RN Comp 2023 - (Lyme Disease )

A home health nurse is caring for a child who has lyme disease. Which of the following is an appropriate action for the nurse to take

a. Ensure the state health department has been notified

b. Administer antitoxin

c. Educate the family to avoid sharing personal belongings

d. Assess for skin necrosis

a. Ensure the state health department has been notified

A nurse is caring for a client who has been admitted to the hospital. (NGN)

- Provide frequent rest periods

- Restrict client sodium intake

- Advise client to avoid using soap and alcohol based lotions

- Instruct the client to avoid blowing their nose forcefully

- Assess the client's IV of orientation

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

a. Administered an antiemetic medication

b. Evaluate functioning of the suction device

c. Provide oral hygiene care

d. Replace the NG tube

b. Evaluate functioning of the suction device

While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion device. Which of the following actions should the nurse take first

a. Initiate a requisition for a replacement CPM device

b. Report the defect to the equipment maintenance staff

c. Remove the device from the room

d. Ensure the device inspection sticker is current

c. Remove the device from the room

A nurse is setting up a sterile field to perform would irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution

a. Remove the cap and place it sterile-side up on a clean surface

b. Pace sterile gauze over areas of spilled

c. Hold the bottle in the center of the sterile field when pouring the solution

d. Hold the irrigation solution bottle with the label facing away from the palm of the hand

c. Hold the bottle in the center of the sterile field when pouring the solution

A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan

a. Wear loose-fitting underwear

b. Take a bubble bath after intercourse

c. Drink four 240 ml (8 oz) glasses of water each day

d. Void every 5-6 hr during the day

a. Wear loose-fitting underwear

A nurse is caring for a newborn. Drag words from the choices below to fill in the blank in the following sentence. (NGN)

The client at risk for developing _____ and _____.

a. Hypoglycemia

b. Bronchopulmonary dysplasia

c. Transient tachypnea of the newborn

d. Tachycardia

Bronchopulmonary dysplasia and Transient tachypnea of the newborn.

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

a. Pale and a 24-hr fluid deficit of 30 mL

b. Sunken fontanels and dry mucous membranes

c. Decrease appetite and irritability

d. Temperature 38 C and pulse rate of 124/min

b. Sunken fontanels and dry mucous membranes

A nurse is conducting health promotion education regarding contraindication to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse includes in the teaching?

a. Hypertension

b. Fibromyalgia

c. Renal calculi

d. Fibrocystic breast diseases

a. Hypertension

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

a. I can continue to take St. john wort while taking this medication

b. I know it will be a couple of weeks before the medication helps me feel better

c. I expect this medication to raise my blood pressure

d. I should take this medication on an empty stomach

b. I know it will be a couple of weeks before the medication helps me feel better

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture

a. Position a pillow under the client's knee

b. Place a towel roll under the client's neck

c. Align a trochanter wedge between the client's legs

d. Apply an orthotic to the client's foot

c. Align a trochanter wedge between the client's legs

A nurse is assessing a client who is post-op following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/h. Which of the following should the nurse anticipate?

a. Initiate continuous bladder irrigation

b. Administer fluid bolus

c. Clamp the catheter tubing for 30 min

d. Obtain a urine specimen for culture and sensitivity

b. Administer fluid bolus

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following should the nurse report to obtain the prescription for warfarin?

a. Fibrinogen lv

b. aPTT

c. INR

d. Platelet count

c. INR

A nurse is assessing a client ho is taking haloperidol and is experiencing pseudo parkinsonism. Which of the following is the signs of pseudo parkinsonism

a. Serpentine limb movement

b. Shuffling gait

c. Nonreactive pupils

d. Smacking lips

b. Shuffling gait

A nurse care for client with expressive aphasia and right hemiparesis after a stroke. What is the best way to promotes communication among staff caring for the client?

a. Posting swallow precautions at the head of client's bed

b. Noting changes in the treatment plan in the client's medical record

c. Recording the clients progress in the nurse's note

d. Have interdisciplinary team meetings for the client on a regular basis

d. Have interdisciplinary team meetings for the client on a regular basis

A nurse is caring for a 2 yo toddler. Which food choice should the nurse recommended to promote independence in eating?

