drug? Proton Pump Inhibitor Uses: GERD, gastric ulcer SE: HA, diarrhea, osteoporosis

Esomeprazole

Name this drug? Antidysrhythmic Uses: a-fib, v-fib, v-tachycardia SE: lung damage, heart failure, liver & thyroid toxicity

Amiodarone

Name this drug? Atypical antipsychotic Uses: schizophrenia, BPD, major depression, autism SE: HA, agitation, EPS (low risk)

Aripiprazole

Name this drug? Colony stimulating factor Uses: Anemia from chronic kidney disease, perioperative SE: Blood clots

Epoetin

Name this drug? Bisphosphonate Uses: Osteoporosis SE: Jaw problems, pain in bones, pain in muscles, and pain in joints

Risedronate

Name this drug? Anticonvulsant Uses: Neuralgia, partial seizures, fibromyalgia SE: Changes in behavior or mood, muscle stitching, confusion

Pregabalin

Name this drug? Insulin. Rapid Acting Uses: Type 1 & 2 diabetes Meletus SE: Hypoglycemia

Aspart

Name this drug? Ca++ Channel Blocker Uses: HTN, Angina, a-fib, a-flutter, SVT SE: Heart failure, peripheral edema

Diltiazem

Name this drug? Smoking cessation aid Uses: Aid efforts to stop smoking SE: Change in appetite, unusual dreams

Varenicline

Name this drug? Loop diuretic Uses: Renal failure, heart failure SE: Hypokalemia, ototoxicity

Furosemide

Name this drug? Fluoroquinolone Uses: Pneumonia, sinusitis, skin infection SE: Tendonitis, phosensitivity

Levofloxacin

Name this drug? Statins Uses: Pneumonia, sinusitis, skin infection SE: Tendonitis, phosensitivity

Atorvastatin

Name this drug? Phosphodiesterase inhibitor Uses: Erectile dysfunction SE: Flushing, erection lasting >4 hrs., MI

Sildenafil

Name this drug? SSRI Uses: Depression, OCD, PTSD< panic attaches SE: Weight changes, drowsiness, loss of libido, hallucinations, insomnia

Sertraline

Name this drug? Narcotic Analgesic Uses: Chronic pain not responding to other analgesics SE: Addiction, respiratory depression

Fyntanyl

Name this drug? Corticosteroid Uses: Seasonal and perennial rhinitis SE: Nausea, dizziness, epitasis

Fluticasone

Name this drug? Nonselective Beta Blocker Uses: HTN, Dysrhythmias, migraine, and many others SE: Bradycardia, hypotension

Propranolol

Name this drug? Cholinesterase inhibitor Uses: Mild to severe AD (attention deficit) SE: May decrease reaction time

Donepezil

Name this drug? ACE inhibitor Uses: HT, MI SE: Persistent cough, angioedema

Lisinopril

Name this drug? Antimycobacterial Uses: TB, some other infections SE: Hepatotoxicity

Rifampin

Name this drug? Anticoagulant Uses: DVT prevention SE: Bleeding, neurological impairment

Enoxaparin

Which medication to give? To prevent heart disease

Atorvastatin (Statins)

Which medication to give? Prevent MI or stroke

Clopidogrel

Which medication to give? Slow the progression of arthritis

Etanercept

Which medication to give? Prevent urinary incontinences

Oxybutynin

Which medication to give? Prevent rubella

MMR Vaccine

Which medication to give? Lower blood pressure

Valsartan (SARTANS)

Which medication to give? Treat neuropathy

Pregabalin

Which medication to give? Treat GERD

Esomeprazole (PRAZOLE)

Which medication to give? Treat Bipolar disorder

Quetiapine

Which medication to give? Treat COPD

Tiotropium

Which medication to give? Treat depression

Duloxetine

Which medication to give? Decrease symptoms of herpes zoster

Valacyclovir (VIR)

Which medication to give? Prevent bronchospasms

Montelukast

A nurse care for a client who is prescribed lithium carbonate therapy. Which findings should the nurse recognize as early signs of toxicity? (SATA) 1. Lethargy 2. Mild thirst 3. Dehydration 4. Blurred vision 5. Slurred Speech

1. Lethargy 3. Dehydration 5. Slurred Speech (think about Lithium and Na+ relation)

A nurse plan discharge for a client who has dependent personality disorder. Which findings indicate a desired response to therapy? (SATA) 1. Demonstrate empathy for others. 2. Creates a daily list of short-term goals. 3. Gathers information before decision-making. 4. Self-administers diazepam to control anger. 5. Manages delusions of grandiosity with quetiapine.

