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COMPREHENSIVE PREDICTOR ADULT
MED SURG QUESTIONS AND CORRECT
ANSWERS (LATEST UPDATE)
...
9% sodium chloride
...
What food recommendation should the nurse include? - CorreCt
Answers -Bran fiber (it forms the stool)

A nurse is teaching a client who is at 41 weeks gestation about a nonstress
test
...
To prevent complications of cardiac
surgery, which of the following instructions should the nurse include in the
plan of care? - CorreCt Answers -Check the client's hgb level is chest tube
drainage is 300 mL in the first 1 hr
...
What action should the nurse plan to take in
regards to the provider? - CorreCt Answers -Have the provider evaluate the
client IN PERSON within one hour

What lab findings are indicative of rheumatic fever - CorreCt Answers Elevated sedimentation rate and C-reactive protein

Lab value and nutritional status - CorreCt Answers -Serum Albumin

hypertension and severe headache - CorreCt Answers -

A nurse is rceiving the lab results of a client who has osteomyelitis and is
receivign tobramycin
...
" following a suicide attempt
...
The client has a closed-suction drain
...
What actions should the nurse plan to take CorreCt Answers -Asses the client's lung sounds prior to the infusion

Verify with another nurse that the unit of blood is compatible with the
client's blood type

A nurse is caring for a client who has C
...
What actions should the nurse
take - CorreCt Answers -Change gloves after contact with infectious
material

Wear gown while providing care

A community health nurse receives a referral for a facility home visit
...

What intervention should the nurse include to decrease cardiac demand for
the newborn regarding feedings - CorreCt Answers -Feed the infant when
she is awake and crying

A nurse is caring for a newborn who has hyperbilirubinemia and a new
prescription for phototherapy
...
discontinue is the newborn's urine turns brown
b
...
Apply a moisterizing lotion to the newborns skin twice daily
d
...
5-2 making the aPTT 60-80 seconds

INR expected reference range for a client with pulmonary embolism CorreCt Answers -2
...
5

what kind of medication is alteplase - CorreCt Answers -a thrombolytic
medication

A nurse is preparing to teach about dietary management to a client who has
Chron's disease and an enteroenteric fistula (formation of a fistula between

two parts of the small bowel)
...
John's wort=serotonin syndrome
-antihistmaines and other anticholinergics have additive aeffects
-increase effects of pi, dopamine occur
-decrease effects of ephedrine, amphetamine

orienteer - CorreCt Answers -Noting the progress of the group toward
assigned goals

giver - CorreCt Answers -sharing experiences as an authority figure

initiator-contributor - CorreCt Answers -offering new and fresh ideas on an
issue

evaluator - CorreCt Answers -measuring the group's work against the
assigned objectives
What mL syringe is used for flushing a PICC line? - CorreCt Answers -10
mL

How often do we flush a PICC line? - CorreCt Answers -Before, between,
and after medication

How much force to do you apply if met with resistance while flushing a
PICC line? - CorreCt Answers -None
...
Which of the following medications should
the nurse prepare to administer? - CorreCt Answers -Adenosine
-Adenosine 6mg rapid IVP (over 1-2 seconds) is given to convert
paroxysmal supraventricular tachycardia (PSVT) to a normal sinus rhythm
...
Which of the following
laboratory values would be expected? (Select all that apply) - CorreCt
Answers -Sodium 128
Urine specific gravity 1
...
This results in the dilutional
hyponatremia and increased urine specific gravity
...
Which of the following diagnostic tests
should the nurse provide? - CorreCt Answers -Electrocardiogram
-An ECG is one of the first diagnostic tests performed for the client
experiencing chest pain because it is a fast, noninvasive test to provide
immediate information
...

Which of the following actions will ensure proper function? - CorreCt
Answers -Keep bulb compressed
-A JP drain is an evacuator unit that exerts constant low pressure as long as
the bulb of the device is fully compressed

A nurse plans care for a client who requires continuous ambulatory
peritoneal dialysis
...
Notify provider of cloudy or opaque effluent
b
...
Apply mask to client during system connect and disconnect
d
...
Warm dialysis bag by applying heating pad prior to installation - CorreCt
Answers -a
...

e
...
peritonitis is
the major cause for discontinuous
- Surgical asepsis (sterile technique) is employed during connection and
disconnection
...
Which of the following findings should the nurse identify as
a contraindication to this medication? - CorreCt Answers -History of
thyroid cancer
- The nurse should identify a personal or family history of thyroid cancer as
a contraindication to taking liraglutide and notify the provider
...


A nurse is monitoring a client who has a prescription for ciprofloxacin 400
mg IV every 12 hr
...
Other adverse effects can include
dizziness, agitation, and confusion
...
Which of the followingactions should the nurse plan to take prior to
the transfusion? - CorreCt Answers -Confirm the plasma compatibility with
another nurse
...
The nurse should also check
the expiration time on the FFP
...
9% sodium chloride solution if
necessary
...
ABO compatibility is
required for transfusion of plasma because donor antibodies could react
with the recipient's antigens
...


Normal range for PT - CorreCt Answers -11-13
...
8-1
...
Which of the following actions should the nurse
take? - CorreCt Answers -Check for blood return
- before infusion a medication through an implanted port, the nurse should
check for blood return
...
9% sodium chloride after each use and at least
once per month
...


A nurse is caring for a client who is receiving the first dose of IV ampicillin
and develops a rash and flushed skin and begins wheezing
...
However, the
nurse should keep the IV open and infuse 0
...

-The nurse should notify the rapid response team to prepare to intubate the
client if needed; however, there is another action
-The nurse should give oxygen via a nonrebreather facemask to a client
experiencing anaphylaxis due to their inability to breathe and risk for
hypoxemia
...
For which of the following findings should the nurse
withhold the medication and notify the provider? - CorreCt Answers Potassium 3
...
1 is below the expected reference range of 3
...

The nurse should identify that hypokalemia increases the sensitivity of
cardiac muscle to digoxin and can increase the risk of dig tox
-The nurse identify that a digoxin level of 1
...
8-2
...
4 and can
result in bradycardia and ventricular dysrhythmias

A nurse is preparing to perform a venipuncture for an older adult client
who has a prescription for IV fluids
...
The compress can be applies to the entire
extremity for 10-20 min
...
The nurse notes edema, skin blanching, and tightness
around the client's IV site
...


Infiltration - CorreCt Answers -cold compress

Phelbitis - CorreCt Answers -heat compress

A nurse is assessing a client who has a chest tube following a thoracotomy
...
The nurse should report this finding to the provider
-Gentle continuous bubbling in the suction chamber indicates that the
suction is working as intended
-The nurse should keep at least 2 cm of water in the water seal chamber to
reduce the risk of air flowing into the client's chest

A nurse is caring for a client following a thoracentesis
...

- the nurse should obtain a prescription for a chest x-ray to assess the client
for a pneumothorax or a mediastinal shift, which can occur if the lung is
punctured during the thoracentesis
...

