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Questions and Answers
What type of care should be initiated for a client whose caregiver requests adult day care services?
What type of care should be initiated for a client whose caregiver requests adult day care services?
PACE
Which of the following findings should the nurse identify as an adverse effect of captopril to report to the provider?
Which of the following findings should the nurse identify as an adverse effect of captopril to report to the provider?
- Blurred vision
- Polyuria
- Tinnitus
- Cough (correct)
Which instruction should the nurse include for a client with a fracture of the right fibula?
Which instruction should the nurse include for a client with a fracture of the right fibula?
- Use a three-point gait. (correct)
- Adjust the crutches for comfort as needed.
- Wear leather-soled shoes.
- Advance the affected leg first when walking upstairs.
What is the priority action for a nurse caring for a client who had abdominal surgery 24 hours ago?
What is the priority action for a nurse caring for a client who had abdominal surgery 24 hours ago?
Which prescription for a postoperative client is contraindicated?
Which prescription for a postoperative client is contraindicated?
What indicates a client's understanding of advance directives?
What indicates a client's understanding of advance directives?
What should the nurse assess first for a client who is 48 hours postoperative following a laryngectomy?
What should the nurse assess first for a client who is 48 hours postoperative following a laryngectomy?
The client is at highest risk for developing _____ as evidenced by the _____ following a total thyroidectomy.
The client is at highest risk for developing _____ as evidenced by the _____ following a total thyroidectomy.
What statement indicates altruism by a client in therapy?
What statement indicates altruism by a client in therapy?
Which child should the nurse assess first?
Which child should the nurse assess first?
What should the nurse do when suspecting physical abuse in a child with scald burns?
What should the nurse do when suspecting physical abuse in a child with scald burns?
Which action should the nurse plan when administering an IM injection to an obese client?
Which action should the nurse plan when administering an IM injection to an obese client?
Select the 4 client findings that indicate a thyroid storm.
Select the 4 client findings that indicate a thyroid storm.
Which newly licensed nurse action requires intervention?
Which newly licensed nurse action requires intervention?
Which finding should the nurse identify as an adverse effect of amitriptyline?
Which finding should the nurse identify as an adverse effect of amitriptyline?
What indicates understanding of asthma management in a parent?
What indicates understanding of asthma management in a parent?
What behavior should the nurse expect in a child with autism spectrum disorder?
What behavior should the nurse expect in a child with autism spectrum disorder?
What action should the nurse take for a client with active pulmonary tuberculosis?
What action should the nurse take for a client with active pulmonary tuberculosis?
The client is at risk for experiencing _____ due to the client’s _____ during pregnancy.
The client is at risk for experiencing _____ due to the client’s _____ during pregnancy.
Health care personnel can proceed with necessary life-saving care when a client is unable to give informed consent in an emergency due to implied consent.
Health care personnel can proceed with necessary life-saving care when a client is unable to give informed consent in an emergency due to implied consent.
What is the nurse's priority activity for a client with a new diagnosis of type 1 diabetes mellitus?
What is the nurse's priority activity for a client with a new diagnosis of type 1 diabetes mellitus?
Select the 3 findings that require immediate follow-up for a client in a mental health clinic.
Select the 3 findings that require immediate follow-up for a client in a mental health clinic.
What is the priority step of the time management process that should be included when teaching newly licensed nurses?
What is the priority step of the time management process that should be included when teaching newly licensed nurses?
What action should the nurse take before performing a paracentesis?
What action should the nurse take before performing a paracentesis?
Which of the following statements by the client indicates an understanding of the teaching regarding common discomforts associated with pregnancy?
Which of the following statements by the client indicates an understanding of the teaching regarding common discomforts associated with pregnancy?
What action should the nurse take for a client recently started on risperidone?
What action should the nurse take for a client recently started on risperidone?
What condition is the client most likely experiencing based on the symptoms?
What condition is the client most likely experiencing based on the symptoms?
Which action should the nurse take for a client receiving chemotherapy and has neutropenia?
Which action should the nurse take for a client receiving chemotherapy and has neutropenia?
Select the statements that indicate understanding of newborn care.
Select the statements that indicate understanding of newborn care.
What should a nurse do when preparing to administer insulin via a pen device?
What should a nurse do when preparing to administer insulin via a pen device?
Which question should the nurse ask to assess for an adverse effect of ibuprofen in an adolescent with juvenile idiopathic arthritis?
Which question should the nurse ask to assess for an adverse effect of ibuprofen in an adolescent with juvenile idiopathic arthritis?
What intervention should a nurse plan for a client with a magnesium level of 2.7 mEq/L?
What intervention should a nurse plan for a client with a magnesium level of 2.7 mEq/L?
