RN Comprehensive Online Practice 2019 B with NGN-with 100% verified solutions- 2024.docx | Exams Nursing | Docsity (2024)

Download RN Comprehensive Online Practice 2019 B with NGN-with 100% verified solutions- 2024.docx and more Exams Nursing in PDF only on Docsity! A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first? A client who is postoperative with abdominal distention and no bowel sounds A client who has diabetes mellitus and a blood glucose level of 105 mg/dL A client who has heart failure and 2+ pitting edema A client who is receiving maintenance IV fluids and needs a new IV catheter A client who is postoperative with abdominal distention and no bowel sounds Using the acute vs. chronic approach to client care, the nurse should first assess the client who is postoperative with abdominal distention and no bowel sounds because these manifestations are indications of a paralytic ileus. For each assessment finding, click to specify if the finding is consistent with attention deficit hyperactivity disorder (ADHD) or intellectual disability (ID). Each finding may support more than 1 disease process. Assessment Findings Intellectual impairment Interrupting others Impaired language skills Hyperreactivity to sensory input Losing necessary things A nurse is caring for a school-age child. Nurses' Notes First visit: A child is brought to the clinic accompanied by guardians. The guardians have RN Comprehensive Online Practice 2019 B with NGN-with 100% verified solutions- 2024 With 150 Q&A received feedback from the child's teacher that the child has become disinterested in schoolwork and has difficulty paying attention during class. The child often loses their school supplies. The guardians report that the child demonstrates these behaviors at home as well. The child refuses to participate in household chores, keeps their room untidy, does not clean up when told to, and is generally careless and disinterested. On assessing, the child is found to be talkative, restless, and easily distracted. 2 weeks later: The child's guardians report that the child seems to be doing better at school. The child is improving at paying attention during class and completing assignments on time. Vital Signs First visit: Blood pressure 94/56 mm Hg Heart rate 90/min Respiratory rate 24/min Temperature 37.2° C (99° F) SaO2 99% on room air 2 weeks later: Blood pressure 98/60 mm Hg Heart rate 88/min Respiratory rate 22/min Temperature 37° C (98.6° F) SaO2 99% on room air Provider Prescriptions Atomoxetine 10 mg PO daily with breakfast for 5 days, then increase dose to 18 mg PO daily with breakfast ADHD Hyperreactivity to sensory input Losing necessary things Interrupting others Intellectual impairment ID Intellectual impairment Hyperreactivity to sensory input reference range of 7.35 to 7.45, an increased PaCO2 above the expected reference range of 35 to 45 mm Hg, and an HCO3- within the expected reference range of 22 to 26 mEq/L. A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? Obtain capillary blood glucose level every 2 hr. Check the neurovascular status of the client's lower extremities every hour. Apply a cold pack to the client's ankle for 30 min every hour. Maintain the affected ankle elevated and immobilized. Apply a cold pack to the client's ankle for 30 min every hour. The nurse should clarify a prescription for a cold pack to the client's ankle because type 1 diabetes mellitus is a contraindication for receiving cold therapy. A client who has type 1 diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Ice can further impair circulation. A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? Initiate contact precautions for the client upon admission. Restrict visitors from entering the client's room during hospitalization. Wear a surgical mask while providing care for the client. Have the client wear a surgical mask while being transported outside the room. Have the client wear a surgical mask while being transported outside the room. A client who has active TB should wear a surgical mask while being transported to prevent transmission of the disease. A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles? Autonomy Nonmaleficence Justice Fidelity Autonomy Autonomy refers to a client's ability to make their own decisions about treatment. Informed consent promotes autonomy by providing clients with complete information about treatment. A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report? Weight loss Jaundice Bradycardia Polyuria Jaundice The nurse should monitor the client for jaundice and report any indication to the provider. Clients who take valproic acid are at risk for liver damage, which can lead to jaundice. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Order Keep the client supine. Oxygen therapy to keep oxygen saturation above 95%. Maintain the client's hips in flexion. Keep the lights in the client's room dim. Cluster nursing care. Monitor blood glucose every 4 hr. Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia. Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred. Anticipated Oxygen therapy to keep oxygen saturation above 95% Monitor blood glucose every 4 hr Keep the lights in the client's room dim. Contraindicated Cluster nursing care. Maintain the client's hips in flexion. Keep the client supine. Oxygen therapy to keep oxygen saturation above 95% is anticipated. The nurse should titrate oxygen therapy to maintain the oxygen saturation level above 95% to avoid hypoxia. The client is exhibiting manifestations of increased intracranial pressure (ICP). Therefore, oxygenation and perfusion are the priority for this client. Cluster nursing care is contraindicated. This client is exhibiting manifestations of increased ICP. The nurse should spread out nursing care out because clustering can contribute to increased ICP. Keep the client supine is contraindicated. The nurse should elevate the head of the bed to promote blood return to the heart of the client who has increased ICP. Monitor blood glucose every 4 hr in anticipated. The client is exhibiting manifestations of increased ICP. Therefore, the nurse should frequently monitor the client's vital signs and blood glucose to avoid secondary brain injury. Hold hands folded below the waist after donning sterile gloves. Pick up and pour solutions with the palm of the hand covering bottle labels. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. Maintain sterile objects within the line of vision. Maintain sterile objects within the line of vision. Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? Perform ADLs for the client to promote rest. Allow for frequent rest periods throughout the day. Use heat to reduce joint inflammation. