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Terms in this set (35)
is a condition in women that consists of male pattern hair growth on the face, lower abdomen, chest and back . #72116868 (58)
During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse POSITION the client while waiting to cover the wound? #72116868 (59)
1. Low Fowler's position with knees bent
2. Prone to prevent further evisceration
3. Side lying lateral position
4. Supine with head of the bed flat
is the protrusion of internal organs through the wall of an incision. #72116868 (59)
A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. What ACTION should the nurse take "FIRST"? #72116868 (60)
1. Check for bleeding at tube connection sites
2. Perform a fast flush of the arterial line system
3. Re-level the transducer to the phlebostatic axis
4. Zero and re-balance the monitor and system.
A low pressure alarm could signal #72116868 (60)
The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of PNEUMONIA. "SELECT ALL THAT APPLY" #72116868 (61)
1. Coarse crackles
3. Pleuritic chest pain
4. Shortness of breath
5. Trachea deviating from midline
Which of the following tasks would the charge nurse on a surgical unit assign to the experienced UNLICENSED ASSISTIVE PERSONNEL (UAP)?
1. Assisting a client in ambulating to the bathroom for the first time following surgery.
2. Explaining why using the incentive spirometer is important to a client with postoperative pneumonia.
3. Feeding a client with dementia who has a blood sugar of 70 mg/dL
4. Taking vital signs every 15 minutes on a client who was just transferred from the post-anesthesia recovery unit.
A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm. What information contained in the admission history of this client will need to be "ADDRESSED" during discharge education?
1. Eat steamed vegetables daily
2. Enjoys eating grilled shrimp weekly
3. Gardens as hobby
4. Takes a bath daily and applies moisturizer
The nurse is educating a client recently diagnosed with anaphylactic allergy to latex. Which statement made by the client indicates that the client UNDERSTOOD the condition correctly?
1. "I do not need to worry about my allergy when I am outside of a health care environment."
2. "I just need to check labels to ensure products do not contain latex and I will be fine."
3. "I should always carry my Epi-pen in case I have difficulty breathing."
4. "I should take better care of myself and eat healthy foods like bananas and chestnuts."
The nurse in the outpatient procedure unit is caring for a client immediately post BRONCHOSCOPY Which assessment data indicate that the nurse needs to contact the health care provider "IMMEDIATELY "?
1. Absence of gag reflex
2. Bright red blood mixed with sputum
4. Respirations 10/min and saturation of 92%
A client receiving a first dose of IV cefazolin has developed a diffuse rash, hypotension and shortness of breath. Place the nurse's subsequent actions in the correct order. ALL OPTIONS MUST
BE USED. #72116868 (66)
1. Give IM epinephrine and start IV normal saline
2. Monitor vital signs for changes
3. Stop the infusion and call for help
4. Administer diphenhydramine IV
5. Assess airway and place client on oxygen
When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which "PRIORITY" manifestation that may occur as a result of the catheterization? #72116868 (67)
The nurse is GIVING REPORT at the end of a shift to the incoming nurse at 1900. A client was admitted with pneumonia that morning. Which information is "MOST IMPORTANT" for the nurse to communicate about the client during the change of shift report (hand-off)? #72116868 (68)
1. Chest x-ray showed left lobe infiltrate and white blood cell count of 14,0000/mm
2. Client spouse was rude to the nurse earlier
3. Current respirations are 24/min, pulse oximetry is 93% on 2L/min
4. Intravenous (IV) line has been infusing without complications.
A 60 year old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. the client can state the name and address but has no recollection of the past 2 days. What is the "PRIORITY " nursing action?
1. Assess vital signs
2. Contact family member
3. Encourage the client to recall recent events
4. Perform a mental status assessment.
The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing?"SELECT ALL THAT APPLY"
is the OPTIC nerve and a sensory nerve
The nurse witnessed a signed informed consent for an inguinal repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also require repair. Which action should the nurse performs? #72116868 (71)
1. Add the secondary hernia to the consent form that the client signed before the procedure.
2. Call the client's medical power of attorney to provide consent for the additional procedure.
3. Document that an additional hernia was found and that it will require surgery at a later time.
4. Witness an additional consent after both procedures are complete and the client is awake.
The nurse is preparing to perform CARDIOVERSION in a client in supraventricular tachycardia shown in the exhibit that has been unresponsive to drug therapy. The client has become hemodynamically
unstable. Which step is MOST IMPOR-
TANT in performing cardioversion? CLICK ON THE EXHIBIT BUTTON FOR ADDITIONAL INFORMATION.