a. Banana slices

b. Grapes

c. Hot dog

d. Popcorn

a. Banana slices

A nurse on med-surge unit got notified that a mass casualty event has occurred. Which action should the nurse take?

a. Act as a liaison between the facility and media

b. Recommend to the provider specific acute care clients for discharge

c. Determine the medical needs of incoming clients through the emergency department

d. Call in additional med-surge unit nursing care staff

c. Determine the medical needs of incoming clients through the emergency department

A nurse has received report for 4 clients. Who should the nurse see first?

a. A client who is scheduled for a procedure in 1 hr

b. A client who received a pain med 30 min ago fir post-op pain

c. A client who has just given a glass of orange juice for a low blood glucose lv

d. A client who has 100 ml of fluid remain in his IV bag

c. A client who has just given a glass of orange juice for a low blood glucose lv

A nurse is performing postmortem care prior to the client's family visit. Which action should the nurse take?

a. Cross patient's arms across their chest

b. Hold client's eyes shut for a few seconds

c. Place client in a high fowler's position

d. Removed the client's dentures from their mouth

b. Hold client's eyes shut for a few seconds

A nurse admitting a schizophrenic client. Client state: "I'm hearing voices". Which responses is the priority for the nurse to state?

a. What are the voices telling you?

b. I realize the voices are real to you, but I don't hear anything

c. Have you taken your med today?

d. How long have you been hearing the voices?

a. What are the voices telling you?

A nurse is administered furosemide IV bolus to a client who has fluid volume excess. Which finding is an indication that the med has been effective?

a. Increase blood pressure

b. Weight loss

c. Decrease inflammation

d. Decrease pain

b. Weight loss

A nurse is caring for a client who requires nasal tracheal suctioning. Identify the

sequence the nurse should follow to perform suctioning.

(Move the steps into the

box on the right placing them in the order of performance. Use all the steps).

- Apply suction while rotating the catheter

- Don sterile gloves

- Insert the catheter during the client inspiration

- Rinse the catheter to remove secretions

- Turn on the suction and set the pressure

1. Turn on the suction and set the pressure

2. Don sterile gloves

3. Insert the catheter during the client inspiration

4. Apply suction while rotating the catheter

5. Rinse the catheter to remove secretions

A nurse is caring for a client who is in a coma and is scheduled for a surgical

procedure. Which of the following action should the nurse take?

a. Send the unsigned informed consent to the facility's risk manager

b. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure

c. Ensure that the client's family supports the provider's decision for surgery

d. Determine if the procedure is medically necessary for the client

b. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure

A nurse is preparing to give IV vancomycin. The client ask if the med can be give 2 hr earlier. Which statement should the nurse make?

a. I can start 30 min earlier

b. I can adjust the time and schedule for when it's convenient for you

c. I can infuse the med at a faster rate

d. I have up to 2 hr after the usual schedule time to give you this med

a. I can start 30 min earlier

A nurse care for a client who required seclusion to prevent harm to others on the unit. Which action should the nurse take?

a. Document the client's behavior prior to being placed in seclusion

b. Assess the client's behavior once every hr

c. Offer fluids every 2hr

d. Discuss with the client his inappropriate behavior prior to seclusion

a. Document the client's behavior prior to being placed in seclusion

A nurse care for an adolescent who has hyperthermia. Which action should the nurse take?

a. Administered oral acetaminophen

b. Cover the adolescent with a thermal blanket

c. Submerge the adolescent's feet in ice water

d. Initiate seizure precaution

d. Initiate seizure precaution

A nurse is caring for a client who asks for info about organ donation. Which responses should the nurse state?

a. I cannot be a witness for your consent to donate

b. You must be at least 21 yo to become an organ donor

c. Your desire to be an organ donor must be documented in writing

d. Your name can't be removed once you are listed on the organ donor list

c. Your desire to be an organ donor must be documented in writing

A parish nurse is leading a support group for clients whose family members have committed suicide. Which strategies should the nurse use during the session?

a. Encourage client to establish a timeline for their own grieving process

b. Initiate a discussion with clients about ways to cope with changes in family dynamics

c. Assist clients in identifying ways suicided could have been prevented

d. Discourage clients from sharing negative aspects of their relationship with the deceased persons

b. Initiate a discussion with clients about ways to cope with changes in family dynamics