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. Allow for frequent rest periods throughout the day. The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to maintain muscle strength, joint function, and range of motion. Which of the following interventions should the nurse implement? Select all that apply. Raise the knee position on the client's bed. Use an automated blood pressure cuff on the client's arm. Administer IV fluids. Prepare for platelet transfusion. Assess the client's mouth every 8 hr. Assess peripheral circulation hourly. Use humidification with oxygen therapy. A nurse is caring for a client during a follow up visit at a gastrointestinal clinic Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Vital Signs 0600: Temperature 37.8° C (100° F) Heart rate 104/minR espiratory rate 26/min Blood pressure 88/56 mm Hg Oxygen saturation 90% on 2 L via nasal cannula Diagnostic Results 0645: Hematocrit 25% (37% to 52%) Hemoglobin 8.3 g/dL (12 to 16 g/dL) WBC count 18,000/mm3 (5,000 to 10,000/mm3) Reticulocytes 8% (0.5% to 2%) Total bilirubin 1.9 mg/dL (0.3 to 1.0 mg/dL) Administer IV fluids is correct. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Use humidification with oxygen therapy in correct. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. Assess peripheral circulation hourly is correct. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells. Assess the client's mouth every 8 hr is correct. The nurse should assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection. A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? An older adult client who is anxious and attempting to pull out an IV line A middle adult client who is reporting nausea after receiving pain medication An older adult client who has kidney failure and returned from dialysis 4 hr ago A middle adult client who has a terminal illness and is requesting a visit from the chaplain An older adult client who is anxious and attempting to pull out an IV line A client who is anxious and attempting to pull out an IV line is at greatest risk for injury. Therefore, the nurse should attend to this client first. A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? A client whose family requests hospital-based hospice care A client who requires transfer to a skilled care facility A client who qualifies for telehealth for pacemaker diagnostics A client whose caregiver requests adult day care services A client whose caregiver requests adult day care services The nurse should initiate a referral for PACE for this client because PACE provides adult day care services along with in-home assessments and supportive services. Acetaminophen 500 mg PO every 4 hr as needed for pain Cefaclor 250 mg PO every 8 hr Vital Signs 1030: Temperature 36.0° C (96.8° F) Heart rate 82/min Respiratory rate 16/min Blood pressure 122/64 mm Hg Oxygen saturation 96% on room air Anticipated Change dressing when soiled Apply heat for abdominal pain as needed Encourage deep breathing exercises every hour Contraindicated Ondansetron 4 mg PO for nausea When taking actions for a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to apply heat for abdominal pain as needed, to encourage deep breathing, and to change the dressing when soiled. The client can use heat for abdominal pain related to carbon dioxide retention. During the procedure, carbon dioxide is inflated into the abdominal cavity for visualization for the provider. The client's dressing should be changed when soiled as needed. The dressing should be clean, dry, and intact to prevent infection. The nurse should identify that medication for nausea should be provided as needed and is contraindicated for scheduled administration. A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching? "I can designate my partner as my health care surrogate." "I am only 40 years old, so I don't need to worry about this yet." "I will need a lawyer's help to draw up the documents." "I understand that my family can alter my advance directives if I become incapacitated." "I can designate my partner as my health care surrogate." This statement indicates that the client recognizes that designating a health care surrogate is part of advance directives. A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first? Determine the client's reading skills. Instruct the client on the technique for esophageal speech. Provide the client with an alphabet board. Show the client how to use an artificial larynx. Determine the client's reading skills. The first action the nurse should take when using the nursing process is to assess the client. 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. Complete the following sentence by using the lists of options. The client is at highest risk for developing Select... as evidenced by the Select.... A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Laboratory Results 0700: Sodium 143 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 104 mEq/L (98 to 106 mEq/L ) BUN 15 mg/dl (10 to 20 mg/dl) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L ) Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3.0 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC 9,500/mm3 (5,000 to 10,000/mm3) Nurses' Notes 0700: Client alert and oriented x 3. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck of 2 on a 0 to 10 scale. Declines pain medication.1100: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client reports muscle cramps in legs as a pain level of 5 on a 0 to 10 scale. Morphine 5 mg IV administered. Encouraged client to ambulate with assistance.1200: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client ambulated down the hall with assistance. Client reports numbness around lips. Vital Signs 0700: Temperature 37.6° C (99.6° F)Heart rate 65/minRespiratory rate 16/minBlood pressure 115/70 mm HgOxygen saturation 98% on room air0900: Temperature 37.2° C (99.0° F)Heart rate 72/minRespiratory rate 18/minBlood pressure 110/72 mm HgOxygen saturation 100% on room air1100: Temperature 37.7° C (99.86° F)Heart rate 76/minRespiratory rate 16/minBlood pressure 108/70 mm HgOxygen saturation 100% on room air Medication Administration Record 1100: 0.9% Sodium chloride at 150 mL/hr Morphine sulfate 5 mg IV The client is at highest risk for developing hypocalcemia as evidenced by the report of numbness around lips. The nurse should recognize cues and determine that the client is at highest risk for developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level. Hypocalcemia is more likely to occur in clients who have experienced a thyroidectomy, due to accidental damage to the parathyroid. Numbness around the lips is a clinical manifestation specific to hypocalcemia. Hypocalcemia presents as muscle spasms and can lead to cardiac dysrhythmias. Pain Blood pressure Heart rate A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Vital Signs 1100: Temperature 37.4° C (99.4° F)Heart rate 98/minRespiratory rate 18/minBlood pressure 128/68 mm HgPulse oximetry 97% on room air 1115: Temperature 37.8° C (100.1° F)Heart rate 110/minRespiratory rate 16/minBlood pressure 138/74 mm HgPulse oximetry 95% on room air1130: Temperature 38.6° C (101.5° F)Heart rate 136/minRespiratory rate 16/minBlood pressure 154/86 mm HgPulse oximetry 95% on 2 L/min via nasal cannula Medication Administration Record 1110: Morphine 4 mg IV bolus Nurses' Notes 1100: