RN COMPREHENSIVE PREDICTOR NURSING STUDY GUIDE 2024 | Exams Nursing | Docsity (2024)

Download RN COMPREHENSIVE PREDICTOR NURSING STUDY GUIDE 2024 and more Exams Nursing in PDF only on Docsity! 1 RN COMPREHENSIVE PREDICTOR NURSING - STUDY GUIDE What can be delegated to Assistive personnel (AP)? - ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients A nurse on a med surg unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP? A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk with a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer C A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning B C D An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question? 2 A. Assisting a client who is 24 hr postop to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift C. providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump 5 Fidelity What is fairness in care delivery and use of resources Justice What is avoidance of harm or injury Non-maleficence A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. Nonmalificience B A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficience D A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice 6 D. Nonmaleficence C 7 A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmalificence D Which of the following situations can be identified as an ethical dilemma? A. A nurse on a med surg unit demonstrates signs of chemical impairment B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form C Most managers can be categorized as authoritative, democratic, and laissez faire makes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings Authoritative includes the group when decisions are made Motivates by supporting star achievements Communication occurs up and down the chain of command Work output by staff is usually of good quality-good when cooperation and collaboration is necessary 10 a. at time of admission b. 2 days after client is admitted 11 c. whenever the nurse has the time to do planning d. when the physician has the discharge order A What is an interdisciplinary team? A group of health care professionals from different disciplines Fill in the blank: 1. is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. , which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. 1 & 2 = collaboration What is the nurse's contribution to an interdisciplinary team? - knowledge of nursing care & its management - a holistic understanding of the client, her/his healthcare needs & healthcare systems. A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils. 2 A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess for which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 12 4. Urine output of at least 30 cc per hour. 4 15 1. use a new sterile catheter each time he performs a catheterization. 2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization. 3. perform the catheterization procedure every 8 hours. 4. limit his fluid intake to reduce the number of times a catheterization is needed. 2 A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 1. take the medication five minutes after the pain has started. 2. stop taking the medication if a stinging sensation is absent. 3. take the medication on an empty stomach. 4. avoid abrupt changes in posture. 4 A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy set-up. 4. Suction equipment. 1 A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. reestablishes a trusting relationship with his/her other parent. 3. verbalizes that s/he is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse. 3 An adolescent client is ordered to take tetracycline HCL (Achromycin) 16 250 mg PO bid. Which of the following instructions should be given to this client by the nurse? 1. "Take the medication on a full stomach, or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 17 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for two weeks." 2 After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes 2 A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4. Magnesium . 1 An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to 1. monitor vital signs, especially blood pressure, every 30 minutes. 2. remain at the client's side to provide reassurance. 3. tell the client the name of the medication and its effects. 4. monitor the anticholinergic effects of the medication. 1 The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention? 20 ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 21 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure. 3 A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge." 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication." 3 The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse should advise the client the BEST time to take this medication is 1. before breakfast. 2. with dinner. 3. with food. 4. at hs. 4 . If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe 1. increasing respiratory difficulty seen with exertion. 2. cough productive of a large amount of thick, yellow mucus. 3. peripheral edema and anorexia. 4. twitching of extremities. 3 The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 22 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place 25 2. "I have a headache and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am and I don't know where I live." 4 A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness. 4 . The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for 1. a client with Alzheimer's requiring assistance with feeding. 2. a client with osteoporosis complaining of burning on urination. 3. a client with scleroderma receiving a tube feeding. 4. a client with cancer who has Cheyne-Stokes respirations. 