Which of the following instructions should the nurse include? - CorreCt
Answers -Dry the affected area in a patting motion after washing
...
The client should wear clothing to cover the affected area and
remain in the shade when possible
- Instruct the client to only use some creams that are prescribed by the
provider to reduce the risk for irritation or injury to the affected area

A nurse is teaching a client who has a colostomy
...


- Certain foods like cruciferous vegetables can increase flatus and odor
...

- Th nurse should teach the client to use pouch deodorizers or breath mints
in the pouch to decrease odor rather than an aspirin tablet, which can cause
ulceration of the stoma
...
Which of the following findings is the priority to report
to the provider? - CorreCt Answers -A decrease in blood pressure from
130/72 to 110/68

A nurse is caring for a client who is receiving radiation therapy to the neck
...
"
- manifestation of infection
...
Spasms of the
hand and fingers when the blood pressure cuff is inflated indicate a positive

Trousseau's sign
...

-manifestations of Hypophosphatemia can include muscle pain and
weakness, which can affect respiratory muscles and cause impaired
ventilation
-manifestations of hypokalemia can include muscle weakness, orthostatic
hypotension, and dysrhythmias
-manifestations of hyponatremia can include altered mental status, muscle
cramping, seizures, and confusion

A nurse is assessing a client who has right-sided heart failure
...
Central
venous pressure is the pressure in the vena cava, near the hear atrium of
the heart, which reflects the amount of blood returning to the heart
...


A nurse is caring for a client who has an intra-arterial blood pressure
monitor
...

-Maintain the pressure bag around the flush solution at 300 to reduce the
backflow of blood into the system and minimize the risk of clotting
-Ensure that the flush system delivers 3-5 mL of solution per hour to reduce
the backflow of blood into the system and minimize the risk of clotting
-Administer 0
...
Which of the
following findings is the nurse's priority to report to the provider? - CorreCt
Answers -Hypotension

A nurse is teaching a client who has breast cancer about receiving radiation
therapy
...
"
-Radiation dermatitis, or a skin rash, near the axilla is to be expected
...
The nurse should teach the client to wash the affected skin
with a mild soap and to use hydrophilic lotions to assist with keeping the
skin dry
...

-Weight gain is not an expected finding

-Instruct the client that radiation usually takes places several days each
week for a period of 5-6 weeks
...
Which of the following actions should
the nurse take? - CorreCt Answers -Perform mouth care once every 2 hours
-Reduces the risk of ventilator-associated pneumonia
-Sometimes there will be a prescription for soft mittens so the patient does
not pull the tube out
-Check respirations at least once every 4 hours for the first 24 hours and
then as needed thereafter
-do not empty the moisture from the ventilator tubing into the cascade
because this can lead to bacterial growth and increases the risk for the
client to develop ventilator-associated pneumonia
...
Which of the following instructions should the nurse include? CorreCt Answers -Wear loose fitting cotton underwear
-Drink 2000-3000 mL of fluid each day to reduce the risk of urinary tract
infections

A nurse is providing teaching to a client who has urinary incontinence
...
The sound of the running
water can trigger the client's urge to urinate
-Establish a new interval schedule by increasing the amount of time
between urination by 10-15 min beyond the last interval

-Using absorption briefs between scheduled toileting diminishes habit
training to reduce urinary incontinence

A nurse is providing palliative care to a client who has cancer
...
The
nurse should instruct the client to limit intake of which of the following
foods? - CorreCt Answers -Broccoli
-avoid gas-producing foods, which include broccoli and cabbage

A nurse is caring for four clients
...
6
-low prealbumin level may be experiencing malnutrition, a risk factor for
skin breakdown

Reference range of prealbumin - CorreCt Answers -15-36

Reference range of glycosylated hemoglobin - CorreCt Answers -4-5
...
Which of the following client conditions should the
nurse identify as increasing risk for falls? - CorreCt Answers -Presbyopia
(near sightedness)

Xerpstomia - CorreCt Answers -Dry Mouth

(Not autoimmune itself, but component of Sjogren Syndrome)

An occupational health nurse is preparing to teach a class on prevention of
back injuries to a group of workers in a factory setting Which of the
following interventions should the nurse include in the teaching? - CorreCt
Answers -Hold the object lifted close to the body
...
Which of the following actions should the nurse take? CorreCt Answers -Assign the client to nurses who are not pregnant or
trying to conceive
...
Diff infection
...
Which of the following lab tests should the nurse plan to
monitor? - CorreCt Answers -Liver function test

A nurse is providing teaching to a client who has type 2 diabetes mellitus
and is starting repaglinide
...
"

A nurse is providing teaching for a client who has a new prescription for
metformin
...
It is a rare but very serious adverse
effect caused by metformin and should be reported to the provider

A nurse is providing teaching to a client who has a prescription for
pramlintide for type 1 diabetes mellitus
...
) - CorreCt Answers "Inject pramlintide just before a meal
...
"

What do early decelerations indicate in the second stage of labor? - CorreCt
Answers -this indicated the progression of labor and they are an expected
findings
...


The nurse should do what in the event of an umbilical cord prolapse CorreCt Answers -Assist the client in to a knee-chest position

What do late or variable decelerations indicate for nursing interventions? CorreCt Answers -Emergency caesarean birth

A nurse is assessing a client who has sickle cell anemia
...
4-1
...
8-2
...
4

Phenytoin toxic level - CorreCt Answers -greater than 30

What is the first action to take when implementing an emergency
preparedness plan - CorreCt Answers -Notify the incident commander

What does a bruit indicate in an extremity with an AV - CorreCt Answers Patency

What does a thrill upon fistula palpation indicate - CorreCt Answers Patency

Why should the nurse encourage ROM exercises in an extremity with an AV
fistula? - CorreCt Answers -maintain muscle strength

Complications of Obstructive Sleep Apnea - CorreCt Answers Hypertension, heart failure, cardiac dysrhythmias, decreased O2, urinary
retention

A nurse is administering cylcophosphamide orally to a school-age child who
has neuroblastoma
...
Which of the following findings should the nurse
expect? - CorreCt Answers -Protein
-due to increased glomerular permeability, protein is allowed to filter
through into the urine
...