2. Creates a daily list of short-term goals. 3. Gathers information before decision-making.

A nurse cares for a client who is admitted for treatment of opioid addiction. Which manifestations of opioid withdrawal should the nurse expect? (SAT) 1. Fever 2. Euphoria 3. Somnolence 4. Diaphoresis 5. Irritability 6. Vomiting

1. Fever 4. Diaphoresis 5. Irritability 6. Vomiting

A nurse admits a client with anorexia nervosa who had a 14 pound weight loss in the past two weeks. Which action should be the priority? 1. Explore client's feelings 2. Remain with client after meals 3. Foster a therapeutic relationship 4. Initiate IV fluid therapy as prescribed

4. Initiate IV fluid therapy as prescribed

A nurse care or an older client who has unexplained weight loss and extensive bruising. Which action should be the priority? 1. Use short, simple sentences 2. Refer client to medical social worker 3. Maintain client's self-esteem and dignity 4. Collect physical data and communication finding to charge nurse

4. Collect physical data and communication finding to charge nurse.

A nurse provides care for a client who has a WBC of 900mm3. Which action increase risk for harm? (SATA) 1. Bathe client every other day 2. Use plastic cup kept at the bedside 3. Wash hand with antimicrobial soap 4. Place fresh plants at least 3 feet from client 5. Dispose of any beverage served to client after 8 hrs. 6. Limit number of personnel who may enter the room

1. Bathe client every other day 2. Use plastic cup kept at the bedside 4. Place fresh plants at least 3 feet from client 5. Dispose of any beverage served to client after 8 hrs. These all INCREASE RISK for harm

A woman who has premature rupture of membranes is admitted for observation. Which finding should concern the nurse? 1. Cloudy amniotic fluid 2. FHR 160/min 3. Irregular uterine contractions 4. Maternal temperature 37.2 C (99 F)

1. Cloudy amniotic fluid

A client remains in the ICU 48 hr. post-intubation. The nurse recognizes which interventions are needed to assist in prevention of ventilator-associated pneumonia? (SATA) 1. Turn ever 2 hr. 2. Wear a face mask 3. Frequent hand hygiene 4. Client positioned supine 5. Clean oral suction device 6. Oral care with disinfectant

1. Turn ever 2 hr. 3. Frequent hand hygiene 5. Clean oral suction device 6. Oral care with disinfectant

A nurse provide teaching about preventing sudden infant death syndrome to the parent of a newborn. Which statement indicates understanding? 1. I will offer the baby a pacifier at sleep time 2. Only one stuffed animal should be kept in the crib 3. The baby's head should be covered while napping 4. A pillow can be used to maintain a side-laying position

1. I will offer the baby a pacifier at sleep time

A client who is at 18 weeks of gestation is scheduled for a test to detect fetal neural tube defects. Which procedure should the nurse expect? 1. Non-stress test 2. Chorionic villus sampling 3. Fetal scalp blood sampling 4. Maternal serum alpha-fetoprotein

4. Maternal serum alpha-fetoprotein

The client is to apply a topical corticosteroid to an area of atopic dermatitis. Which teaching the client about this drug, the nurse should tell the client to? 1. apply the medication often during the day 2. avoid stopping the medication abruptly 3. use gloves for application 4. expect that the problem will worsen before it improves

2. avoid stopping the medication abruptly

The client is going to the beach. Which of the following suggestions regarding protection for the sun is accurate? 1. use sunscreen with lowest SPF number 2. Use sunscreen, even on overcast days 3. Sitting in the shade will protect you from sun exposure 4. Wear light-colored, loosely woven clothes

2. Use sunscreen, even on overcast days

A client developed herpes simplex. The nurse documents that the client has which of the following type of skin lesions? 1. vesicle 2. pustule 3. nodule 4. wheal

1. vesicle

If an area of the skin is indurated, it means that it is? 1. reddened 2 hardened 3 inflamed 4 draining

2 hardened

A client has iron-deficiency anemia. The nurse anticipates that which of the following abnormalities will be present during inspection of the nailbeds? 1. pink color 2. cyanosis 3. jaundice 4. pallor

4. pallor

A nurse care for a client who is receiving Mg+ sulfate IV for preeclampsia. Assessment finding include: absent deep tendon reflexes and RR 10/min. Which action should be implemented first? 1. Administer calcium gluconate IV 2. Place client high-fowler's position 3. Stop magnesium sulfate infusion 4. Decrease magnesium sulfate infusion

3. Stop magnesium sulfate infusion

A nurse is preparing a client who is in active labor for epidural anesthesia. Which action should be implemented at this time? 1. Infuse an isotonic IV bolus 2. Place indwelling bladder catheter 3. Assist client in left side-laying position 4. Measure bilateral deep tendon reflexes