A nurse is developing a care plan for a client who is in buck’s traction and is

scheduled for surgery for a fractured femur of the right leg. Which of the following

intervention should the nurse delegate to an assistive personnel?

a. Ask the client to describe her pain

b. Check the client's pedal pulse on the right leg

c. Observe the position of the suspended weight

d. Remind the client to use the incentive spirometer

d. Remind the client to use the incentive spirometer

A nurse is caring for a client who repeatedly refuse meals. The nurse overhears the UAP told the client: "If you don't eat, I'll put restraints on your wrists and feed you." The nurse intervene and explain the the UAP that the statement constitute which torts?

a. Battery

b. Assault

c. Negligence

d. Malpractice

b. Assault

A nurse is caring for a client who has admitted to the antepartum unit. Click to highlight the findings that require follow up. (NGN)

- 30 ys at 33 weeks gestation, Gravida 4 para 3

- Maternal blood type: Rh+

- Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks

- Client reports lover Back pain and pinkish vaginal discharge

- Uterine contraction every 8 mins, palpate strong, duration 30 secs

- FHR baseline 145, minimal variability

- Cervical exam indicates 2 cm, 50% effaced, 0 station

- Membranes intact

- Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks

- Client reports lover Back pain and pinkish vaginal discharge

- Uterine contraction every 8 mins, palpate strong, duration 30 secs

- Cervical exam indicates 2 cm, 50% effaced, 0 station

A nurse is caring for a client who has admitted to the antepartum unit. Complete the sentence by using the list of choice. (NGN)

The nurse should recognize the client is experiencing ______ due to ______

Preterm labor and previous preterm birth

A nurse is caring for a client who has admitted to the antepartum unit. Select 2 complications client at risk for developing. (NGN)

a. Disseminated intravascular coagulation

b. Sepsis

c. Preeclampsia

d. Seizure

e. Placenta previa

f. Preterm prelabor rupture of membranes (PROM)

b. Sepsis

f. Preterm prelabor rupture of membranes (PROM)

A nurse is caring for a client who has admitted to the antepartum unit. Choose anticipated or unanticipated for each potential prescription (NGN)

- Place client in supine pos

- Limited intake to 3000 ml/day

- Administer oxytocin

- Maintain bedrest with bathroom privileges

- Administer betamethasone

- Administer terbutaline

Anticpated:

- Limited intake to 3000 ml/day

- Administer oxytocin

- Administer betamethasone

Unanticipated:

- Place client in supine pos

- Maintain bedrest with bathroom privileges

- Administer terbutaline

** The nurse continues to care for the client. Which actions should the nurse takes? (NGN)

- Vaginal culture

- Urine culture

- Obtain provider prescription for antibiotics

- Ibuprofen 600 mg Q6h for mild to moderate pain

- Obtain prescription for phenazopyridine

- Urine culture

- Obtain provider prescription for antibiotics

- Obtain prescription for phenazopyridine

** The nurse continues to care for the client. Highlight the finding indicate improvement in client's condition. (NGN)

- Client rate back pain 0

- No report of vaginal discharge

- Membrane intact

- No uterine contractions noted

- FHR baseline 138, minimal variability

- No further report of burning with urination

- WBC 12,000 (5000 - 10,000)

- Platelet 188,000 (150,000 - 400,000)

- Temp: 37.1 (98.7)

- BP 120/78

- Client rate back pain 0

- No report of vaginal discharge

- No uterine contractions noted

- No further report of burning with urination

- WBC 12,000 (5000 - 10,000)

- Platelet 188,000 (150,000 - 400,000)

- Temp: 37.1 (98.7)

- BP 120/78

A nurse is teaching a client who has new diagnosis of DM about foot care. Which instruction should the nurse include?

a. Soak feet twice daily

b. Round the edge of toe nail when trim

c. Use moisturizing lotion between toe

d. Wear clean cotton socks ever day

d. Wear clean cotton socks ever day

A nurse is preparing to feed a newly admitted client who has dysphasia. Which action should the nurse take?

a. Instruct client to lift her chin when swallow

b. Talk with the client during her feeding

c. Sit at or below the client's eye lv during feedings

d. Discourage client form coughing during feedings

c. Sit at or below the client's eye level during feedings

A nurse is caring for a client who has acute glomerulonephritis. Which findings should the nurse expect?