What is an expected lab finding in a urinalyses for a client who has
urolithiasis - CorreCt Answers -Uric acid crystals
-urolithiasis is the process of forming stones in the kidney, bladder, and/or
urethra

UTI urinalysis findings - CorreCt Answers -WBC, Nitrates

A nurse is providing colostomy care for a client using a two-piece oouching
system
...
3 cm (0
...
How should the nurse prevent
clogging of the tube? - CorreCt Answers -Flush the client's gastrostomy tube
with 30 mL of water before and after administering the medications
-this will clear the tube of any residuals and ensures patency
-Crush each medication separately from the tube feeding formula and
administer them separately
-Change the feeding bag every 72 hours: this prevents clogging, and reduces
the risk of infection

A client who is prone to uric acid calculi should avoid eating foods
containing what? - CorreCt Answers -Purine

What are some foods containing purine? - CorreCt Answers -Organ meats
Chicken
Red Wines
Red meat
some seafoods

gastric lavage - CorreCt Answers -cleansing procedure in which the
stomach is irrigated with a prescribed solution

A nurse is performing gastric lavage for a client who has GI bleeding and an
NG tube in place
...
9% sodium chloride, sterile water, or tap water for
irrigation of the client's NG tube

-The nurse should use lavage solution that is at room temperature to reduce
the risk of injury to the client
-After installing the lavage solution, the nurse should manually withdraw
the solution and blood from the client's NG tube
-The nurse should instill the solution in volumes of 200-300 mL at a time
to reduce injury

A nurse is providing discharge instruction to a client following a total hip
arthroplasty
...

This can impede circulation and result in flexion contractures

What is a flexion contracture - CorreCt Answers -A bent (flexed) joint that
cannot be straightened actively or passively
...
(Think of lock jaw)

An increase in Amylase is indicative of what? - CorreCt Answers Pancreatitis, cholecystitis, or renal failure

A nurse is conducting visual acuity testing using the Snellen letter chart for
a school-age child who has eyeglasses
...
What medication should the nurse plan to administer? - CorreCt
Answers -Hydrocortisone
-this will assist with replacing cortisol levels
...

The nurse should inform the client that what nutrient (in addition to
protein) promotes wound healing? - CorreCt Answers -Vitamin C

What nutrient helps promote the functioning of the nervous system CorreCt Answers -Vitamin B1

What nutrient aids in blood clotting and muscle contraction - CorreCt
Answers -Calcium (Do not take with warfarin)

Which nutrient is necessary for muscle activity and fluid balance - CorreCt
Answers -Potassium

Kawasaki disease - CorreCt Answers -Inflammation of in the walls of some
blood vessels in the body
signs include rash and fever, peeling of skin
IVIG

High-dose aspirin
live vaccines must be pushed off
keep a record of the child's temp until they have no fever for several days
will be irritable for up to two months

Anti-depressants and older adults - CorreCt Answers -Antidepressants
should be given at half of the adult dose
...


uterine atony - CorreCt Answers -inability of the uterus to contract
effectively

A nurse is preparing to massage the fundus of a client who is postpartum
and experiencing uterine atony
...
Ask the client to
lie on her back with her knees flexed
2
...
Position a hand around the top of the client's fundus
4
...
Use slight downward pressure to compress the client's fundus

What do Category 1 fetal heart rate tracing indicate - CorreCt Answers -This
is an expected finding and does not mean the fetal distress

The nurse should discontinue oxytocin infusion and apply oxygen for what
fetal heart rate tracings?
What do you do if discontinuing oxytocin does not resolve? - CorreCt
Answers -Cat 2 (indeterminate) and Cat 3 (abnormal)
the nurse should admin 0
...
What medication should the nurse plan to administer to promote
uterine contractions? - CorreCt Answers -Methylergonovine

The nurse should administer magnesium sulfate to pregnant patient who
has - CorreCt Answers -Preeclampsia
-this will lower the blood pressure and minimize the risk for seizures

Tizanidine can cause what - CorreCt Answers -Liver damage
...
If this is ineffective the patient should contact the provider

parasthesia - CorreCt Answers -abnormal sensation such as numbness,
burning and tingling

A nurse is planning care for a client following a total hip arthroplasty
...
An assessment indicates 3 cm dilation
...


-therapeutic rest can include hydrotherapy and analgesia to relieve pain
...
Contractions are frequent and painful but ineffective in promoting
dilation and effacement
...

This swing is caused by the release of stress hormones to counter low
glucose levels
...
Which of the following actions should
the nurse include in the plan? - CorreCt Answers -Monitor the client's
nighttime blood glucose levels
-monitoring the client's nighttime blood levels over time can provide an
accurate diagnosis of this effect
-The nurse should plan to administer a smaller dose of intermediate-acting
insulin at bedtime or increase the client's bedtime snacks to avoid
conditions that can lead to the effect
-The nurse should evaluate the client's evening caloric intake based on the
insulin dose and exercise programs during the day to avoid conditions that
could lead to the effect

An increased intake of phosphate-containing foods, such as carbonated
beverages, a lack of time outdoors in sunlight, and decreased estrogen or
testosterone are risk factors for what disease? - CorreCt Answers Osteoporosis

after acute inflammation has subsided in a patient with diverticulitis, he or
she should increase the intake of what foods? - CorreCt Answers -Those

that are high in fiber, such as wheat bran, while-grain bread, and fresh
fruits and vegetables that do not contain seeds
...
The pain disappears in 1-2 days
...
5-5

AST level - CorreCt Answers -0-35

-enzyme that is measured as part of liver function tests

Function of liver/gallbladder - CorreCt Answers -DIGESTING FATS
-Liver produces biles
...
Bile acids emulsify the fat in the
intestine
...
Vitamin and protein
production and detoxification of drugs
...

One of main functions of liver is metabolism (detoxification) of drugs

Chyme - CorreCt Answers -A semi-solid mixture of food and gastric
secretions that is formed in the stomach

Gastrin - CorreCt Answers -A hormone that is produced in the stomach
mucosa that stimulates the release of gastric secretions during the process
of digestion

Glycogen is stored where - CorreCt Answers -In the liver and is released in
the form of glucose to meet the body's energy needs

What does a peak flow meter rate in the yellow zone indicate - CorreCt
Answers -inadequate control of asthma
-the client should obtain 3 readings and write down the highest reading

A client who has Addison's disease with have what kind of skin appearance?
- CorreCt Answers -Darkening/bronzing of the skin on both exposed and
unexposed parts of the body due

A client who has Cushing's disease will have what kind of skin appearance?
- CorreCt Answers -Purple striae on the chest and abdomen

A client who has systemic lupus erythematosus will have what kind of skin
appearance? - CorreCt Answers -A butterfly rash across the bridge of her
nose

Lupus - CorreCt Answers -an inflammatory disease caused when the
immune system attacks its own tissues
...
These
can periodically get worse and then improve
...
This should be reported to the provider
-fetal bradycardia is associated with fetal cardiac defects, maternal
hypoglycemia, and fetal viral infections

There should be at least how long of resting between contractions? CorreCt Answers -one minutes
...
4) or greater
-this is associated with chorioamnionitis

chorioamnionitis - CorreCt Answers -an infection caused by bacteria
ascending from the vagina into the uterus

can an AP measure oral intake? - CorreCt Answers -yes

can an AP provide postmortem care? - CorreCt Answers -yes

Blumberg's sign - CorreCt Answers -rebound tenderness
common in appendicitis, cholecystitis

A nurse should expect to find ascites in a client who has what? - CorreCt
Answers -chronic pancreatitis or pancreatic cancer

Kehr's sign - CorreCt Answers -Referred pain down the left shoulder;
indicative of a ruptured spleen or liver trauma

Paternalism - CorreCt Answers -a type of relationship between clients and
health care providers in which the health care providers believe they know
what is best for the clients
...
The newborn is

pink with acrocyanosis
...