1 An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client 1. eat a high-protein, low-residue diet. 2. lie on her unoperated side. 3. exercise her arms and legs. 4. cough and deep breathe. 4 Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae? 26 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 27 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding. 4 An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client 1. in semi-Fowler's position. 2. prone, with the head turned to the side. 3. with the head of the bed elevated 45° and the neck extended. 4. supine, with the head in the midline position. 1 Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep. 1 The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self- esteem and isolation. 30 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan. 31 3 The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client. 2 A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids. 4 A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0mg/dL. 4. The patient's hemoglobin is 8.5g/dL. 3 A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? 1. The client's urine test is positive for glucose and acetone. 32 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vagin*l discharge. 4. The client says she feels pressure against her diaphragm when the baby moves. 35 3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside. 3 What type of infectious diseases are required to be reported to the health department? - severe cases of Staphylococcus aureus infections including methicillin- resistant Staphylococcus aureus (MRSA) What is the process of taking a telephone order from a provider? Patient name, drug, dose, route, frequency read back for accuracy A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene A B E A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting D 36 A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. 37 Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter A A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room A A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside A Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing b) apply intermittent suction when withdrawing the catheter c) place the catheter in a location that is clean and dry for later use 40 a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chloride C 41 A nurse is reinforcing teaching regarding the use of a cane to a client who has left- leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step C Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability b) hypotension c) flushing d) bradycardi a A A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the wound C A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale 42 c) black coffee d) orange sherbet D 45 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation. 2 During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake. 2 3 4 The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal. 3 The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse 46 should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 47 3. Slowing of reflexes. 4. Fatigue. 1 When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers 4 What are some ways to identify a patient before giving a medication? The Joint Commission requires 2 client identifiers be used when administering medications. - clients name - assigned identification number - telephone number - birth date or other personal-specific identifiers. Bar code scanners may be used to identify clients What are some things to teach about home safety with elderly patients? - Removing items that could cause the client to trip, such as throw rugs and loose carpets - Placing electrical cords and extension cords that against a wall behind furniture - Making sure that steps and sidewalks are in good repair - Placing grab bars near the toilet and in the tub or shower and installing a stool riser - Using a non-skid mat in the tub or shower - Placing a shower chair in the shower - Ensuring that lighting is adequate both inside and outside of the home A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in 50 B. Bradycardia C. Clammy skin D. Bradypnea 51 A What do you do when a client has a seizure - lower to bed/floor - protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement seclusion and restraints -must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min What position is good to use for a patient who is at high risk for a pressure ulcer 30 degree lateral position is recommended for clients at risk for pressure ulcers health promotion (injury prevention-suffocation): infant (birth-1 yr) -avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach 52 -remove drawstrings from jackets and other clothing hypotension is classified with a reading below normal; systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation What temperature should pork be cooked at 55 denial anger bargaining depression acceptance discrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual loss anticipatory grief involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self- esteem somatic complaints persist for an extended period of time dysfunctional grief Signs for meningococcemia Vomiting, febrile, petechial rash (unstable) Levothyroxine effects Used to restore client's metabolic rate * Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension Multiple Sclerosis Patient Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug) * Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone) * Vomiting = causes dehydration * Hair Loss = emotional distress 56 * Amenorrhea = emotional distress Malnourished COPD patients 57 (1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soup Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others "I don't deserve to die, this isn't fair" Anger stage Which Grief Process when Client acknowledges the impending loss while remaining hopeful "If I could just make it through this, I'd never smoke again" Bargaining Stage How should you respond when client wants to discontinue dialysis "What has changed to make you decide this?" = Seek clarification from client to establish mutual understanding while staying therapeutic What should the nurse do when one member of a support group expresses anger repeatedly? Focus more on the group members who have a positive outlook (Speak to group member privately to uncover source of anger) What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given? Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should give = TDaP (Tetanus, Diphtheria, Pertussis) Long term effects of NSAIDS (Ibuprofen) Gastric Ulcerations, perforations, hemorrhage, hypertension Alcohol Use Manifestations of Withdrawal 60 A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: 61 a) restrict fluid intake to 1 qt (1,000 ml)/day. b) drink liquids only between meals. c) don't drink liquids 2 hours before meals. d) drink liquids only with meals. B A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Instruct the patient to keep a record of food intake b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake C A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant D Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle. A Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension b) Bradycardia c) Warm moist skin 62 d) Polyuria A 65 what are normal creatinine levels? what are normal BUN levels? 0.8-1.4 mg/dL 8-25 mg/dL What are total serum protein values (normals) 6-8 g/dL Describe pre-albumin this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks) what is normal pre-albumin values? what are normal serum levels of magnesium ? what is a normal potassium serum level? 17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia) what are good sources of folic acid? Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils. Sources of potassium beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas what is important about the diet of someone taking ACE inhibitors? can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas) Taking Coumadin. Which foods should the client limit? 66 Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes 67 what is a normal hematocrit level in a female? What are normal Hgb values (female)? what are normal values for WBCs? 37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uL what foods should you avoid if you have diverticulitis? avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber) When taking MAOI's, limit your consumption of thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar... At what age does bone loss begin with osteoporotis what are normal Calcium levels? at age 35 (women) 8.6-10 mg/dL A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of calcium gluconate (because hypocalcemia causes Chvostek's sign) What are the S/S of lithium toxicity? (depakote for bipolar disorder) fine hand tremors, mild GI upset, slurred speech and muscle weakness a nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin) . which of the following over the counter medication should the nurse instruct the client to avoid Aspirin 70 a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for which of the following should the nurse monitor this client orthostatic hypotension a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV) . for what adverse effect should the nurse monitor this client the nurse should monitor the client respiratory depression a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider serum potassium 5.2 a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at risk Toxic level of digoxin a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching i should decrease the amount of calcium in my diet while taking the medication A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity? * Verapamil (Calan) Adverse effect of Verapamil Avoid grapefruit juice Interaction of diuretics and ACE inhibitors excessive reduction in blood pressure and symptomatic hypotension or hyperkalemia What can prevent MI, stroke, or death in high-risk patients 71 Ramipril What to monitor for when taking enoxaparin (lovenox) Hyperkalemia Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported What are the therapeutic effects of protamine Antidote to severe heparin overdose + Reversal of heparin administered during procedures How to prevent adverse effects of oxycodone can cause respiratory depression. What is the nursing intervention and/or client education ? Monitor vital signs. › Stop opioids for respiratory rate less than 12/min, and notify the provider. › Have naloxone and resuscitation equipment available. › Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines, consumption of alcohol). opioid agonists can cause Constipation What is the nursing intervention and/or client education ? Advise the client to increase fluid/fiber intake and physical activity. › Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract decreased bowel motility, or a stool softener such as docusate sodium (Colace) to prevent constipation. Adverse effects of ferrous sulfate constipation; upset stomach; black or dark-colored stools; or. temporary staining of the teeth. 72 Baclofen (Lioresal) therapeutic outcome: Decrease the frequency and severity of muscle spasms (MS). 