a. Polyuria

b. Hypertension

c. Weight loss

d. Hematuria

d. Hematuria

A nurse is care for a client whose partner recently died. The nurse sits with client to provide comfort. Which following ethical principles is the nurse demonstrating?

a. Fidelity

b. Veracity

c. Autonomy

d. Beneficence

d. Beneficence

An ED nurse is care for a child who reports being sexually abused by a family member. Which action should the nurse take?

a. Use leading statements to obtain info from the child

b. Ensure that multiple nurses are present for the physical examination

c. Explain to the child what will happen when the abuse is reported

d. Reassure the child that no one will be told about the abuse

c. Explain to the child what will happen when the abuse is reported

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which tasks should the nurse identify as tertiary prevention?

a. Using an electronic messaging system to remind clients when to take med

b. Educate clients about contraindications to specific immunizations

c. Help client understand health screenings covered by their insurance plans

d. Provide info about the benefits if exercise

a. Using an electronic messaging system to remind clients when to take med

A nurse is care for a client who has given informed consent for electroconvulsive therapy. Just before the treatment, the client tells the nurse she's considering not doing the treatment. Which statement should the nurse make?

a. Most people who have this procedure feel better following the treatment

b. Your dr wouldn't have ordered this treatment unless it was necessary

c. It's ok to be nervous before the treatment

d. You don't have to go through with the treatment

d. You don't have to go through with the treatment

A nurse is teaching a new parent about breastfeeding her 2 week old infant. Which statements by the parent indicates understanding of the teaching?

a. After 5-10 min when the breast is empty, my baby should be removed from the breast

b. Manually expressing my milk will decrease my milk supply

c. My baby should always start on the same breast when feeding

d. The more my baby is at the breast sucking, the more milk I will produce.

d. The more my baby is at the breast sucking, the more milk I will produce.

A nurse is preparing to reposition a client who has a stroke. Which action should the nurse take?

a. Evaluate the client's ability to help with repositioning

b. Reposition client without the use of assistive device

c. Raise the side rails on both sides of the client's bed during reposition

d. Discuss the client's preferences for determining a reposition schedule

a. Evaluate the client's ability to help with repositioning

A nurse is providing discharge teaching to a client who is post-op following the repair of a detached retina. Which statements by the client indicate understanding of the teaching?

a. I can go jogging after 2 weeks

b. I should bend at the waist when putting on my shoes

c. I can lift objects that are less than 10 lbs

d. I can resume activities, such as sewing

c. I can lift objects that are less than 10 lbs

A nurse is giving discharge teaching about home care of a surgical incision to a client who speaks a different language. The nurse communicating using an interpreter. Which action should the nurse take?

a. Speak slowly when talking to the interpreter

b. Pause in the middle of sentence

c. Speak directly to the client

d. Use gestures to convey meaning

c. Speak directly to the client

A nurse is teaching a client who has new prescription for enoxaparin. Which pain med should the nurse include that can be taken concurrently with enoxaparin?

a. Ibuprofen

b. Naproxen sodium

c. Acetaminophen

d. Aspirin

c. Acetaminophen

A nurse is receiving report for a group of clients. Which clients should the nurse assess first?

a. A client who has epidural analgesia and weakness in the lower extremities

b. A client who has a hip fracture and a new onset of tachypnea

c. A client who has sinus arrhythmia and is receiving cardiac monitoring

d. A client who has DM and an HbA1c of 6.8%

b. A client who has a hip fracture and a new onset of tachypnea

A nurse is assessing skin of a client who has dark skin. Which locations should the nurse observe to assess for cyanosis?

a. Sacrum

b. Palms of the hands

c. Shoulders

d. Area of trauma

b. Palms of the hands

A charge nurse is teaching new staff about factors that increase a client's risk to become violent. Which factors should the nurse include as the best predictor future violence?

a. A history of being in prison

b. Male gender

c. Experiencing delusions

d. Previous violent behavior

d. Previous violent behavior

A nurse is assessing a client who is in active labor. which findings should the nurse report to provider?

a. Temp 37.4 (99.3)

b. Early decelerations in FHR

c. FHR baseline 170/min

d. Contractions last 80 secs

c. FHR baseline 170/min

A quality control control nurse is reviewing med prescription for a group of clients. Which prescription is correct?

a. Tetracycline 200 mg PO

b. Epoetin alfa 150 units/kg three times weekly

c. Digoxin 0.25 mg PO daily

d. Cimetidine PO twice daily

c. Digoxin 0.25 mg PO daily

A nurse if care for a client in an ED. (Bowtie NGN)

Action to take:

- Teach client to use self talk

- Ask: "What kind of drug have you been taking?"