What foods should the nurse recommend to a client taking an iron
supplement? - CorreCt Answers -Citrus foods, strawberries, melons, and
tomatoes
-foods high in vitamin C are encouraged
...
5 of 1:1000 sub q

ARBS - CorreCt Answers -SARTAN
Antihypertensive, heart failure, MI, diabetic neuropathy

Calcium Channel Blockers - CorreCt Answers -DIPINE
Antihypertensive
Admin iv injection over 2-3 min, slowly taper
Use: angina, hypertension
cautious in patient taking digoxin and beta blocker
-contraindicated for heart failure, heart block, bradycardia
side/adverse effects: constipation, reflex tachycardia, peripheral edema,
toxicity
verapamil and diltiazem: a fib, a flutter, SVT

Bronchitis - CorreCt Answers -Inflammation and hypersecretion of mucus
in the bronchi and bronchioles caused by chronic exposure to irritants

Emphysema - CorreCt Answers -air sacs in the lungs (alveoli) are damaged
-over time the inner walls weaken and rupture
-narrowing of bronchioles
-trapping air resulting in loss of elasticity, presents as barrel chest

-shortness of breath, put in high fowlers

COPD patients should receive low concentration of O2 because of what CorreCt Answers -The stimulus to breathe is their low PO2 (partial
pressure of O2)

Addison's disease - CorreCt Answers -hyposecretion of adrenal cortex
hormones caused by autoimmune disease, TB, histoplasmosis,
adrenalectomy, tumors, HIV; can be induced by abrupt cessation of steroid
medication

Addisonian diet - CorreCt Answers -High protein, high carb, high sodium,
increase fluids
Low potassium
Consume small frequent meals to prevent hypoglycemia
avoid caffeine and alcohol

Atherosclerosis - CorreCt Answers -Plaque build-up in artery wall

Why are eggs bad for those with hypertension - CorreCt Answers -they are
high in cholesterol

Antiembolic stockings should be removed how frequently - CorreCt
Answers -1-3 X daily to check skin

Paracentesis - CorreCt Answers -Removing fluid from abdominal space
through a slender needle

ADH/Vassopresson - CorreCt Answers -Anti-diuretic hormone
-regulates the amount of water in body
-accomplishes in kidneys
-tubules to retain
Increased in SIADH
-Decrease in Di

Lumbar Laminectomy - CorreCt Answers -Removing the back portion of a
vertebra in the lower back to create more room within the spinal canal

ET Placement verifying - CorreCt Answers -Check for end-tidal carbon
dioxide levels by using a capnometry
chest x-ray

Lumbar spinal surgery drainage amount in the first 24 hours - CorreCt
Answers -No more than 250 mL
-risk for fluid volume deficit if higher

Internal pressure in long bone fractures does what? - CorreCt Answers forces fat globules from the marrow into the systemic circulation, where
they act as emboli
-s and s include: confusion, combativeness secondary to hypoxia

Theophylline Levels - CorreCt Answers -10-20
toxic greater than 20

asthma

Autonomic Dysreflexia - CorreCt Answers -syndrome in which there is a
sudden onset of excessively high blood pressure
-common in spinal cord injuries that involve the thoracic nerves of the
spine or above (T6 or above)

Nystagmus - CorreCt Answers -involuntary eye movement which causes the
ye to rapidly move from side to side, up and down, or in a circle, may blur
vision

Diplopia - CorreCt Answers -double vision

Expected findings in autonomic dysreflexia - CorreCt Answers -Spots in the
visual field
blurred vision
nasal congestion
severe headache
facial flushing

The first action to take when implementing an emergency preparedness
plan - CorreCt Answers -Notify the incident commander to initiate the
command hierarchy and maintain order

Complications of obstructive sleep apnea - CorreCt Answers -hypertension,
heart failure, cardiac dysrhythmias

A client who is prone to uric acid calculi should avoid what? - CorreCt
Answers -Purine:
organ meats, chicken, red wines, red meats

abruptio placentae - CorreCt Answers -Persistent uterine contractions
Board-like abdomen
Dark red vaginal bleeding

Total hip arthroplasty - CorreCt Answers -install a raised toilet seat
maintain hip @ 90 degree when sitting to minimize hip flexion and prevent
hip dislocation
use a walker
no pillow under the knees when lying down for this can impede circulation
and result in flexion contractures

Nonpharmacologic measures for PTSD - CorreCt Answers -guided imagery

Chlopromazine - CorreCt Answers -potentially life threatening adverse
effects: neurolopetic malignant syndrome
can cause: high temp, dysrhythmias, decrease in LOC, labile BP

Macular degeneration - CorreCt Answers -Decreased central vision
-due to bleeding into the macula or yellow spots under the retina

Retinal detachment - CorreCt Answers -floating dark spots

Cataracts - CorreCt Answers -Double vision

Glaucoma - CorreCt Answers -increase in intraocular pressure

Elevate effected leg with DVT and taking hep - CorreCt Answers -

Newborn safety - CorreCt Answers --set hot water @ or below 120
-crib slats should be no more than 2
...


Sickle cell disease: manifestation of vaso-occlusive crisis - CorreCt Answers
--Hematuria, resulting from ischemia of the kidneys
-painful swelling of the hands
-visual disturbances

Admin a Unit of plasma over how long - CorreCt Answers -30-60 minutes

Zollinger-Ellison Syndrome (ZES) - CorreCt Answers -Too much gastric
acid
lab profile: gastric aspirate

-hydrochloric acid and pepsin
NPO 12 hours
Avoid alcohol, tobacco, meds that change gastric pH for 24 hour

Refeeding Syndrome - CorreCt Answers -Metabolic Disturbance that occurs
due to the reinstitution of nutrition to person or animals who are starved
-fatigue, weakness, confusion, inability to breath, high blood pressure,
arrhythmias, seizures, heart failure

Fat overload syndrome - CorreCt Answers -fever
increased triglycerides
clotting
multiple organ system failure
discontinue infusion and notify provider immediately

thrombophelbitis - CorreCt Answers -inflammation process that causes a
blood clot to form and block one or more veins
-ambulate
-antiembolic stockings and SCD's
-anticoagulant prophylaxis

Warfarin - CorreCt Answers -daily blood draws for the first 5 days
avoid calcium
avoid Tylenol/ibuprofen
report changes in stool color

Chron's disease - CorreCt Answers -chronic inflammation of the intestinal
tract that extends through all layers
-bleeding is rare
-right lower q pain

Chron's Disease Diet - CorreCt Answers -high calorie, high protein, low
fiber, no dairy