1. Infuse an isotonic IV bolus

The nurse is bathing a client. When the nurse lifts the client's foot to clean it, the nurse notices that it is cool to the touch. Which of the following actions would be most appropriate for the nurse to take first? 1. document finding on the client's chart 2. place the extremity under a blanket and continue to bath 3. inspect hair distribution on the lower half of the leg 4. compare the temperature to the foot with the client's other foot

4. compare the temperature to the foot with the client's other foot

A nurse cares for a client who is receiving oxytocin and has a uterine contractions with a duration of 120 seconds. The FHR is 85mpm. Which action should be the priority? 1. place client in supine position 2. discontinue oxytocin infusion 3. apply 100% oxygen via face mask 4. Notify HCP immediately

2. discontinue oxytocin infusion

The client is to undergo surgical excisional biopsy of a skin lesion on his arm. Which of the following should the nurse include in preoperative teaching? 1. discussion of general anesthesia 2. remain NPO after midnight 3. avoidance of aspirin 48 hrs. prior to surgery 4. need for postoperative antibiotics

3. avoidance of aspirin 48 hrs. prior to surgery

A nurse cares for a client who has Rh- blood and delivered a newborn with Rh+ blood. Which maternal lab should be monitored to determine RhoGAM administration? 1. Platelets 2. Hemoglobin 3. Direct Coombs' 4. Indirect Coombs'

4. Indirect Coombs' (Direct = Baby) (Indirect = Mom)

A nurse initiates IV therapy for an older adult. Which of the following actions should be implemented? 1. Slap the extremity gently to visualize veins 2. Ensure that the tourniquet is applied tightly for a brief time. 3. Use an inflated blood pressure cuff in place of a tourniquet 4. Inset the IV catheter at high angle to help avoid rolling veins.

3. Use an inflated blood pressure cuff in place of a tourniquet

A nurse cares for a newborn delivered at 41 wks. gestation who is jittery with a weak cry. Which action should be first? 1. Send a specimen for a serum glucose 2. Perform a heel-stick for glucose levels 3. Request provider to order a drug screen 4. Administer soy based formula to newborn.

2. Perform a heel-stick for glucose levels

After insertion is completed a nurse should perform which of the following assessments prior to infusing antibiotics through a client' tunneled central venous catheter. (SATA) 1. Observe the antecubital fossa for edema 2. Aspirate the IV port for a brisk blood return 3. Validate there is no resistance when flushing the line with normal saline 4. Evaluate the client's discomfort level at the insertion site when the infusion begins. 5. Review the radiology report to confirm the catheter tip rests in the superior vena cava.

2. Aspirate the IV port for a brisk blood return 3. Validate there is no resistance when flushing the line with normal saline 5. Review the radiology report to confirm the catheter tip rests in the superior vena cava.

A client is receiving TPN and lipids. The nurse should recognize which of the following measures should be implemented? (SATA) 1. Change TPN infusion tubing ever 24 hrs. 2. Discontinue infusion lipids after 12 hrs. 3. Clean the IV injection port before and after each time it is used 4. Increase the rate if the infusion falls behind schedule 5. Monitor blood glucose levels before meals and at bedtime

1. Change TPN infusion tubing ever 24 hrs. 2. Discontinue infusion lipids after 12 hrs. 3. Clean the IV injection port before and after each time it is used

A client develops swelling of the eyes, face, tongue, and lips after administration of intravenous penicillin. Which action should the nurse perform first? 1. Give diphenhydramine 25 mg IV 2. Administrator epinephrine 0.2 mL IM 3. Raise HOD to 45* or higher 4 Prepare to administer 1 liter fluids bolus

2. Administrator epinephrine 0.2 mL IM

A provider prescribes amoxicillin 500 mg oral every 12 hrs. for a client. The nurse should be concerned if the client reports a history of allergic reaction to which of the following classifications of medication? 1. Macrolides 2. Quinolones 3. Sulfonamides 4. Cephalosporins

4. Cephalosporins

A client diagnosed with pneumonia received ceftriaxone 1g IV ever 12 hrs. for 4 days. Which of the following statements should be of most concert to the nurse? 1. My IV site is a little tender 2. I still have a productive cough 3. I feel nauseated very time I eat 4. I have had runny diarrhea all day

4. I have had runny diarrhea all day

A nurse reviews discharge documentation written by the provider for a client who takes clopidogrel daily. Which of the following information should be clarified before speaking with the client? (SATA) 1. Schedule for INR each month 2. use saline nasal spray as needed 3. Take 81mg aspirin each morning 4. Instruct client to report any usual bleeding or bruising 5. Rotate self-injection site to include abdomen and deltoid area