- Reduce external stimuli

- Ask: "Have you been sick recently?"

- Engage with client several times each day to establish trust

Complication most likely experiencing

- Brief psychotics disorder

- Delirium

- Anxiety

- Substance use disorder

Parameters to monitor

- Ability to care for self

- Fearfulness

- Suicide risk

- Temperature

- ?

- Complication experiencing: Brief psychotics disorder

- Action to take: Reduce external stimuli, engage with client several times each day

- Monitor: ability to care for self, suicide risk

A nurse is providing in-service about client evacuation during a fire. Which of the following clients should be evacuate first?

a. A client who is ambulating and receiving O2

b. A client who has a fracture and is balance suspension traction

c. A client who is bedridden and wears hearing aid

d. A client who uses a wheelchair and is confuse

a. A client who is ambulating and receiving O2

A nurse is planning care for an older adult client who has dementia. Which interventions should the nurse include? (SATA)

a. Give one simple direction at a time

b. Refute client's delusions using logic

c. Allow client to choose among a variety of activities each day

d. Reinforce orientation to time, place, person

e. Establish eye contact when communicating with the client

a. Give one simple direction at a time

d. Reinforce orientation to time, place, person

e. Establish eye contact when communicating with the client

A nurse is providing discharge teaching to the partner of a client who has a

tracheostomy. Which of the following information should the nurse include in

the teaching?

a. How to operate portable suction machine

b. How to secure trache tube with ties at the back of the neck

c. How to change the nondisposable trache tube daily

d. How to change trache dressing using clean technique

a. How to operate portable suction machine

A nurse care for a client who report xerostomia after radiation therapy to the mandible. Which actions should the nurse take?

a. Suggest rinsing his mouth with an alcohol-based mouth wash

b. Provide humidification of the room air

c. Offer the client saltine cracker between meal

d. Instruct client on the use of esophageal speech

b. Provide humidification of the room air

A public heath nurse work in a rural area is developing a program to improve health for local population. Which action should the nurse take?

a. Launch a media campaign to increase awareness about industrial pollution

b. Have a nurse from outside the community provide health lectures at the county hospital

c. Encourage rural residents to focus health spending on tertiary heath intervention

d. Provide anticipatory guidance classes to parents through public school

d. Provide anticipatory guidance classes to parents through public school

A nurse is assessing a child who has bacteria pneumonia. Which of the following manifestation should the nurse expect?

a. Drooling

b. Malaise

c. Tinnitus

d. Rhinorrhea

b. Malaise

** A nurse from an emergency department is caring for a client. Highlight findings that requires follow-up. (NGN)

Client presents for evaluation of severe pain in upper abdomen that radiates into his back. States pain began approximately 12 hr ago and is worse when he is supine or after he eat. Rates pain a 7. Sclera noted to be yellow. HR regular, lungs clear. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Report last bowel movement was yesterday. Denies recent illnesses. Takes no prescribed meds. Client alert and oriented x4

- Client presents for evaluation of severe pain in upper abdomen that radiates into his back

- States pain began approximately 12 hr ago and is worse when he is supine or after he eat

- Sclera noted to be yellow

- Abdomen firm, bowel sounds hypoactive

- Client guards abdomen and grimaces during palpation

A nurse from an emergency department is caring for a client. Specify if the finding is consistent with pancreatitis or peritonitis. (NGN)

Bloody stools

Hyperbilirubinemia

Abdominal pain

Elevated WBC

Pancreatitis:

- Hyperbilirubinemia

- Abdominal pain

- Elevated WBC count

Peritonitis:

- Bloody stool

- Abdominal pain

- Elevated WBC count

A nurse from an emergency department is caring for a client. Complete the following sentence (NGN)

The nurse should first address the client's _____

- Lung sound

- Pain lv

- Bowel sound

followed by client's _____

- Blood sugar

- BP

- Temp

Lung sound and temp

** A nurse from an emergency department is caring for a client. Specific if the prescription is anticipated or contraindicated. (NGN)