The client is asleep, easily aroused. Rates pain at incision site as 8 on a scale of 0 to 10. Portable wound bulb suction device in place with scant serosanguinous drainage present. Dressing to neck dry and intact.1115: Client asleep. Arousable with name called loudly multiple times. Client rates pain as 7 on a scale of 0 to 10. Reports having a hard time staying awake.1130: Client asleep. Arousable with name called loudly several times. Client rates pain as 5 on a scale of 0 to 10. Restless upon awakening, oriented to person. Mental status Temperature Blood pressure Heart rate When analyzing cues, the nurse should identify that thyroid storm can be caused by trauma to the thyroid gland, such as surgery, and excessive release of thyroid hormone greatly increases the metabolic rate. Fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness, are characteristic of thyroid storm. A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor? Documents client tasks upon completion Starts a task then determines what supplies are needed Completes a client assessment while infusing an IV antibiotic over 30 min Returns to the nurses' station after completing several tasks in the same location Starts a task then determines what supplies are needed The preceptor should intervene and instruct the newly licensed nurse to gather supplies before performing client tasks to practice effective time management. A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? Diarrhea Frequent urination Excessive salivation Blurred vision Blurred vision The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider. A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? "I will administer aspirin to my child to treat pain or fever." "I will record an average of three readings from my child's peak expiratory flow meter." "I will place carpet in my child's bedroom to control allergens." "I will make sure my child receives a yearly influenza immunization." "I will make sure my child receives a yearly influenza immunization." Children who have asthma should be immunized and protected from infections. Therefore, the nurse should educate the parent to ensure the child receives a yearly influenza immunization. A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? Strict adherence to routines Difficulty paying attention to tasks Disobedience to authority figures Excessive anxiety when separated from parents Strict adherence to routines The nurse should identify that a child who has autism spectrum disorder can exhibit strict adherence to routines or rituals, a fixation to specific objects, and resistance to change. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? Wear a surgical mask when providing client care. Have visitors maintain a distance of 1.8 m (6 feet) from the client. Restrict fresh flowers from the client's room. Assign the client to a private room with negative air pressure. Assign the client to a private room with negative air pressure. To control the spread of active tuberculosis, the nurse should assign the client to a private room with negative air pressure. Hypoactive bowel sounds in lower quadrants. Skin warm and dry to touch in trunk and all extremities. Pedal pulses strong and equal bilaterally. Capillary refill less than 3 seconds in toes bilaterally.1900: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds in all quadrants. Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 88/min and regular Respiratory rate 18/min Blood pressure 130/84 mm Hg Oxygen saturation 97% on room air Medical History History of osteoarthritis, hypertension, GERD, and iron-deficiency anemia. Medication Administration Record 0800: Ferrous sulfate 325 mg PO once daily 0900: Lisinopril 10 mg PO once daily Atorvastatin 40 mg PO once daily Docusate sodium 200 mg PO twice daily 1100: Hydrocodone 5 mg/acetaminophen 325 mg PO every 4 hr as needed for postoperative pain Diagnostic Results 0700: Hct 42% (42% to 52%) Hgb 14 g/dL (14 to 18 g/dL) Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L) Actions to Take Assist client to semi-Fowler's position Prepare to administer IV fluids. Potential Condition intestinal obstruction Parameters to Monitor Bowel sounds Urine output Upon recognizing and analyzing the client cues of hypoactive bowel sounds in all quadrants, abdominal distention, change in pain from intermittent to constant, and last bowel movement 5 days ago, the nurse's primary hypothesis should be that the client is most likely experiencing intestinal obstruction. It is important to generate solutions and actions that relieve the pressure from abdominal distention to promote lung expansion and to reduce the risk of developing fluid and electrolyte imbalances because the client is NPO. Therefore, the nurse should assist the client to semi-Fowler's position and prepare to administer IV fluids as prescribed. The nurse should assess bowel sounds at least twice daily for the return of peristalsis and monitor urine output because the client is receiving IV fluids. A manifestation of intestinal obstruction is dehydration. A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint? In this image, the adolescent is abducting the hip joint by moving the leg away from the midline of the body. A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan? Avoid including raw fruits in the client's diet. Restrict visits from young children to 2 hr per day. Measure the client's temperature once per shift. Use disposable gloves from a box outside the client's room. Avoid including raw fruits in the client's diet. The nurse should exclude raw fruits and vegetables from the client's diet to reduce the risk of bacterial infections. A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication? "Have you experienced muscle stiffness?" "Have you had any stomach pain or bloody stools?" "Have you experienced a dry cough?" "Have you noticed an increase in urine output?" "Have you had any stomach pain or bloody stools?" The nurse should ask the client about the presence of stomach pain or bloody stools, which is an indication of gastrointestinal bleeding, an adverse effect of ibuprofen. Complete the following sentence by using the lists of options. The client is at greatest risk for developing Select... as evidenced by Select.... A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG). Laboratory Results 0630: Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Chloride 116 mEq/L (98 to 106 mEq/L ) BUN 24 mg/dL (10 to 20 mg/dl ) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L Total calcium 9.