1. Schedule for INR each month 5. Rotate self-injection site to include abdomen and deltoid area

A nurse cares for a client who is prescribed alteplase. The concurrent use of which medication should be of concern? 1. Warfarin 2. Metoprolol 3. Furosemide 4. Levothyroxine

1. Warfarin

A nurse is providing discharge teaching to a client prescribed ferrous sulfate. Which client statement indicates a need for additional teaching? 1. I will dilute the medicine in juice or water 2. I will eat more foods high in fiber every day 3. I will take medicine before eating breakfast 4. I will call the doctor if my stools are dark green or black

4. I will call the doctor if my stools are dark green or black (normal finding)

A nurse provides discharge teaching to a client who has a diagnosis of chronic kidney disease and a new prescription for metoprolol. Which action is most important for the client to accomplish? 1. identify symptoms of uremia 2. Verbalize how to obtain a daily weight 3. Create a list of low sodium food options 4. Demonstrate ability to check heart rate

4. Demonstrate ability to check heart rate (hold medication if HR <60 bpm)

A nurse plans to teach a parenting class. Which measure should be included to prevent the most common cause of death for infants and children? 1. Avoid unknown animals 2. Place infant on back during sleep 3. Secure a child in a restraint car seat 4. Apply a water safety jacket when near a body of water.

3. Secure a child in a restraint car seat

A nurse should advise a client to discontinue lisinopril and see the provider immediately if which of the following manifestations occur? 1. A persistent dry cough 2. Dizziness when standing 3. A rash on the torso and neck 4. Swelling of the tongue and lips

4. Swelling of the tongue and lips

A nurse admits a toddler who is scheduled for surgery. Which assessment is most important to document in the care plan? 1. The child's rituals and routines at home 2. The parent's methods of reward and discipline 3. The child's ability to separate from the parents 4. The parent's understanding of the child's hospitalization

1. The child's rituals and routines at home

A 54 yo client recently diagnosed with diabetes mellitus asks about diet and exercise management. The nurse recognizes a need for further education based on which statement by the client? 1. I need to carry glucose tablets to the gym 2. It is okay to exercise of my blood sugar is less than 240 mg/dL 3. I should not eat before running, to prevent complications 4. It is important to walk 20 minutes a day to improve my health.

3. I should not eat before running, to prevent complications

A nurse cares for a toddler who has glomerulonephritis. Which intervention should be the priority of care? 1. Record I/O every 2 hrs 2. Assess BP ever 1 hr 3. Maintain diet with reduced sodium content 4. Plan actives to allow for request rest periods

2. Assess BP ever 1 hr

A client asks the nurse, "should I skip my injection of glargine because I have not eaten for 8 hrs.?" The client's glucose is 106 mg/dL. Which action should the nurse perform? 1. Delay administration until morning 2. Offer sips of orange juice and reassess 3. Administer the medication as prescribed 4. Hold the insulin and document the action

3. Administer the medication as prescribed

A nurse recognizes which statement requires follow-up when providing an in-home assessment of a client who has diabetes mellitus? (SATA) 1. after exercise, I check my feet 2. my tennis shoes are for walking 3. I have a broken toenail that will fall off soon 4. do not remove my socks, because my feet hurt 5. walking around barefoot is more comfortable for me

3. I have a broken toenail that will fall off soon 4. do not remove my socks, because my feet hurt 5. walking around barefoot is more comfortable for me

A newly licenses nurse plans postoperative care for a client who had a hypophysectomy via the transsphenoidal approach. Which cation would require intervention by the charge nurse? 1. Elevate client's HOB at all times 2. Performs hourly neurological assessments 3. Encourage client to cough and deep breathe 4. Monitors type and amount of nasal drainage

3. Encourage client to cough and deep breathe

Which action should the nurse perform for a client who returned one hour ago following a thyroidectomy? (SATA) 1. Assess for Chvostek's sign 2. Evaluate for changes in quality of voice 3. Apply a cervical collar securely around the neck 4. Listen for high pitched, harsh respiratory sounds 5. Monitor for tachycardia and elevated temperature

1. Assess for Chvostek's sign 2. Evaluate for changes in quality of voice 4. Listen for high pitched, harsh respiratory sounds 5. Monitor for tachycardia and elevated temperature

A nurse prepares to infuse fresh frozen plasma for a client having experienced arterial blood loss. Which of the following results would the nurse expect? 1. Increase platelets level 2. Elevate RBC count 3. Promote blood volume expansion 4. Raise hemoglobin and hematocrit percentage