- Administer famotidine 20 mg via intermittent IV BID

- Insert an indwelling catheter

- Administer Lactated Ringer's 1 l via IV bolus

- Insert a NG tube and maintain low intermittent suction

- Administer famotidine 20 mg via intermittent IV BID: An

- Insert an indwelling catheter: Co

- Administer Lactated Ringer's 1 l via IV bolus: An

- Insert a NG tube and maintain low intermittent suction: An

A nurse from an emergency department is caring for a client. Select 3 statements the nurse should include in the teaching about self-care. (NGN)

a. Notify your provider if you experience vomiting or diarrhea

b. Limit alcohol intake to no more than 1 drink per day

c. You should eat foods that are low in fat

d. You can drink beverages that contain caffeine

e. You should eat foods high in protein

a. Notify your provider if you experience vomiting or diarrhea

c. You should eat foods that are low in fat

e. You should eat foods high in protein

A nurse from an emergency department is caring for a client. Which statements by the client indicate understanding of discharge teaching? (SATA)

a. I will eat small, frequent meal

b. I should expect my bowel movements to be pale in color

c. I will limit my morning coffee to no more than 2 cups

d. I will notify my provider if my urine is dark

e. I will eat fish for diner at least twice per week

a. I will eat small, frequent meal

b. I should expect my bowel movements to be pale in color

d. I will notify my provider if my urine is dark

A nurse is planning care for a client who is scheduled for a thoracentesis. Which if the following actions should the nurse plan to take.

a. Position the client on the affected side for 4hr following procedure

b. Instruct client to avoid coughing during the procedure

c. Inform client that he will be NPO for 6hr prior to the procedure

d. Place client in the prone position during procedure

b. Instruct client to avoid coughing during the procedure

A nurse is assessing a 2 year old toddler which of the following findings

should the nurse expect?

a. Head circumference exceeds chest circumference

b. Palpable fontanels

c. Natural loss of deciduous teeth

d. Nontender, protruding abdomen

d. Nontender, protruding abdomen

A nurse manager is updating protocols for the use of belt restrain. Which guidelines should the nurse manager include?

a. Remove client's restrain q4h

b. Document client's condition every 15 min

c. Request a PRN restraint prescription for clients who are aggressive

d. Attach the restraint to the bed's side rails

b. Document client's condition every 15 min

A nurse in a PACU is transferring care of a client to a nurse on med-surg unit. Which statement should the nurse include in the report?

a. The estimated blood loss was 250 ml

b. Client is a member of the board of directors

c. There was a total of 10 sponges used during the procedure

d. Client was intubated without complications

a. The estimated blood loss was 250 ml

A nurse in ED care for a client who has a closed head injury. Which action should the nurse take first?

a. Determine client's Glasgow coma scale

b. Insert an indwelling catheter for client

c. Administer mannitol IV bolus to client

d. Prepare client for a brain MRI

a. Determine client's Glasgow coma scale

A nurse in ED care for a client following a motor-vehicle crash. Client's Glasgow scale rating is 15. Which finding should the nurse expect?

a. Client oriented x3

b. Client open eyes to sound

c. Client is unable to obey commands

d. Client withdraws from pain

a. Client oriented x3

A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 s. Which dysrhythmias is client displaying?

a. 1st degree atrioventricular block

b. Complete heart block

c. Premature atrial complexses

d. A-fib

a. 1st degree atrioventricular block

The nurse is caring for a client who at end-stage kidney disease. The client's adult child asks about becoming a living kidney donor for their parent. Which conditions in the child's medical history is contraindicated with the procedure?

a. Amputation

b. Osteoarthritis

c. Hypertension

d. Primary glaucoma

c. Hypertension

A nurse is caring for a client. Specify if the finding is consistent with ulcerative colitis, diverticular, or crohn's disease (NGN).