Ulcerative Colitis - CorreCt Answers -Recurrent ulcerative and
inflammatory disease of the superficial mucosa of the colon
contiguous (touching) ulcers
left lower q pain
liquid and bloody stools (10-20 a day)
fever, high pitched bowel sounds, rebound tenderness-perforation, passage
of mucus and pus from the bowel

ulcerative colitis diet - CorreCt Answers -low-residue
high calorie
high protein
limits high fiber

Diverticular disease - CorreCt Answers -3 conditions that involve numerous
small sacs or pockets in the wall of the colon
Diverticulosis: presence of pouchlike herniation (diverticula) along the
intestine wall (sigmoid colon most common) (high fiber)

Diverticular bleeding: injury of small vessels
Diverticulitis: inflammation of one or more diverticula (clear diet, go onto
low fiber)

Diverticular diet - CorreCt Answers -avoid laxatives, morphine is
contraindicated

Peritonitis - CorreCt Answers -inflammation of the peritoneum and lining
of abdominal cavity
-rigid board like abdomen (hallmark sign)
-Nausea and vomiting
-Tachycardia, febrile
-rebound abdominal tenderness

Fowlers and semi fowlers
Ng tube to low intermittent suction

Hypoparathyroidism - CorreCt Answers -hyposecretion of parathyroid
hormone; may result in hypocalcemia, hyperphosphatemia and tetany

hyperparathyroidism - CorreCt Answers -excessive levels of parathyroid
hormone
hypercalcemia, hypophosphatemia

Tetany - CorreCt Answers -intermittent muscle spasms

AP/UAP - CorreCt Answers -under the direction of an LPN or RN
skills:
-basic hygiene care and grooming
-provides assistance with ADL such as nutrition elimination and mobility
-Basic skills: vital signs, pulse oximetry, and I and O
-Maintains safe environments
-Noninvasive/Do not require sterile technique

LPN - CorreCt Answers -Supervised by RN or Provider
-Meets healthcare needs of clients
-Cares for stable and/or chronic patients with expected outcome
-Reinforcement teaching
-Contributes to care plan
-Calculates and monitors IV flow rate
-Administers IVPB meds
-Monitor IV fluids
-tube insertion
-Trach suction

Diseases that must be reported to Public Health Officials - CorreCt Answers
-communicable diseases
-chicken pox (varicella)
-herpes simplex
-resp syncytial virus
-HIV

-TB (pulmonary)
-Vancomycin-resistant enterococci (VRE)

Occurrence Report - CorreCt Answers -Occurrence report is created for
unexpected or unused events not consistent with the operations of a client
-can include events affecting: client, employee, visitor, volunteer

Radiation - CorreCt Answers --wear led apron
-instruct visitors to stand 6 feet away
-place "caution: radioactive material" sign on door

care and maintenance of TPN - CorreCt Answers -Monitor weight daily
Monitor and record I and O, note fluid balance
Monitor serum glucose levels every 4-6 hours
Monitor for signs of infection
Change dressing every 48-72 hours
Change IV tubing and fluid every 24 hours

If TPN is unavailabl - CorreCt Answers -admin dextrose 10% in water to
prevent hypoglycemia

parathyroid hormone - CorreCt Answers -this hormone helps maintain an
appropriate balance of calcium in the bloodstream and in tissues that
depend on calcium for proper functioning

A nurse prepares to perform a dressing change
...
Name
b
...
Phone number
d
...
Photo identification
f
...
b
...
d
...


What is the sequence in which a nurse should follow when moving clients
who can partially bear weight from a bed to a chair - CorreCt Answers -1
...

2
...

3
...
Rock the client to a standing position
...
Request the client pivot on the foot farther from the chair
...
Which of the following topics would be appropriate for this class?
Select all that apply
a
...
STIs and pregnancy
c
...
Memory and cognition
e
...
Eating disorders and nutirtion - CorreCt Answers -a
...
c
...
f
...
Which of the
following circumstances requires an occurence report? Select all that apply
a
...
Visitor falls in hallway
c
...
Oxygen therapy is refused
e
...
b
...

Which of the following information is needed? Select all that apply
a
...
"
b
...
"
c
...
"
d
...
"
e
...
" - CorreCt Answers -a
...
e
...
What does
this heritage practice following a death? - CorreCt Answers -The oldest
child will bathe the body

A client states, "I have not been sleeping well
...
Walk briskly
b
...
Take a warm bath
d
...
Take a warm bath

A nurse provides discharge education to a client who has MRSA
...
"Discontinue antibiotics after a scab forms
b
...
"
c
...
"
d
...
"
e
...
"
f
...
" - CorreCt
Answers -b
...
d
...
f
...
Which of the following infectious
disease requires droplet precautions? Select all that apply
a
...
Measles
c
...
Pertussis
e
...
d
...


A client is admitted to the telemetry unit for sustained paroxysmal
supraventricular tachycardia
...
Atropine
b
...
Nitroprusside
d
...
Adenosine

A nurse plans care for a client who has a serum potassium of 7
...
Place on a cardiac monitor
b
...
Infuse 100 mL of 10% glucose IV
d
...
Administer sodium polystyrene
f
...
33% sodium chloride IV fluid bolus - CorreCt Answers -a
...
c
...
e
...

- cardiac monitoring is crucial with patients with hyperkalemia
...
Hyperkalemia cab
cause life-threatening dysrhythmias and cardiac arrest
...

Elevated serum creatinine can be an indication of renal function, a major
cause of hyperkalemia
...
IV
regular insulin is typically infused with severe hyperkalemia
...
Sodium
polystyrene sulfonate binds with the potassium for excretion
...
Which of the
following findings would be expected? select all that apply
...
fever
b
...
tachycardia
d
...
nausea and vomiting - CorreCt Answers -a
...
c
...

-fever and chills are manifestation of pyelonephritis related to
inflammation responses
...

-Tachycardia and tachypnea are manifestations related to fever and/or
pain
...
Which of the following actions may reduce the incidence of fat
emboli?
a
...
provide supplemental oxygen
c
...
administer sub q hep - CorreCt Answers -a
...
Which client
statement validates teaching was effective?
a
...
"

b
...
"
c
...
"
d
...
" - CorreCt Answers a
...
Which of the
following actions should the nurse implement to prevent transient edema
of the affected arm? Select all that apply
a
...

b
...

c
...

d
...

e
...
e
...
A modified radical mastectomy involves removal of a portion of the
axillary lymph nodes, which can cause transient edema
...

-Gentle muscle pumping exercises (such as making a fist and releasing) can
help decrease postoperative edema by causing muscle contraction, which
improves circulation
...


A nurse assess a client who has Guillain Barre syndrome
...
Diplopia
b
...
thrombocytopenia
d
...
hyperactive reflexes - CorreCt Answers -a
...


What should a nurse do prior to removing a client's NG tube? - CorreCt
Answers -Auscultate for bowel sounds
-The nurse should verify the presence of bowel sounds prior to removing
the NG tube to evaluate the success of abdominal decompression and the
return of peristalsis

A client who has liver failure is scheduled for a paracentesis
...
Instruct client to void
b
...
elevate head of bed
d
...
obtain informed consent - CorreCt Answers -a
...
d
...