1. Charge the defibrillator
2. Push the synchronize button
3. Sedate the client
l4. Select energy level
The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to AVOID?. SELECT ALL THAT APPLY . #72116868 (73)
2. Broccoli with cheese
3. Multigrain bagel
5. Spaghetti with sauce
A registered nurse is precepting a new nurse in the intensive care unit. The client is sedated with propofol, on a mechanical ventilator and is receiving enteral feeding via nasogastric tube. The new nurse performs interventions to prevent aspiration. The preceptor should INTERVENE if the new nurse performs which of the following actions? #72116868 (74)
1. Assesses gastric residual volume every 4 hours
2. Measures the number of centimeters the feeding tube is secured at the nare every 4 hours.
3. Requests that the physician change the client from continual to bolus feedings
4. Use a sedation scale to titrate down the sedation (if possible )
The nurse is caring for a client with chronic, stable angina, The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is EFFECTIVE?
1. Client is able to shower, dress, and fix hair without any chest pain.
2. Client reports a reduction in stress level and anxiety.
3. Clients report being able to sleep through the night.
4. Client's blood pressure is 128/78 mm Hg and heart rate is 82/min.
The nurse is evaluating a parent's understanding of post-circumcision care for a newborn.Circumcision was performed using the clamp method. Which statement by the parent demonstrates a "NEED FOR FURTHER TEACHING?" #71941465 (02)
1. "Bleeding should be no larger than the size of a quarter."
2. "I should apply petroleum jelly to the glans at diaper changes."
3. "My baby should have 4-6 diapers in 24 hours."
4. "Yellow exudate on the glans penis indicates infection."
forms as part of the normal healing process after the first 24 hours. #71941465 (02)
forms as part of the normal healing process after the first 24 hours. It is not a sign of infection and should not be removed forcefully. #71941465 (02)
The nurse teaches the client taking atorvastastin to call the health care provider (HCP) if experiencing which symptom associated with a SERIOUS ADVERSE EFFECT of atorvastatin ? #71941465 (03)
3. Muscle aches
4. Numbness in the feet
is a statin drug prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. #71941465 (03)
A nurse in the gynecology clinic is reviewing client histories. Which report would be "MOST" concerning to the nurse? #71941465 (04)
1. 25 year old client who reports a fish like vaginal odor for the past month
2. 30 year old client with an intrauterine device who reports heavy bleeding with menses
3. 40 year old client with endometriosis who reports persistent pain during intercourse.
4. 60 year old client who reports bloating and pelvic pressure for the past 2 months
results in more deaths than any other gynecologic cancer. Symptoms are often subtle and may include abdominal bloating, pelvic pain or pressure, abdominal girth increase. #71941465 (04)
The nurse administers 15 units of aspart insulin subcutaneously to a hospitalized client with type 1 diabetes mellitus at 7:00 am for a fasting blood glucose of 180 mg/dL. Which nursing action is a "PRIORITY"? #71941465 (05)
1. Ensure that the client continues to fast for at least 30 more minutes.
2. Give the client breakfast within 15 minutes
3. Recheck the blood glucose in 1 hour.
4. Teach the client about the signs and symptoms of hyperglycemia.
The nurse cares for a client with Addison's disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur. Which client information is "MOST IMPORTANT " to report to the primary health care provider (PHCP)?
1. Blood pressure change from 128/80 mm Hg to 90/50 mm Hg
2. Development of a Ist degree atrioventricular (AV) block on electrocardiogram (ECG).
3. Report of right femur pain of 7 on a scale of 1-10.
4. Vesicular breath sounds auscultated over the lung tissue.
is adrenocortical insufficiency or hypofunction of the adrenal cortex. A deficiency in all 3 classes of adrenal corticosteroids, including glucocorticoids, mineralocorticoids, and androgens.
is a potentially life-threatening complication of Addison's disease. It can lead to shock and should be reported immediately to the PHCP
A client is admitted to the intensive care unit with suspected PHEOCHROMOCYTOMA . The client's vital sign are temperature of 99.6 F (37.5C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respiration of 20/min. The client is sweating profusely and reports a severe headache. Which prescription should the nurse implement "FIRST"? #71941465 (07)
1. Draw labs to assess electrolyte panel
2. Give acetaminophen 650 mg by mouth as needed for headache.
3. Place a fan the client's room.
4. Start nitroprusside infusion at 0.5 mcg/kg/min.
The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which INTERVENTION should the nurse implement? "SELECT ALL THAT APPLY " #71941465 (09)
1. Encourage the parents to leave the child's favorite stuffed animal.
2. Establish a daily schedule similar to the child's home routine.
3. Give the child time to calm down alone when visibly upset.
4. Provide frequent opportunities for play and activity.
5. Remove visual reminders of the parents from the room
The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess "FIRST"? #71941465 (10)
1. Client with anemia who began receiving a unit of packed red blood cells 1 hour ago.
2. Client with hemoglobin of 7g/dL who needs to be started on IV iron therapy.
3. Client with seizure activity who received lorazepam 20 minutes ago.
4. Client with suspected leukemia scheduled for a bone marrow biopsy in 1 hour.
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