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3.0 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC count 9,500/mm3 (5,000 to 10,000/mm3) I&O tea is effective. The client can also safely use ginger ale and ginger snaps to alleviate nausea associated with pregnancy. A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective? Hemoglobin 14.9 g/dL WBC count 12,000/mm3 Potassium 4.8 mEq/L BUN 18 mg/dL Hemoglobin 14.9 g/dL The nurse should identify that packed RBCs are administered to clients who have a decreased level of hemoglobin or hematocrit. This hemoglobin level is within the expected reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females, indicating the therapy has been effective. A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis? Obesity Acromegaly Estrogen replacement therapy Sedentary lifestyle Sedentary lifestyle A sedentary lifestyle is a risk factor for osteoporosis. The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels. A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using? (Click on the audio button to listen to the clip.) Tangentiality Flight of ideas Word salad Perseveration Flight of ideas Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent topic changes. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take Hold all antipsychotic medications. Request a prescription for benztropine. Administer lorazepam as prescribed. Provide a cooling blanket. Initiate reverse isolation procedures. Condition Most Likely Experiencing Akathisia Neuroleptic malignant syndrome Pseudoparkinsonism Severe neutropenia Parameter to Monitor Hydration status Temperature Manifestations of infection Motor restlessness Dysphagia Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months ago Current medications: Haloperidol 5 mg PO TID Sumatriptan 50 mg PO every 2 hr PRN headache Vital Signs 1030: Heart rate 122/min Respiratory rate 28/min Blood pressure 182/85 mm Hg Temperature 39.7° C (103.5° F) Oxygen saturation 90% on room air Nurses' Notes 1030: Client arrived at ED via ambulance. Emergency medical technicians (EMTs) report being called to client's home by the client's partner. According to EMTs, partner stated they found the client with decreased responsiveness, muscle rigidity, posturing, and diaphoresis. 1045: Client unresponsive to questions, does not follow simple commands. Sinus tachycardia; S1S2 on auscultation; peripheral pulses +4. Respirations rapid and labored at 28/min, chest clear on auscultation. Bowel sounds active x 4 quadrants; incontinent of urine. Febrile, diaphoretic. Muscle rigidity with extensor posturing of arms. 1100: Assessment reported to ED provider, prescription for transfer to intensive care unit received. Action to Take Hold all antipsychotic medications Provide a cooling blanket. Insert indwelling urinary catheter. Administer methylergonovine. A nurse is caring for a client who is 1 hr postpartum. Nurses' Notes 1200: Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous IV infusion. 1215: Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified. Vital Signs 1200: Temperature 37.5° C (99.5° F) Heart rate 92/min Respiratory rate 22/min Blood pressure 100/60 mm Hg SaO2 97% on room air 1215: Temperature 37.1° C (98.8° F) Heart rate 112/min Respiratory rate 26/min Blood pressure 90/52 mm Hg SaO2 92% on room air Provide emotional support. Administer oxygen. Firmly massage the uterine fundus. Weigh the perineal pads. Insert indwelling urinary catheter. Administer methylergonovine. When taking action for the client, the nurse should firmly massage the uterine fundus, administer methylergonovine, weigh the perineal pads, provide emotional support, inserting an indwelling urinary catheter, and administer oxygen. The nurse should identify that the client is experiencing a postpartum hemorrhage, which requires immediate intervention to prevent hemorrhagic shock. A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? Turn off the CPM machine during mealtime. Maintain the client's affected hip in an externally rotated position. Instruct the client how to adjust the CPM settings for comfort. Store the CPM machine under the client's bed when not in use. Turn off the CPM machine during mealtime. The nurse should turn off the CPM machine during meals to promote client comfort and dietary intake. A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge? A client who has cellulitis and is receiving oral antibiotics every 8 hr A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex A mother and their newborn 12 hr postdelivery A client who has lower extremity weakness and is newly admitted for observation A client who has cellulitis and is receiving oral antibiotics every 8 hr A client who has cellulitis and is receiving oral antibiotics can safely continue this treatment at home. Therefore, the nurse should recommend this client for discharge. A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) "You will give the medication every 4 hours." "Shake the medication bottle well before each dose is given." "Store the medication in the refrigerator." "Report diarrhea to the provider immediately." "Discard the unused portion of medication after 21 days." "Shake the medication bottle well before each dose is given" is correct. A suspension medication should be mixed before administration. "Store the medication in the refrigerator" is correct. This medication should be kept cool, not at room temperature. "Report diarrhea to the provider immediately" is correct. Diarrhea can be a manifestation of a Clostridium difficile infection and should be reported to the provider. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? The client is taking numerous deep, measured breaths. The client is calmly telling their partner that "the staff here is so controlling." The client is sitting with their head in their hands and appears to be crying. The client is pacing around the chair in which their partner is sitting. The client is pacing around the chair in which their partner is sitting. Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? An older adult client who reports constipation of 4 days with eyes open and once with eyes closed. A Romberg test is performed to assess balance and motor function. A nurse is caring for a client who is postoperative following administration of general anesthesia. Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles. A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? Place the client in the lithotomy position. Elicit a vagal response by performing gentle rectal stimulation. Administer oral bisacodyl 30 min prior to the procedure. Insert a lubricated gloved finger and advance along the rectal wall. Insert a lubricated gloved finger and advance along the rectal wall. The nurse should insert a lubricated gloved finger and advance it along the rectal wall when digitally evacuating stool. A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority? Amount of vagin*l bleeding Amount of urinary output Pain level Fundal height Amount of vagin*l bleeding The first action the nurse should take using the nursing process is to assess the amount of vagin*l bleeding. A client who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount of vagin*l bleeding is the nurse's priority. A nurse is caring for a client who is pregnant. The nurse is providing discharge teaching to the client. For each discharge instruction, click to specify if each action is recommended or contraindicated for the client. Nursing action Drink warm ginger ale when nauseated. Eat every 2 to 