-a distended bladder would increase the risk of an unintended puncture of
the bladder
...
During the procedure, the
client sits on the edge of the bed or in a chair
-Abdominal girth is a good indicator of the degree of ascites
...
To measure the girth, the
client lays flat and is measured around the umbilicus are at the end of
exhalation
-A paracentesis is an invasive procedure and requires informed consent

ascites - CorreCt Answers -abnormal accumulation of fluid in the abdomen

What is the main cause of ascites? - CorreCt Answers -Pressure builds up in
the veins of the liver and it doesn't work as it should
...
don sterile gloves
b
...
elevate the drainage bag above bladder
d
...
Which of the following conditions can cause
this to occur? select al that apply
a
...
kinked tubing
c
...
tube is disconnected
e
...
b
...
e
...
This increased resistance can occur if the client
coughs or "fights" the vent
...

Which of the following rewarming methods should be implemented?
a
...
Apply a heating blanket
c
...
Administer heated oxygen - CorreCt Answers -b
...
The treatment includes
external rewarming devices such as heating blankets, warm blankets, warm
packs
...
Treatment may also include warm, high
carb fluids that do not contain caffeine or alcohol

atelectasis - CorreCt Answers -collapsed lung

What should a new mother do if her nipples become sore and cracked due
to breastfeeding? - CorreCt Answers -Apply colostrum to the nipples after
feeding to help them heal
...

-the application of warm compresses prior to feeding or pumping promotes
the flow of the breast milk and assists to ensure complete emptying of the
breast
...


-The client CAN and SHOULD continue to breast feed from both the
unaffected and the affected breast
...
If it
is too painful, the client should pump
...
Which of the following actions should the charge nurse
include in the teaching regarding situations requiring an amniotomy? CorreCt Answers -Placing a fetal scalp electrode
- a fetal scalp electrode is attached to the presenting part of the fetus in
order to provide accurate continuous monitoring of the fetal heart rate
...


What is effleurage? - CorreCt Answers -Lightly stroking the abdomen
during a contraction
...


A client who is in active labor is admitted to a labor and delivery unit and
reports, "My water just broke and my baby is breech
...


If a missed dose of iron - CorreCt Answers -Take a dose as soon as you
realize you missed as long as it is within 12 hours of the missed dose
...
Iron is best absorbed when taken on an empty stomach
...


A nurse is caring for a client who is in active labor and is scheduled to
receive epidural anesthesia
...
Every 24 hours the fundus should be descended
approximately 1-2 cm
...


A client is in active labor and is positive for GBS
...
7-99

Warfarin lab tests - CorreCt Answers -PT/INR

Heparin lab tests - CorreCt Answers -aPTT

Prior to a newborn glucose heelstick - CorreCt Answers -clean the chosen
puncture site with alcohol
warm the newborn heel for 5-10 min to dilate the blood vessels
Puncture either side of the outer aspects of the newborn's heel
...
Report to the provider immediately

Manifestations of endometritis (infection of uterus lining) postpartum CorreCt Answers -Fever for 2 consecutive days, chills, foul-smelling lochia,
abdominal tenderness

Maternal metabolism, physical exertion, and delivery of the placenta can
lead to a decreased what - CorreCt Answers -blood glucose level

Magnesium sulfate antidote - CorreCt Answers -calcium gluconate 10%

How to tell if clacium gluconate was effective in the treatment of
magnesium toxicity - CorreCt Answers -Rep rate between 12-20

Magnesium sulfate toxicity - CorreCt Answers -absent deep tendon reflexes,
slurred speech, decreased perfusion to organs and tissues causing oliguria,

respiratory depression, blurred vision, decreased consciousness, and
cardiac dysrhythmias and arrest

Hormone tested for during a pregnancy test - CorreCt Answers -hCG

umbilical cord - CorreCt Answers -a tube containing the blood vessels
connecting the fetus and placenta
-2 arteries carrying deoxygenated blood to the placenta
-1 vein carrying oxygenated blood to the baby

Fetus' source of oxygen - CorreCt Answers -Placenta

Amniotic fluid - CorreCt Answers -fluid within the amniotic sac that
surrounds and protects the fetus
-replaced every 3 hours
-800-1200 mL at the end of pregnancy
-Functions: temp regulation, protection, promotes musculoskeletal
development

Do fetal and maternal blood mix? - CorreCt Answers -no

ambivalence - CorreCt Answers -during 1st trimester
nursing intervention: assess meaning of pregnancy to the client/partner
and socioeconomic supports; refer if needed

Accepting - CorreCt Answers -2nd trimester

assess if ambivalence is increased and how the client views the fetus

Preparing for birth - CorreCt Answers -3rd trimester
teach manifestations of onset of labor, newborn care, feeding methods,
birth control, and home preparation for baby, as well as birthing plan

Skin in the 2nd and 3rd trimesters - CorreCt Answers -striae, linea nigra,
chloasma (darkening of the skin)
-discuss that commercial treatments are not useful; pigmentation usually
disappears after pregnancy; striae may fade

Nutrition during pregnancy - CorreCt Answers -average weight gain 25-35
pounds
caloric increase 300-400kcal/day
protein increase by 25 g/day
iron intake 30 mg/day
folate intake 600 mcg/day
limit caffeine intake

When can hCG be detected? - CorreCt Answers -6-11 days in serum and 26
days in urine after conception following implantation

Non stress test measures what - CorreCt Answers -the fetal CNS

Reactive NST - CorreCt Answers -normal finding
two or more fetal heart rate accelerations within 20 minutes

Before 32 weeks gestation, FHR acceleration is defined as what - CorreCt
Answers -an increase of at least 10 beats/min lasting at least 10 seconds

Biophysical profile - CorreCt Answers -Uses real-time ultrasound to
visualize physiological characteristics of the fetus

Five variables of a biophysical profile - CorreCt Answers -1
...
gross body movements
3
...
reactive FHR
5
...
S and S include dizziness, lightheadedness, pale, clammy skin
...
2 mg IM or PO as prescribed

Calcium Gluconate - CorreCt Answers -Antidote for magnesium sulfate
toxicity

Nursing interventions for Calcium Gluconate administration - CorreCt
Answers -Administer calcium gluconate 1 g (10 mL in 10% solution) IV for
signs of toxicity
Dilute with equal parts normal saline and administer 0
...
25 mg every 20 min as needed
Monitor for adverse effects
Do not administer if client reports chest pain
Notify provider if blood pressure is less than 90/60, pulse is greater than
130, signs of pulmonary edema, FHR greater than 180
Administer Beta Blocking agent as antidote

Terbutaline adverse effects - CorreCt Answers -tremors, dizziness,
headache, tachycardia, hypotension, anxiety

Indomethacin - CorreCt Answers -May be used as tocolytic for preterm
labor or for oxytocin induced tachysystole
prostaglandin synthetase inhibitor