75 c. "Rinse your eyes with saline each morning to prevent postoperative infection." d. "Take the prescribed stool softener to avoid increasing intraocular pressure." d. "Take the prescribed stool softener to avoid increasing intraocular pressure." A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions? a. Suction the nasogastric tube. b. Flush the tube with 30 mL of sterile water. c. Remove the nasogastric tube. d. Check the residual volume. d. Check the residual volume. Which of these actions best demonstrates cultural sensitivity by a nurse? a. The nurse talks in a slow-paced speech. b. The nurse asks clients about their beliefs and practices toward pregnancy. c. The nurse uses charts and diagrams when teaching pregnant clients. d. The nurse can speak several different languages. b. The nurse asks clients about their beliefs and practices toward pregnancy. Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration? a. Hyperreflexia. b. Tachycardia. c. Bradypnea. d. Agitation. b. Tachycardia. When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include: a. the urinary meatus. b. vomitus. c. contaminated water. d. sexual intercourse. a. the urinary meatus. 76 A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if the client is agitated? 77 a. Encourage the client to verbalize feelings. b. Lock the client in a secluded room. c. Ask the other clients to give feedback regarding the client's behavior. d. Ignore the client's inappropriate behavior. a. Encourage the client to verbalize feelings. Which of these measures should a nurse include when planning care for a school- aged child during a sickle cell crisis episode? a. Monitoring for signs of bleeding. b. Providing pain relief. c. Administering cool sponge baths to reduce fevers. d. Offering a high calorie diet. b. Providing pain relief. Which of these instructions should a nurse include in the plan of care for a 32- week gestation client who had an amniocentesis today? a. "Drink at least six glasses of fluids during the next six hours after the test." b. "Call the clinic if you experience any abdominal cramps." c. "Don't be concerned if you have some vagin*l spotting in the next 12 hours." d. "When you get home, stay on bed-rest for the next 48 hours." b. "Call the clinic if you experience any abdominal cramps." An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of these lunches by the client indicates a correct understanding of foods high in iron content? a. Peanut butter and jam sandwich. b. Chicken nuggets with rice. c. Tuna salad sandwich. d. Beefburger with cheese. d. Beefburger with cheese. A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis? a. Elevated serum potassium level. b. Elevated serum amylase level. 80 A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client's care plan? 81 a. Explaining that staff does not poison clients. b. Focusing on how the hospital staff helps clients. c. Allowing the client to eat food from sealed containers. d. Telling the client that not eating the food that is served will result in privilege restrictions. c. Allowing the client to eat food from sealed containers. Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring? a. Gatch the knee of the bed. b. Administer anticoagulants preoperatively. c. Apply sequential compression devices. d. Maintain the legs in a dependent position. c. Apply sequential compression devices. When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at ideal body weight for her height is: a. at least 15 pounds. b. 15 to 20 pounds. c. 25 to 35 pounds. d. at least 45 pounds. c. 25 to 35 pounds. Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy. a. Sharp unilateral abdominal pain. b. Uncontrollable vomiting. c. Marked abdominal distention. d. Profuse vagin*l bleeding. a. Sharp unilateral abdominal pain. Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs additional instructions regarding the principles of delegation? 82 a. "Please bathe the client in room 12, and then bring the client to the dining room for breakfast by 9 A.M." b. "Please bathe the client in room 10, administer a back rub, and then evaluate if 85 Which of these assessments is the priority for a client who sustained second-degree burns of the face and neck? a. Respiratory status. b. Renal function. c. Level of pain. d. Signs of infection. a. Respiratory status. A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which of these positions? a. Supine, flat. b. Orthopneic. c. Trendelenberg. d. Side-lying. d. Side-lying. Which of these instructions should a nurse include in the discharge teaching for a client who has diabetes mellitus? a. "Soak your feet in hot water once a day." b. "Cut your toenails in an oval shape weekly." c. "Avoid using any soap on your feet." d. "Apply lotion to your feet each day." d. "Apply lotion to your feet each day." A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the nurse take first? a. Assess the client. b. Notify the physician. c. Contact the nurse manager. d. Complete an incident report. a. Assess the client. An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an elevated blood pressure. Which of these actions should a nurse take? a. Add a 5% dextrose solution to the line. 86 b. Raise the head of the bed. 87 c. Stop the transfusion. d. Measure the client's temperature. c. Stop the transfusion. When caring for a client who has hepatitis B, a nurse should wear: a. gloves when administering oral medications to the client. b. a gown when changing the client's position. c. gloves when removing the intravenous cannula. d. a gown when emptying the client's used bath water. c. gloves when removing the intravenous cannula. Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective airway clearance? a. Absence of wheezing throughout the lung fields. b. Clear lung sounds on auscultation. c. Pulse oximetry level of 80%. d. Frequent coughing throughout the day. b. Clear lung sounds on auscultation. A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a nurse ask the child's mother to determine if the medication is being administered correctly? a. "Are you using a straw to administer the medicine?" b. "Has your child been urinating more frequently?" c. "Have you increased your child's milk intake each day?" d. "Is there a change in the color of your child's skin?" a. "Are you using a straw to administer the medicine?" Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea, should a nurse recognize as suggestive that the infant is dehydrated? a. Bulging anterior fontanel. b. Pulse rate of 120/minute. c. Decreased urine output. d. Cyanosis of the mucus membrane. 90 a. Restricting visitors to the client's immediate family members. 91 b. Limiting the client care activities to no more than five minutes each. c. Allowing the client to perform self-care as tolerated. d. Providing the client with a non-stimulating environment. c. Allowing the client to perform self-care as tolerated. A client, who is newly diagnosed with cancer says to anurse, "I suppose I need to complete all unfinished business as soon as possible." Which of these responses is appropriate? a. "Yes, you should do this immediately. b. "Don't you think you should stay focused on your treatment for now? c. "Exactly what things are you talking about?" d. "It sounds like you are concerned with your diagnosis." d. "It sounds like you are concerned with your diagnosis." Which of these interventions should plan for a child who is receiving chelation therapy for lead poisoning? a. Keeping an accurate record of intake and output. b. Instituting measures to prevent skeletal fractures. c. Maintaining isolation precautions. d. Maintaining strict bed rest. a. Keeping an accurate record of intake and output. A nurse obtains these vital signs on an adult client. Which finding should the nurse follow-up first? a. Heart rate, 60/minute and regular. b. Respiration, 30/minute and deep. c. Temperature, 97.1 °F (36.2 °C) d. Blood pressure, 136/86 mm Hg b. Respiration, 30/minute and deep. When determining the duration of a uterine contraction, a nurse should measure the contraction from the: a. beginning of one contraction to the end of that contraction. b. end of one contraction to the beginning of the next contraction. c. beginning of one contraction to the beginning of the next contraction. 92 d. strongest point of one contraction to the strongest point of the next contraction. a. beginning of one contraction to the end of that contraction. 95 c. 2.0 A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse take? a. Include the 9:00 A.M. scenario in the shift report. b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". c. Put the information in the margin and indicate the accurate time placement by drawing an arrow. d. Draw a line through the previous charting with "error" and then re- record everything, including the new information. b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". While giving a bath to a client, a nurse notices that the client's back appear reddened. Which of these interpretations and additional assessments should the nurse make? a. The client's skin is sensitive to touch; lightly rub the client's chest area. b. The client has decreased circulation; palpate the peripheral pulses. c. The client is showing signs of pressure; press on the skin and observe for a return of color. d. The client is allergic to the soap; check the extremities for discoloration. c. The client is showing signs of pressure; press on the skin and observe for a return of color. A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice. During the duration of the newborn's treatment, a nurse should: a. cover the newborn's closed eyes with patches. b. measure the newborn's pulse and respirations every two hours. c. keep the newborn under the light at all times, even during the feedings. d. notify the physician if the newborns stools become greenish yellow. a. cover the newborn's closed eyes with patches. Which of these symptoms should a nurse expect to assess in a client who develops hypoglycemia? a. Fruity breath odor. 96 b. Polyuria. 97 c. Diaphoresis. d. Flushed skin. c. Diaphoresis. A client is eight hours postoperative after a transurethral resection of the prostate (TURP). Which of these observations, if noted by a nurse, indicates a complication? a. Hourly urine output of 90 mL. b. Reports of bladder spasms. c. BP 92/60 mm Hg, pulse rate 118/minute. d. Pink-tinged urine output. c. BP 92/60 mm Hg, pulse rate 118/minute. A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia, which include: a. flushed skin and thirst. b. irritability and hunger. c. sweating and jitteriness. d. lethargy and tremors. a. flushed skin and thirst. Which of these laboratory test results should a nurse monitor for a client who is receiving intravenous heparin therapy at a rate of 1,500 units per hour for the treatment of an acute pulmonary embolism? a. Partial thromboplastin time. b. Clot retraction time. c. Platelet levels. d. Bleeding time. a. Partial thromboplastin time. Which of these techniques should a nurse use to assess for correct placement of a nasogastric tube prior to administering a feeding? a. Aspirate 10 mL contents and measure the pH. b. Slowly inject 50 mL of saline and observe for resistance. c. Inject 20 mL of water and listen for gurgling sounds. d. Observe for bubbles after submerging the end of the tube in a cup of water.