Fever

Steatorrhea

Anemia

Weight loss

Diarrhea

Ulcerative Colitis:

- Fever

- Weight Loss

- Diarrhea

Diverticulitis:

- Fever

- Anemia

- Diarrhea

Crohn's Disease (ALL):

- Steatorrhea

- Weight loss

- Anemia

- Fever

- Diarrhea

A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which statements should the nurse make?

a. We can review some info to help you select a safe alternative practitioner

b. If there are therapies available to you, your provider will tell you about them.

c. Feel free to try whatever therapies that fit within your personal belief system

d. I'm sure you can find alternative remedies through an online support group.

a. We can review some info to help you select a safe alternative practitioner

A nurse is prepare to obtain a heath history from a client on bedrest. Which positions should the nurse take to place the client at ease?

a. Sit in a chair next to the bed

b. Stand at the side of the bed

c. Sit on the bed next to the client

d. Stand at the foot of the bed

a. Sit in a chair next to the bed

A nurse is care for a newborn whose mother was talking methadone during pregnancy. Which findings indicate the newborn is experiencing withdrawal?

a. Bulging fontanels

b. Acrocyanosis

c. Bradycardia

d. Hypertonicity

d. Hypertonicity

A nurse is care for a client who is receiving TPN. The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which actions should the nurse take?

a. Administer dextrose 10% in water

b. Give 500 mL lactated Ringer's

c. Slow TPN infusion rate

d. Temporarily discontinue the infusion

a. Administer dextrose 10% in water

A nurse is auscultating for crackles on a pneumonia client. Which area of the anterior chest wall should the nurse auscultate?

C: below left chest

A nurse is providing teaching about immunizations to a client who is pregnant. Which statements should the nurse include in the teaching?

a. The immunization for varicella should be given at least 1 month prior to delivery

b. You can receive rubella immunization during third trimester

c. Hep B immunization should not be obtained until after you finish breast feeding

d. You can received the immunization for influenza at any time during pregnancy

d. You can received the immunization for influenza at any time during pregnancy

A nurse is planning teaching for a client and their family about home oxygen therapy. Which info should the nurse plan to teach?

a. Apply petroleum jelly to soothe the mucous membranes

b. Use synthetic fabrics for the client's bedding

c. Clean the equipment with an alcohol-based cleaning product

d. Avoid using nail polish remover around the client

d. Avoid using nail polish remover around the client

A nurse is instructing a school-age child who has asthma about peak expiratory flow meter. Which instructions should the nurse include in the teaching?

a. Place tongue on the mouthpiece of the meter

b. Maintain a semi-fowler's position during testing

c. Record the average of the readings

d. Blow into the meter as hard and quickly as possible

d. Blow into the meter as hard and quickly as possible

A nurse is caring for a client who is 12 hr postpartum and has 3rd degree perineal laceration. Client report not having a bowel movement for 4 days. Which med should the nurse give?

a. Bisacodyl 10 mg rectal suppository

b. Magnesium hydroxide 30 mL PO

c. Famotidine 20 mg PO

d. Loperamide 4 mg PO

b. Magnesium hydroxide 30 mL PO

A nurse is provide discharge teaching to the parents of a toddler who has cystic fibrosis. Which instructions should the nurse include?

a. Perform chest percussion and postural drainage at least twice daily

b. Restrict intake of foods that contain gluten

c. Administer pancreatic enzymes on an empty stomach

d. Use a nebulizer to administer a bronchodilator following airway clearance therapy.

a. Perform chest percussion and postural drainage at least twice daily

A nurse is planning care for a client who has a prescription for bowel-training program after a spinal cord injury. Which actions should the nurse include on the care plan?

a. Increase the amount of refined grains in client's diet

b. Provide client with a cold drink prior to defecation

c. Administer a suppository 30 min prior to scheduled defecation times

d. Encourage a maximum fluid intake of 1500 mL/day

c. Administer a suppository 30 min prior to scheduled defecation times

** A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

a. An angiocatheter

b. A 25-gauge needle

c. A butterfly needle

d. A noncoring needle

d. A non coring needle

A nurse is assessing a client immediately after a cardiac catheterization. The nurse should notify provider for which findings?

a. Report of discomfort at the insertion rate

b. HR 90/min

c. Bounding pulse in the affect extremity

d. Hematuria over the insertion site

d. Hematoma over the insertion site

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate visa continuous IV. Which therapeutic effects should the nurse monitor?

a. Deep tendon reflexes +2

b. Pulse 100/min

c. Urine output 20 mL/hr

d. 1+ proteinuria via urine dipstick

c. Urine output 20 mL/hr

A nurse is teaching a newly licensed nurse about care for clients in ED. Which actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

a. Use a face shield with a mask when providing care

b. Tell the client, "you seem to be very upset"

c. Engage the panic alarm

d. Initiate seclusion protocol

b. Tell the client "you seem to be very upset"