Nursing interventions for Indomethacin administration - CorreCt Answers
-Monitor contractions and FHR
Monitor vital signs: note that indomethacin can mask maternal fever
Administer with food as to limit GI distress
Only administer if gestational age is LESS THAN 32 WEEKS

Magnesium Sulfate - CorreCt Answers -Tocolytic used for preterm labor
CNS depressant to prevent seizures in preeclampsia

Nursing interventions for Magnesium Sulfate administration for preterm
labor - CorreCt Answers -Monitor contractions and FHR
Monitor fetal movement and FHR variability

Monitor vital signs and urine output

Nursing interventions for magnesium sulfate administration for
preeclampsia - CorreCt Answers -Monitor vital signs, urine output, DTRs,
and LOC
Monitor magnesium levels (therapeutic range 4-8)
Administer via infusion pump in dilated form
Use indwelling catheter to monitor urinary elimination
Stop immediately if: resp rate goes below 12, altered LOC, magnesium level
is 10 mEq/L or 9 mg/dL
Administer calcium gluconate 1g/10 mL in 10% solution at 0
...
1mg/kg IV, IM, SQ, ET tube
Adult: administer 0
...
25 mg subcutaneously to decrease uterine
activity

A nurse is updating the plan of care for a client who is 48 hours
postoperative following a laryngectomy and is unable to speak
...
By determining the client's level of reading skills and

cognition, the nurse can best provide the client with a variety of customized
techniques to practice and use after verbal skills are lost

A nurse is teaching a client who has a new prescription for total parenteral
nutrition through a central line
...
What actions should the nurse take? CorreCt Answers -Recommend rescreening in 1 year
-the nurse should identify a blood level of 3 mcg/dL is within the expected
reference range
...
What actions should the nurse
take? - CorreCt Answers -Auscultate the apical pulse for at least 1 minute
Assess the apical pulse when the newborn is in a quiet state

A nurse is providing teaching for a client who has a fracture of the right
fibula with a short-leg cast in place and a new prescription for crutches
...
What instruction should the nurse
include? - CorreCt Answers -Use a three-point gait
-a three point gait allows the clients to be mobile without bearing weight on
the affected extremity
A health care provider will initially measure crutches for the client
...

When walking upstairs, the client should advance the unaffected leg first
...
What information should the nurse include? CorreCt Answers -Your body temp might decrease slightly just prior to
ovulation
Body temp rises about 0
...
4 degrees after ovulation
...
What action should the nurse take FIRST - CorreCt Answers Change position of the client
-when providing client care, the nurse should use the least restrictive
intervention first
...
If this method is
unsuccessful, the nurse should attempt to flush or aspirate the client's tube
to remove the clog

Limiting feedback to the staff and avoiding change initiation is what kind of
leadership style - CorreCt Answers -Laissez-faire

Making decisions quickly and relying solely on their own judgement/not
seeking input from others is what kind of leadership style? - CorreCt
Answers -Autocratic

A nurse is caring for a client who is receiving continuous bladder irrigation
following a transurethral resection of the prostate
...
What
action should the nurse take? - CorreCt Answers -Irrigate the catheter with
0
...
Therefore, the nurse should irrigate the cath with 0
...

Avoid increasing tension on the urinary catheter
- this can cause bladder irritation, bleeding, and subsequent catheter
blockage, and can ultimately lead to urinary retention
Keep the client in bed
- the findings indicate an internal obstruction
Removing the catheter can cause further harm

risperidone can cause what - CorreCt Answers -orthostatic hypotension,
dizziness, which can lead to falls
...

What finding should the nurse identify as an indication that the medication
is effective? - CorreCt Answers -Decreased hallucinations

urine osmolality range - CorreCt Answers -50-1200 mOsm/kg

Why administer high-dose antibiotic therapy to child with cystic fibrosis CorreCt Answers -Children who has cystic fibrosis metabolize antibiotics
more rapidly and require higher doses of antibiotics to help fight aggressive
infections

A nurse is assessing an infant who has hydrocephalus and is 6 hr
postoperative following placement of a ventriculoperitoneal (VP) shunt
...


Hematocrit reference range for children - CorreCt Answers -32-44
higher indicates dehydration

Urine specific gravity range - CorreCt Answers -1
...
030

BUN reference range for a child - CorreCt Answers -5-18 mg/dL

WBC range - CorreCt Answers -5000-10,000

BUN range for adults - CorreCt Answers -10-20

A client is having left sided weakness following a stroke
...
What actions should the nurse take? - CorreCt Answers Monitor the client's IV site for manifestations of an infection every 4 hours
Monitor the WBC count every 24 hours

Monitor the client's mouth every 8 hours for manifestation of an infection,
such as sores and lesions
Change the IV tubing every 24 hours

Manifestations of ovarian cancer - CorreCt Answers -abdominal bloating
increase in abdominal girth
pelvic or abdominal pain
early satiety
urinary frequency or urgency

When do you empty an ileostomy - CorreCt Answers -At 1/3-1/2 of the way
full

If no stool is passed after 6-12 hours of an ileostomy - CorreCt Answers contact provider

fluid intake of how much for ileostomy - CorreCt Answers -1920

ileostomy appliance should be changed - CorreCt Answers -every 3-7 days
to prevent skin irritation around the stoma

Elevate leg with dvt when sitting - CorreCt Answers -yes

clients who have rheumatoid arthritis require foods high in
should get what medications - CorreCt Answers -protein, vitamins, and iron
NSAIDS

should take hot showers to help relieve morning stiffness

CPM machine? - CorreCt Answers -

At what week gestation does a client get tested for maternal serum alphafetoprotein? - CorreCt Answers -week 16

How should a child who has heart failure take his or her digoxin
medication? - CorreCt Answers -With a small glass of water after
swallowing the med

A parish nurse is leading a support group for clients whose family members
have committed suicide
...
What actions should the nurse make sure to include in the
plan of care? - CorreCt Answers -Administer low dose heparin
-this will help prevent dvt during long periods of innactivity

A nurse is providing teaching to the parents of an infant who has a cleft lip
palate
...
What behaviors should the nurse expect? CorreCt Answers -Distractibility and poor judgement

coarctation of the aorta - CorreCt Answers -congenital cardiac condition
characterized by a narrowing of the aorta

What is an expected finding for an infant who has coarctation of the aorta? CorreCt Answers -Weak femoral pulses

A nurse is developing an in-service about personality disorders
...
Upon assessment, the nurse notes tidaling in the water seal
...