The client is at greatest risk for developing ________ as evidenced by electrolyte imbalance.
The client is at greatest risk for developing ________ as evidenced by electrolyte imbalance.
Which finding indicates that the use of ginger tea is effective for a pregnant client?
Which finding indicates that the use of ginger tea is effective for a pregnant client?
Which finding should the nurse report for a newborn after delivery?
Which finding should the nurse report for a newborn after delivery?
What finding indicates the therapy of packed RBCs has been effective?
What finding indicates the therapy of packed RBCs has been effective?
Which nutrient should a nurse instruct a client with Crohn's disease to decrease?
Which nutrient should a nurse instruct a client with Crohn's disease to decrease?
Which variable should the nurse include as a risk factor for osteoporosis in older adults?
Which variable should the nurse include as a risk factor for osteoporosis in older adults?
According to Nägele's rule, what is the estimated date of birth for a client with the LMP of May 8?
According to Nägele's rule, what is the estimated date of birth for a client with the LMP of May 8?
Which alteration in speech indicates the client with bipolar disorder is using?
Which alteration in speech indicates the client with bipolar disorder is using?
What task should a nurse delegate to an assistive personnel (AP)?
What task should a nurse delegate to an assistive personnel (AP)?
What action should a nurse take when transferring a stroke patient to a rehabilitation facility?
What action should a nurse take when transferring a stroke patient to a rehabilitation facility?
Which actions should the nurse take when caring for a postpartum client who indicates signs of hemorrhage?
Which actions should the nurse take when caring for a postpartum client who indicates signs of hemorrhage?
The client is at risk for developing ____ due to ____.
The client is at risk for developing ____ due to ____.
Which statement indicates that the family understands home hospice care?
Which statement indicates that the family understands home hospice care?
Which action should the nurse take regarding the continuous passive motion (CPM) machine?
Which action should the nurse take regarding the continuous passive motion (CPM) machine?
What finding should prompt a referral for occupational therapy for a stroke patient?
What finding should prompt a referral for occupational therapy for a stroke patient?
In which situation should the RN intervene when observing an LPN and AP moving a client?
In which situation should the RN intervene when observing an LPN and AP moving a client?
The nurse should first address the client's ____ followed by the client's ____.
The nurse should first address the client's ____ followed by the client's ____.
What should a nurse identify as an adverse effect of epinephrine?
What should a nurse identify as an adverse effect of epinephrine?
Which task should the nurse assign to the member of the group functioning as the orienteer?
Which task should the nurse assign to the member of the group functioning as the orienteer?
What intervention should the nurse include in the care plan for a client with left-sided weakness after a stroke?
What intervention should the nurse include in the care plan for a client with left-sided weakness after a stroke?
What action should the nurse take for a client with immunosuppression and a continuous IV infusion?
What action should the nurse take for a client with immunosuppression and a continuous IV infusion?
Which client should the nurse assess first?
Which client should the nurse assess first?
Match the assessment findings with the appropriate disorder:
Match the assessment findings with the appropriate disorder:
Which statement indicates an understanding of isolation precautions?
Which statement indicates an understanding of isolation precautions?
What isolation precautions should be initiated for a client with pneumonia?
What isolation precautions should be initiated for a client with pneumonia?
Which manifestation of ovarian cancer should the nurse include in teaching?
Which manifestation of ovarian cancer should the nurse include in teaching?
Identify the acid-base imbalance for a client with pH 7.2, PaCO2 60 mm Hg, and HCO3- 25 mEq/L.
Identify the acid-base imbalance for a client with pH 7.2, PaCO2 60 mm Hg, and HCO3- 25 mEq/L.
Which prescription should the nurse clarify for a client with type 1 diabetes and ankle pain?
Which prescription should the nurse clarify for a client with type 1 diabetes and ankle pain?
What action should the nurse take to prevent TB transmission?
What action should the nurse take to prevent TB transmission?
Informed consent promotes which ethical principle?
Informed consent promotes which ethical principle?
Which adverse effect should the nurse monitor for in a client taking valproic acid?
Which adverse effect should the nurse monitor for in a client taking valproic acid?
Which potential provider prescription is anticipated for a client post-stroke?
Which potential provider prescription is anticipated for a client post-stroke?
Calculate the manual IV infusion gtt/min for 1,500 mL at 50 mL/hr using 15 gtt/mL.
Calculate the manual IV infusion gtt/min for 1,500 mL at 50 mL/hr using 15 gtt/mL.
Which statement about basal body temperature method of birth control is true?
Which statement about basal body temperature method of birth control is true?
What action should be included in the care plan for a child with cystic fibrosis?
What action should be included in the care plan for a child with cystic fibrosis?
What finding is expected in a client with pulmonary edema?