3 hr. Alternate eating solid foods and liquids. Increase intake of high-fat foods. Recommended Drink warm ginger ale when nauseated. Eat every 2 to 3 hr. Alternate eating solid foods and liquids. Contraindicated Increase intake of high-fat foods. When taking action and providing discharge teaching for a client who has hyperemesis gravidarum, the nurse should recommend the client should eat every 2 to 3 hr to avoid having an empty stomach, which can increase nausea. The client should separate liquids from solids every 2 to 3 hr to help minimize nausea. The client should eat foods high in protein that are low in fat. Warm ginger ale or ginger tea can also decrease nausea. A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.) Broccoli Yogurt Pepperoni pizza Cream cheese Bologna sandwich Broccoli is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli does not contain tyramine. Yogurt is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Yogurt contains little or no tyramine. Cream cheese is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Cream cheese contains little or no tyramine. A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? The last time the provider evaluated the client The client's most recent ventilator settings The time of the client's last dose of pain medication The frequency in which the client presses the call button The time of the client's last dose of pain medication The nurse should recognize that an effective handoff report provides a baseline of the client's status for comparison and should include any recent changes or priority situations affecting the client's condition. Therefore, the time of the client's last dose of pain medication is important to include so the receiving nurse can anticipate what time to give the next dose. A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first? Instruct a staff member to maintain a log of emergency care provided. Apply cervical spine collars to children who have suspected neck trauma. Antisocial Histrionic Paranoid Borderline The nurse should identify that clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation. A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 18g A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? Radial vein of the inner arm Great saphenous vein of the leg Dorsal plexus vein of the foot Basilic vein of the hand Radial vein of the inner arm The nurse should select the radial vein of the inner arm when initiating IV access for an older adult client because this site will have adequate subcutaneous tissue. A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make? "I'm sure your family does not want you to die." "Why would you believe such things?" "How does this make you feel?" "You should talk to your family about your feelings." "How does this make you feel?" This response encourages the client to evaluate their feelings. A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? Decreased blood pressure Decreased hallucinations Decreased cholesterol Decreased esophageal reflux Decreased hallucinations The nurse should recognize that chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia. A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching? "I will change your IV tubing once every 48 hours." "Abdominal distention is an expected effect of this therapy." "I will need to check your gastric residual before administering feedings." "I will need to measure your weight daily." "I will need to measure your weight daily." The nurse should instruct the client that daily weight measurement is a necessary part of administering nutrition through a central line to avoid fluid overload and monitor for adequate weight gain. A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take? Contact the facility's ethics committee. Obtain consent from the client's employer. Limit care to comfort measures. Proceed with provision of medical care. Proceed with provision of medical care. When a client is unable to give informed consent in an emergency, health care personnel can proceed with necessary life-saving care because the law considers this implied consent. A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority? Instruct the client about the importance of regular medical appointments. Encourage the client to participate in daily exercise. Explain proper foot care techniques to the client. Ensure that the client understands the medication regimen. Ensure that the client understands the medication regimen. The priority action the nurse should take when using the safety vs. risk reduction approach to client care is to ensure the client understands the medication regimen. The greatest risk to the client is the potential to develop hypoglycemia or hyperglycemia, which can be life-threatening if treated incorrectly. A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up. Speech Neuro status "I will use the bulb syringe first in her mouth and then in her nose" is correct. The client should suction the newborn's mouth first to remove secretions that the newborn could aspirate when suctioning the nares. A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take? Hold the insulin pen device perpendicular to the client's skin to inject the medication. Shake the insulin pen device prior to injecting the medication. Withdraw the insulin from the pen device into an insulin syringe. Hold the pen device in place for 3 seconds after injecting the insulin. Hold the insulin pen device perpendicular to the client's skin to inject the medication. The nurse should hold the insulin pen perpendicular to the client's skin to inject the medication, which ensures the insulin enters the subcutaneous tissue. A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take? Initiate continuous cardiac monitoring. Administer 40 mEq/L potassium chloride PO with orange juice. Provide a diet rich in legumes, nuts, and green vegetables. Monitor the client for tetany. Initiate continuous cardiac monitoring. The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest. A nurse is assessing a newborn following a vagin*l delivery. Which of the following findings should the nurse report to the provider? Heart rate 136/min Nasal flaring Transient strabismus Overlapping of sutures Nasal flaring The nurse should report any indications of respiratory distress such as nasal flaring, retractions, and grunting. A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? Calories Protein Potassium Fiber Fiber The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation. A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)? February 1 February 8 February 15 February 22 February 15 Using Nägele's rule, the nurse should add 7 days to the first day of the client's LMP (8 + 7 = 15) and then subtract 3 months. Therefore, the nurse should document the client's EDB as February 15th. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Evaluate dietary intake for a client who has anorexia. Measure the vital signs of a client who just returned from the PACU. Arrange the lunch tray for a client who has a hip fracture. Assess I&O for a client who is receiving dialysis. Arrange the lunch tray for a client who has a hip fracture. Assisting a client with meals is within the range of function of the AP. A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take? Facilitate an interdisciplinary conference at the new facility for the family. Refer the client and family to a social worker for assistance and a follow-up meeting. Reassure the client's family that the same provider will provide care at the new facility. Tell the family that the rehabilitation facility has an excellent client care record. Facilitate an interdisciplinary conference at the new facility for the family. Initiating an interdisciplinary conference will address the family's concerns about providing optimal care for the client. A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Box 1 due to Box 2. address is the client's urine output. Urine output of 30 mL/hr or less for more than 2 hr requires assessment. When using the greatest risk framework, the nurse should identify that the urine output should be addressed next. The nurse should recognize the risk of autonomic dysreflexia from urinary retention and should observe the client's abdominal distention, assess for bladder distention, and check the urinary catheter tubing for obstruction. A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication? Hypotension Report of tinnitus Report of chest pain Ecchymosis Report of chest pain The nurse should identify that a report of chest pain by the client can indicate an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, which can result in angina. A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? Measuring the group's work against the assigned objectives Noting the progress of the group toward assigned goals Sharing experiences as an authority figure Offering new and fresh ideas on an issue Noting the progress of the group toward assigned goals Noting the progress of the group toward assigned goals is the task of the orienteer. A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? Massage bony prominences on the client's left side. Support the client's left arm on a pillow while sitting. Position the bedside table on the client's left side. Place the client's cane on their left side while ambulating. Support the client's left arm on a pillow while sitting. The nurse should the support the client's affected arm to prevent the extremity from hanging freely because this can cause shoulder subluxation. A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? Assess the client's IV site every 8 hr. Check the client's WBC count every 48 hr. Monitor the client's mouth every 8 hr. Change the client's IV tubing every 48 hr. Monitor the client's mouth every 8 hr. The nurse should monitor the client's mouth at least every 8 hr for manifestations of an infection, such as sores or lesions. A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style? Avoids initiating change Seeks input from the other nurses Makes decisions quickly Limits the amount of feedback to the staff Seeks input from the other nurses A nurse manager who uses a democratic leadership style includes members of the team when making decisions and encourages staff members to participate in the decision-making process. A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum- assisted birth? Constipation Urinary urgency Cervical laceration Retained placenta Cervical laceration The nurse should assess the client for complications associated with a vacuum- assisted birth such as perineal, vagin*l, or cervical lacerations. A nurse on a mental health unit is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Order Fluoxetine 20 mg PO daily Initiate suicide precautions Low-sodium diet Potassium 40 mEq PO daily Anticipated Initiate suicide precautions Potassium 40 mEq PO daily Contraindicated Fluoxetine 20 mg PO daily Low-sodium diet WBC Albumin level Abdominal pain location Ulcerative Colitis Temperature Weight WBC Albumin level Peritonitis Temperature WBC Heart rate Temperature is consistent with Crohn's disease, ulcerative colitis, and peritonitis. The client's temperature is elevated. This can occur with all three of the above disease processes due to inflammation and infection. Weight is consistent with Crohn's disease and ulcerative colitis. The client has lost weight since their initial appointment 2 months ago. Unintended weight loss can occur with Crohn's disease and ulcerative colitis due to malabsorption in the gastrointestinal tract. Bowel pattern is consistent with Crohn's disease. The client reports frequent soft, loose stools without the presence of blood. This is most consistent with Crohn's disease. Clients who has ulcerative colitis often have liquid, bloody stools. WBC is consistent with Crohn's disease, ulcerative colitis, and peritonitis. The client's WBC is elevated, which can occur with all three of the above disease processes because of inflammation and infection. Heart rate is consistent peritonitis. The client's heart rate is elevated, which may occur with peritonitis due to inflammation, infection, and dehydration. Albumin level is consistent with Crohn's disease and ulcerative colitis. The client has a decreased albumin level. Unintended weight loss can occur with Crohn's disease and ulcerative colitis due to malabsorption in the gastrointestinal tract. Abdominal pain location is consistent with Crohn's disease. The client reports abdominal pain in the right lower quadrant, which occurs with Crohn's disease. Clients experiencing peritonitis often experience generalized abdominal pain that can radiate to the shoulder and back. An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions? A client who is at 33 weeks of gestation and has severe gestational hypertension A client who is at 16 weeks of gestation and has a hydatidiform mole A client who is at 28 weeks of gestation and is experiencing vagin*l bleeding A client who is at 36 weeks of gestation and has a positive group B streptococcal culture A client who is at 33 weeks of gestation and has severe gestational hypertension The nurse should initiate seizure precautions for a client who has severe gestational hypertension because an extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment, place suction equipment and oxygen at the bedside, and position the call light within the client's reach. A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take? Assess the apical pulse while the newborn is crying. Palpate the radial pulse for 30 seconds. Listen to the apical pulse while palpating the radial pulse. Auscultate the apical pulse at least 1 min. Auscultate the apical pulse at least 1 min. The nurse should auscultate the apical pulse to obtain an accurate assessment of heart rate and rhythm. Auscultation of a newborn's heart sounds can be difficult because of the rapid rate and the transmission of respiratory sounds. A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? Chest x-ray Serum liver enzyme levels ABGs