3. Promote blood volume expansion

A nurse prepares to administer medication to a client who has asthma. Which effect should the nurse recognize as an adverse response to the bronchodilator therapy? 1. Hyperkalemia 2. Hypoglycemia 3. Increased myocardial oxygen use 4. Limited routes of administration

3. Increased myocardial oxygen use

An older adult client reports recurring calf pain after walking one to two blocks that disappears with rest. The client has weak pedal pulses, and skin on the left lower leg is shiny and cool to the touch. Which nursing intervention is appropriate at this time? 1. Position the left leg dependently 2. Elevate the left leg above the heart 3. Immobilize the left leg to prevent further injury 4. Assess dorsiflexion and extension of the left foot

1. Position the left leg dependently

A client receives a transfusion of packed RBCs and tells the nurse "My IV site is painful and looks like it is swollen." Which action should the nurse take? 1. Continue to monitor the site for signs of infection or infiltration 2. Double check the blood type of the unit of blood with another nurse. 3. Start a new IV at another site and resume the transfusion at the new site. 4. Discontinue the transfusion and send the remaining blood and tubing to the lab.

3. Start a new IV at another site and resume the transfusion at the new site.

A client who has recently undergone surgery for a tracheostomy is now at home. The nurse recognizes a need for immediate intervention when the caregiver does which of the following? 1. Suctions intermittently for 15 seconds 2. Places an air humidifier at the bedside 3. Cuts a 4x4 gauze to put around the tracheostomy tube 4. Removes old tracheostomy ties before the new one are secured

4. Removes old tracheostomy ties before the new one are secured

A nurse admits a client who sustained a C3 spinal cord injury. Which findings should the nurse recognize as priority of care? 1. HR 52/min 2. RR 10/min 3. Temp 97 F (36 C) 4. BP 88/54 mmHg

2. RR 10/min

A nurse prepares an older adult for a scheduled colonoscopy. Which should be the nurse's initial action? 1. Chill bowel cleansing solution 2. Monitor frequency of elimination 3. Provide oral intake of clear liquids 4. Place portable commode at bedside

4. Place portable commode at bedside

A client presents to the emergency department and reports a history of Gravida 3 Para 2. Which should the nurse's initial action after observing a presenting part? 1. Provide emotional support to the client 2. Notify labor and deliver staff members 3. Time the frequency and duration of the contractions 4. Prepare for delivery of the newborn in the ED

4. Prepare for delivery of the newborn in the ED

A nurse is seeing a client in the outpatient care center and notes that the client has a history of rheumatic heart disease, atrial fibrillation, and alcoholism. The clients vital signs are: BP 190/94, HR 130 and irregular, RR 13. The nurse should recognize that the client is at greatest risk for which problem? 1. Edema 2. Hypoglycemia 3. Syncope 4. Thrombi

4. Thrombi - Heart rhythm is Atrial Fibrillation (A-Fib) which leads to clots which leads to pulmonary embolism (PE)

A client in the ICU is receiving an IV of D5W 1/2 NS at 75 mL/hr. Electrolyte studies reveal: Na+ 143, K+ 3.1, and chloride 98. The client develops the PVCs. The nurse should? 1. draw stat ABGs to determine changes in PO2 2. obtain a Rx to add K+ to the current IV 3. obtain a Rx to change the IV to D5W at 100 mL/hr. 4. use standing orders and administer lidocaine

2. obtain a Rx to add K+ to the current IV

A patient is receiving a drug that decreases peripheral arterial resistance. The nurse anticipates that the effect of this drug on the patient's cardiac function will result in 1. increase in preload 2. decrease in afterload 3. decrease in contractibility 4. decrease in stroke volume

2. decrease in afterload

A telemetry nurse assesses a patient who has a wide QRS complex and an HR 35 on the cardiac monitor. Which assessment would the nurse complete next? 1. pulmonary auscultation 2. pulse strength and amplitude 3. LOC 4. mobility and gait stability

3. LOC Level of consciousness

The nurse evaluates the fluid resuscitation for a patient in shock is effective upon a find that the patient's 1. urine output is 1 mL/kg/hr. 2. pulse pressure becomes narrow 3. pulmonary artery wedge pressure decreases 4. blood pressure is within the patient's normal range

1. urine output is 1 mL/kg/hr. If you know the client's weight, you want a minimum of 0.5 mL/kg/hr. for proper organ perfusion

A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is 1. normal mentation 2. increase in BP 3. verbalization of reduced anxiety 4. reduction in HR and RR

1. normal mentation proves that organs are being profuse properly (increase LOC, the brain is being profuse).