-an air leak would have to be continuous bubbling

Stimulant withdrawal - CorreCt Answers -fatigue

What is a risk factor that is the best predictor of future violence in a client? CorreCt Answers -previous violent behavior

While feeding a client who has dysphagia, the nurse should sit where? CorreCt Answers -At or below the clients eyes level during feedings

How long does it take for amitriptyline to take effect - CorreCt Answers -a
couple of weeks

in order to promote intake for a client who has COPD with severe dyspnea,
what should the nurse include in the plan of care? - CorreCt Answers -Limit
fluid intake with meals

what should the nurse observe for when administer alteplase revombinant
(fibrolytic) for a thrombus in the coronary artery? - CorreCt Answers Bruising of the skin

Gentamicin Adverse Effects - CorreCt Answers -nephrotoxicity and
ototoxicity
-look for creatinine increase

What should the nurse do if a client who is receiving intermittent enteral
feedings starts to develop diarrhea? - CorreCt Answers -Slow the infusion
rate

A nurse is assessing a client following abdominal surgery
...
What statement by the client indicates an understanding
of mixing insulins? - CorreCt Answers -I will not mix this insulin with other
types of insulin

A nurse is caring for a client who is immunocompromised
...
What should the nurse include in the plan of care regarding locks? CorreCt Answers -Place locks at the tops of exterior doors

A nurse is caring for a client who repeatedly refuses meals
...
" The nurse should intervene and explain to the AP that
this statement constitues what tort - CorreCt Answers -assault

Does a nurse have to document whether or not a client has prepared his or
her advance directives? - CorreCt Answers -yes

A nurse is reviewing lab results for a client who has heart failure and notes
a serum potassium level of 5
...
WHat medication should the nurse
withhold? - CorreCt Answers -spironolactone

Biofeedback requires what - CorreCt Answers -concentration to control
physiological responses

A nurse is teaching the parent of a child who has a new onset of seizures
and is to undergo an EEG about the procedure
...
Which of the
following assessment findings should the nurse expect? Select all that apply
- CorreCt Answers -Lochia serosa
Fundus 4 cm below the umbilicus

Total gastrectomy and vitamins - CorreCt Answers -B12

A nurse is caring for a child who has cystic fibrosis and requires postural
drainage
...
What should the nurse do? - CorreCt Answers
-Assist the adolescent in applying for medicaid

What should a nurse do when she has suspicions of elder abuse? - CorreCt
Answers -privately interview the client about her condition

a nurse is caring for a client who is experiencing expressive aphasia and
right hemiparesis following a cerebrovascular accident
...
What
should the nurse do to provide cath care> - CorreCt Answers -provide
perineal hygiene after defecation

A newly licensed nurse working at an HIV clinic is reviewing the
responsibilities of her position at the clinic
...

The nurse should initiate a referral to what interprofessional care team? CorreCt Answers -speech-language pathologist

What food allergy indicates a risk for a latex allergy - CorreCt Answers bananas
-avocados and chestnuts

A nurse should measure what daily on a patient who has a PICC line CorreCt Answers -the arm circumference above the insertion site

Approximated surgical incision heals by what - CorreCt Answers -primary
intention

A nurse in a mental health clinic receives a request from a client who is
undergoing psychotherapy to obtain a copy of the therapist's notes
...
What action should the
nurse take in regards to where to set the oxygen - CorreCt Answers -away
from curtains or drapes

A nurse is caring for a client following a thyroidectomy
...
The nurse should emphasize the
importance of what factor in the prevention of sickle cell crisis? - CorreCt
Answers -adequate hydration

home health nurse is assessing a client who has ALS and has had recent
weight loss
...
What
finding should the nurse expect? - CorreCt Answers -severe periocular pain

A nurse is caring for a toddler who has retinoblastoma
...
Which of the following instructions should the nurse include
in the teaching? - CorreCt Answers -Apply petroleum jelly to the glans with
diaper changes
-you don't want it to stick to the diaper

Can an AP remind a client to use an incentive spirometer? - CorreCt
Answers -yes

A nurse is caring for a newborn whose mother was taking methadone
during her pregnancy
...
" The client is weak and unable to
walk
...
What does
the nurse have to do? - CorreCt Answers -Ensure the state health
department has been notified

A nurse is caring for a client who has an NG tube
...
What action should the nurse take? - CorreCt Answers Position the ultrasound stethoscope above the symphysis pubis to assess
the fetal heart rate

action for fraying on the electrical cord of a CPM - CorreCt Answers Remove the device from the room

Bacterial meningitis precautions - CorreCt Answers -droplet
seizure

adverse effect of sertraline - CorreCt Answers -excessive sweating

What blood work must you obtain prior to a cardiac cath - CorreCt Answers
-CBC with differential

A nurse in the emergency departmnt is caring for a client who has a new
diagnosis of acute myocardial infarction and is being treated with
thrombolytic, aspirin, and IV heparin
...
The client states, "The voices are telling me to jump
...
Which of the actions should the
charge nurse take? - CorreCt Answers -report to the nursing manager dont
confront

hip fracture and new onset of tachypnea - CorreCt Answers -

What must all implanted ports be accessed with - CorreCt Answers -a non
coring needle

platelet range (normal) - CorreCt Answers -150,000-450,000

client who has leukemia and platelet level of 95,000 - CorreCt Answers -

Leukemia - CorreCt Answers -cancer of white blood cells

A fib puts your at risk for - CorreCt Answers -pulmonary emboli

A nurse is teaching about home care to the parents of an infant who has a
tracheostomy
...
Which of the following statements by the client indicates that
teaching has been effective - CorreCt Answers -I have grab bars next to my
tub

A nurse is providing teaching to a client who is undergoing radiation
therapy and has stomatitis
...
What should be the first actions of the nurse - CorreCt Answers Review the child's electronic pain diary

A nurse is providing teaching to a client who is receiving misoprostol for
induction of labor
...
The nurse notices redness and warmth to touch
around the insertion site
...
min for the past 15 min
...
Which of the following medications requires the nurse to follow
facility procedures in the safe handline of a hazardous material spill? CorreCt Answers -Doxorubicin hydrochloride (chemo drug)

A nurse in an emergency departmnt is reviewing the medical record of a
client who is having an acute MI
...
The client refuses to
see any family members
...
Which
of the following guidelines should the nurse include? - CorreCt Answers Document the client's condition every 15 minutes

A nurse is preparing an in-service for a group of nurses about malpractice
issues in nursing
...
Which of the
followign clients should the nurse refer for speech therapy? - CorreCt
Answers -A client who has dysphagia following a stroke (speech swallow)

hypervolemia - CorreCt Answers -bounding pulse

What vitamin should a client be instructed to increase while taking
phenytoin - CorreCt Answers -vitamin D
-this medication causes a vitamin D deficiency

A nurse is caring for a group of clients
...
Which of the
following foods should the nurse provide for this client? - CorreCt Answers
-peanut butter sandwich
-high fat, finger food, high cal

a nurse is caring for a client who asks for information regarding organ
donation
...
Which of the
following actions should the nurse take? - CorreCt Answers -Inform the
client of the risks involved if she leaves AMA

A nurse is providing an in-service about client evacuation during a fire
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What diagnostic
procedure should the nurse plan to teach the patient regarding pernicious
anemia? - CorreCt Answers -Schilling test

The Schilling test for pernicious anemia involves: - CorreCt Answers -the
administration of radioactive cobalamin and the measurement of its
excretion in the urine

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