Urine culture and sensitivity Serum liver enzyme levels Valproic acid can cause hepatic toxicity. Therefore, the nurse should expect the provider to prescribe laboratory tests to assess the child's liver function prior to and periodically during therapy. A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include? Clean the mouthpiece with warm water every 2 weeks. Wait 10 seconds between inhalations. Take a quick inhalation when pressing the dispenser. Take the medication 15 min before playing sports. Take the medication 15 min before playing sports. The nurse should instruct the child to take the medication 5 to 20 min prior to exercise to promote bronchodilation. The medication's effects begin immediately, peak in 30 to 60 min, and can last for up to 5 hr. A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? Weight gain Decrease in anteroposterior diameter of the chest HCO3- 24 mEq/L postoperative following an appendectomy. These findings should be reported to the provider. A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? Delegate non-nursing tasks to ancillary staff. Stock client rooms with extra supplies. Assign dedicated equipment to each client's room. Change continuous IV infusion tubing every 24 hr. Delegate non-nursing tasks to ancillary staff. Delegating non-nursing tasks to ancillary staff is an effective method of providing high-quality, cost-effective care because this will allow additional time for nurses to focus on skilled tasks. A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse? The child exhibits discomfort while walking. The child has thin extremities. The child has bruises on the upper back. The child is wearing a stained shirt. The child exhibits discomfort while walking. The nurse should identify this finding as a potential indication of child sexual abuse. A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) The nurse should first inspect the client's abdomen to assess skin integrity and symmetry. Next, the nurse should perform auscultation. Because palpation and percussion can alter bowel sounds, the nurse should auscultate prior to these steps. After auscultation, the nurse should percuss the client's abdomen for tympany, dullness, absence, or flatness of resonance. Lastly, the nurse should palpate the abdomen for tenderness, pain, or the presence of a mass A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching? Check the functioning of oxygen equipment once each week. Wear clothing made with cotton fabrics while oxygen is in use. Apply petroleum-based lubricant to the nares as needed. Store full oxygen tanks on their side. Wear clothing made with cotton fabrics while oxygen is in use. The nurse should instruct the client to wear clothing made with cotton fabrics rather than synthetic or woolen fabric when the oxygen is in use. Woolen and synthetic fabrics can generate static electricity, which increases the risk for a fire. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? aPTT PT INR WBC count aPTT Prior to adjusting the client's continuous heparin infusion, the nurse should review the client's activated partial thromboplastin time (aPTT). The expected reference range for the aPTT is 40 seconds. Clients who are receiving continuous heparin therapy should have an aPTT of 60 to 80 seconds, which is 1.5 to 2 times the expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value. A nurse is caring for a client. Complete the following sentence by using the list of options. The client is exhibiting manifestations of Select... anorexia nervosa bulimia nervosa binge eating disorder and is at risk for Select... parotid swelling esophageal rupture arrhythmia The client is exhibiting manifestations of anorexia nervosa and is at risk for arrhythmia. When analyzing cues, the nurse should identify the client is exhibiting manifestations of anorexia nervosa and is at risk for developing cardiac arrhythmia. Manifestations of anorexia nervosa include low BMI, weight loss, food restriction, lanugo, edema, cold extremities. Complications of anorexia nervosa can include arrhythmias, decreased bone density, muscle weakening, and heart failure. A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take? Prepare to administer vitamin K1. Prepare to administer alteplase. Withhold the heparin infusion. Withhold the next dose of warfarin. Withhold the heparin infusion. MY ANSWER The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced, or the infusion withheld, until the aPTT returns to the therapeutic range. A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol? Weight loss Wheezing Blood pressure 146/92 mm Hg Heart rate 110/min Wheezing MY ANSWER The nurse should recognize that wheezing can indicate the client is experiencing an adverse reaction to the medication. A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take? Insert air in the tube and listen for gurgling sounds in the epigastric area. Aspirate contents from the tube and verify the pH level. Review the medical record for previous x-ray verification of placement. Explore the client's reasons for refusing the treatment. Discuss the client's refusal with the provider. Explore the client's reasons for refusing the treatment. The first action the nurse should take when using the nursing process is assessment. The nurse should gather more data regarding the client's decision to refuse the blood transfusion. A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? Irritability Increased urination Vomiting Facial flushing Irritability The nurse should instruct the client to monitor for irritability, which can indicate decreased blood glucose levels. A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan? Encourage the client to take a cool sponge bath each morning. Administer opioid analgesia. Increase the client's dietary iron intake. Restrict the client's intake of foods high in purines. Increase the client's dietary iron intake. Clients who have rheumatoid arthritis require foods high in protein, vitamins, and iron to promote tissue repair. The nurse should encourage the client to increase their intake of dietary iron. NSAIDS, rather than opioid analgesic medications, are used to relieve the pain and inflammation associated with rheumatoid arthritis. A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? Agency for Healthcare Research and Quality National Institutes of Health Department of Agriculture World Health Organization Agency for Healthcare Research and Quality MY ANSWER The nurse should gather data from the Agency for Healthcare Research and Quality (AHRQ) regarding health care services for migrant farmworkers. The goal of AHRQ is to improve the quality of health care services for all populations, including low- income groups and minorities. This data should help the nurse to develop an evidence-based plan to improve health care services for specific populations. A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first? Form a committee of staff members to investigate current staffing issues. Provide support to staff