A nurse care for a client who is admitted to the med-surge unit. Select 5 findings that required immediate follow up. (NGN)

a. Stool result

b. H&H

c. RR

d. HR

e. Current medication

f. Temp

g. WBC

h. BP

a. Stool result

b. H&H

d. HR

e. Current medication

h. BP

A nurse care for a client who is admitted to the med-surge unit. Complete the sentence (NGN)

The nurse anticipates client will likely requires _____

- an endoscopy

- an antifungal prescription

- O2 via nonbreather mask

as evidenced by client's _____

- temp

- stool result

- RR

an endoscopyAEB client's stool result

A nurse care for a client who is admitted to the med-surge unit. Complete the sentence (NGN)

The nurse should first anticipate to _____

(- place client in a supine pos with elevated feet

- obtain IV access

- recheck client's O2

- call the surgical) suite to notify that the client is arriving STAT

then _____

(- prepare to give IV fluid

- check an ABG

- check an ECG

- transport client for endoscopy)

obtain IV access FIRST, THEN - prepare to give IV fluid

The nurse reviews the entries in the medical record. The nurse preparing client for a blood transfusion. Which action should the nurse take? (SATA)

a. Have a 2nd nurse confirm the info on the blood lable

b. Insert a large bore IV catheter

c. Witness client sign an informed consent

d. Flush the transfusion tubing with dextrose 5% in water

e. Explain to the client that transfusion reactions are not serious

a. Have a 2nd nurse confirm the info on the blood lable

b. Insert a large bore IV catheter

c. Witness client sign an informed consent

The nurse reviews the entries in the medical record. The nurse is ready for blood transfusion. Specify if the action is indicated or not indicated (NGN)

- Document the blood product transfusion in the client's medical record.

- Stay with the client for the first 15 min of transfusion

- Titrate the rate of infusion to maintain client's blood pressure at least 90/60

- Obtain the first unit of packed RBCs from the blood bank

- Start an IV bolus of lactacted ringer's solution

INDICATED:

- Document the blood product transfusion in the client's medical record

- Stay with the client for the first 15 min of transfusion

- Obtain the first unit of packed RBCs from the blood bank

NOT INDICATED:

- Titrate the rate of infusion to maintain client's blood pressure at least 90/60

- Start an IV bolus of lactacted ringer's solution

The nurse assessing client after the transfusion of 2 units of packed RBCs. Highlight the finding indicate improvement in client's condition. (NGN)

- WBC 6000

- Hemo 12

- Hema 36%

- BP 112/74

- HR 95

- RR 18

- Temp 37.5 (99.5)

- O2 100 at 2 L nasal canula

- General: no distress

- HEENT: oropharynx clear, mucous membranes moist and pink

- Resp: bilateral breath sound clear

- GI: Epigastric tenderness to palpation, no rebound tenderness or guarding

- Neuro: awake and alert

- Hemoglobin 12

- Hematocrit 36%

- BP 112/74

- HR 95

- General: no distress

- HEENT: oropharynx clear, mucous membranes moist and pink

A nurse cares for a client who has placenta previa. Which findings should the nurse expect?

a. Spotting

b. Nausea

c. Polyhydramnios

d. Uterine tenderness

a. Spotting

A nurse in a mental health clinic received a request from client to obtain a copy of the therapist's note. Which responses should the nurse make?

a. Are you not happy with the treatment?

b. We can provide a copy of your records, but the therapist's note are not included

c. Why are you interested in seeing your therapist's note

d. I don't think you will benefit from reviving your therapist's notes right now

b. We can provide a copy of your records, but the therapist's note are not included

A nurse is preparing to give med that is available in a glass ampule. Which action should the nurse plan to take?

a. The nurse should use a filter needle to withdraw the med

b. The nurse should break the neck of the ampule toward their body

c. The nurse should use the same needle to draw up and inject the client

d. The nurse should dispose of the ampule in the trash can

a. The nurse should use a filter needle to withdraw the med

A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identity which conditions is contraindicated for receiving the treatment?

a. Hypertension

b. Obesity

c. Hypothyroidism

d. Herpes zoster

d. Herpes zoster