members who are resistant to staffing changes. Schedule a staff meeting to present the different options to staff members. Give the staff members advance written notice of staffing changes. Form a committee of staff members to investigate current staffing issues. The first action the nurse should take when using the nursing process is to assess the current staffing issue. The first stage of change is the "unfreezing stage," in which information is gathered about the problem. Therefore, the first action the nurse manager should take is to form a committee to investigate the problem. A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? "I will not allow anyone to smoke near my baby." "I will place bumper pads in my baby's crib." "My baby's head should be placed on a pillow for sleeping." "My baby should sleep in a side-lying position." "I will not allow anyone to smoke near my baby." This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SIDS. A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? Check the client's blood type and crossmatch it against the provider's orders. Ask the client to state their blood type prior to beginning blood administration. Compare information on the blood product to the informed consent form. Verify the client and blood product information with another licensed nurse. Verify the client and blood product information with another licensed nurse. The nurse should compare the blood product label against the medical record and the client's identification number with another nurse to ensure the correct blood product is administered to the correct client. A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? Perform gastrostomy feedings through a client's established gastrostomy tube. Determine if the PRN pain medication administered 30 min ago has helped. Provide instructions about client care to a family member over the telephone. Teach a client how to measure their own blood pressure. Perform gastrostomy feedings through a client's established gastrostomy tube. The nurse should delegate providing gastrostomy feedings through the client's established gastrostomy tube to an AP because this task is within the AP's range of function. A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect? Dry, coarse hair Bradycardia Tremors Periorbital edema Tremors Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia. A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A nurse is caring for an adolescent. Select the 4 findings that require follow-up. Pedal pulse Pain Blood pressure Capillary refill Skin temperature Heart rate Pedal pulse Pain Capillary refill Skin temperature When recognizing cues, the nurse should identify the assessment findings that require follow-up in an adolescent who has an injury to the right leg include capillary refill, pedal pulse, skin temperature, and pain. The adolescent rates their pain as 10 on a scale of 0 to 10, which requires follow-up by the nurse. A capillary refill of 4 seconds is not within the expected reference range of less than 2 seconds. A pedal pulse of +1 is diminished and not within the expected reference range. Skin temperature of the right extremity is cool to the touch, which is an unexpected finding. These findings are indicative of decreased perfusion to the extremity and require follow-up by the nurse. A nurse is caring for an adolescent. Which of the following actions should the nurse take after the adolescent returns from surgery? Select all that apply. Apply warm packs to right extremity for the first 24 hr. Elevate affected limb at chest level. Perform neurovascular assessments every hour. Assist the adolescent with ambulation from bed to chair. Remove indwelling urinary catheter when no longer indicated. Elevate affected limb at chest level. Perform neurovascular assessments every hour. Remove indwelling urinary catheter when no longer indicated. When analyzing cues for a post-operative adolescent, actions the nurse should take include elevating the affected limb at chest level, performing neurovascular assessments every hour, and removing the indwelling urinary catheter when it is no longer indicated. The nurse should elevate the affected limb at chest level to reduce edema. Neurovascular assessments should be performed every hour for the first 24 hr post-surgery for immediate recognition of neurovascular compromise. For clients who have an indwelling urinary catheter, evidence-based practice indicates the catheter should be removed as soon as possible or within 24 hr if no longer indicated. The nurse is continuing to care for the adolescent. Complete the following sentence by using the lists of options. The client is at highest risk for developing Select... compartment syndrome pulmonary embolism infection as evidenced by the client's drop Select... temperature immobility paresthesia The client is at highest risk for developing compartment syndrome as evidenced by the client's drop paresthesia. The nurse should determine that the priority hypothesis is the adolescent is developing compartment syndrome as evidenced by paresthesia in the right foot. When using the urgent vs. nonurgent approach to care, the nurse determines that the priority finding is paresthesia. This can indicate compartment syndrome, which requires immediate intervention. Therefore, this finding is the highest priority. The nurse is continuing to care for the adolescent. Which of the following prescriptions should the nurse anticipate from the provider? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent. Potential Prescription Prepare the adolescent for surgery. Remove the splint. Apply ice to the affected extremity. Elevate the right leg above heart level. Anticipated Prepare the adolescent for surgery. Remove the splint. Contraindicated Apply ice to the affected extremity. Elevate the right leg above heart level. When generating solutions for an adolescent who has compartment syndrome, the nurse should anticipate that the adolescent will need a fasciotomy. A fasciotomy is needed to decrease atrial spasms and increase perfusion within the muscle compartments. The nurse should recognize that elevating the right leg above heart level, and applying ice to the affected extremity are all contraindicated for an adolescent who has compartment syndrome. Elevating the right leg above heart level and applying ice to the affected extremity will further compromise blood flow. The nurse is continuing to care for the adolescent. The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery? The adolescent has not voided in 4 hr. The adolescent's blood pressure is 131/89 mm Hg. The adolescent's parents have concerns regarding the surgery. The adolescent reports severe pain. The adolescent's parents have concerns regarding the surgery. When taking actions for an adolescent who is scheduled for a fasciotomy, the nurse should notify the provider if the parents of the adolescent have questions or concerns regarding the procedure, which could indicate lack of understanding about the informed consent