What finding is expected in a client with pulmonary edema?
How should the nurse maintain sterile technique during a dressing change?
How should the nurse maintain sterile technique during a dressing change?
What action should the nurse take for a client with rheumatoid arthritis?
What action should the nurse take for a client with rheumatoid arthritis?
In caring for a client with sickle cell disease, which interventions should be implemented? (Select all that apply)
In caring for a client with sickle cell disease, which interventions should be implemented? (Select all that apply)
Which client should the nurse attend to first?
Which client should the nurse attend to first?
For which client should the home health nurse initiate a referral to PACE?
For which client should the home health nurse initiate a referral to PACE?
Why should the nurse turn off the CPM machine during meals?
Why should the nurse turn off the CPM machine during meals?
Which client should the nurse recommend for discharge?
Which client should the nurse recommend for discharge?
Which instructions should the nurse include in the teaching for a child's medication?
Which instructions should the nurse include in the teaching for a child's medication?
What is an indication of potential violence in a client?
What is an indication of potential violence in a client?
Which client should the nurse recommend for treatment first?
Which client should the nurse recommend for treatment first?
When should the nurse initiate a request for a high-frequency chest compression vest?
When should the nurse initiate a request for a high-frequency chest compression vest?
Which client should the nurse intervene to prevent a potential food and medication interaction?
Which client should the nurse intervene to prevent a potential food and medication interaction?
What is a potential adverse effect of PEEP?
What is a potential adverse effect of PEEP?
Why should the nurse assess the amount of vaginal bleeding in a client in the fourth stage of labor?
Why should the nurse assess the amount of vaginal bleeding in a client in the fourth stage of labor?
Which discharge instructions are recommended for a client with hyperemesis gravidarum?
Which discharge instructions are recommended for a client with hyperemesis gravidarum?
What food recommendations should the nurse make for a client taking phenelzine?
What food recommendations should the nurse make for a client taking phenelzine?
What information should the nurse include in the change-of-shift report?
What information should the nurse include in the change-of-shift report?
What is the first action the nurse should take in an emergency situation?
What is the first action the nurse should take in an emergency situation?
What task should the nurse delegate to an assistive personnel (AP)?
What task should the nurse delegate to an assistive personnel (AP)?
What is the priority intervention for a client with a fever and fluid-filled vesicles?
What is the priority intervention for a client with a fever and fluid-filled vesicles?
What is the risk for the client with a history of seizure activity?
What is the risk for the client with a history of seizure activity?
What is the characteristic of a client with borderline personality disorder?
What is the characteristic of a client with borderline personality disorder?
What is the amount of mannitol the nurse should administer?
What is the amount of mannitol the nurse should administer?
Which site should the nurse select for IV access in an older adult client?
Which site should the nurse select for IV access in an older adult client?
What is the nurse's response to the client's statement about their family?
What is the nurse's response to the client's statement about their family?
What is the indication that the medication is effective?
What is the indication that the medication is effective?
What information should the nurse include in the teaching for a client with total parenteral nutrition?
What information should the nurse include in the teaching for a client with total parenteral nutrition?
What should the nurse do in an emergency situation when unable to locate the client's family?
What should the nurse do in an emergency situation when unable to locate the client's family?
Study Notes
Change-of-Shift Report
- Prioritize assessment of postoperative clients with abdominal distention and absent bowel sounds, indicating potential paralytic ileus.
- Stable clients, like those with blood glucose levels of 105 mg/dL, may be assessed later.
ADHD vs Intellectual Disability
- Key indicators for ADHD include hyperreactivity, disorganization (losing items), and interrupting others.
- Intellectual disability may encompass similar deficits, particularly in cognitive function and language skills.
Infection Control Education
- Understanding that airborne precautions must be followed for clients with conditions like tuberculosis requires a negative-pressure room.
- Droplet precautions are necessary for clients with measles or pneumonia, using surgical masks as needed.
Ovarian Cancer Signs
- Abdominal bloating is an early sign of ovarian cancer; other signs include changes in bowel habits and urinary symptoms.
Acid-Base Imbalances
- A pH of 7.2, PaCO2 of 60 mm Hg indicates respiratory acidosis, necessitating recognition of these abnormalities in acid-base balance.
Type 1 Diabetes Management Post-Injury
- Cold therapy is contraindicated in clients with diabetes due to impaired circulation risks.
- Regular neurovascular checks and blood glucose monitoring are critical after injuries.
Tuberculosis Precautions
- Clients with active TB should wear masks when outside their rooms to minimize transmission risks to others.
Informed Consent and Ethics
- Informed consent promotes client autonomy, giving them the right to make informed decisions regarding their treatment plans.
Valproic Acid Adverse Effects
- Monitor for signs of jaundice as a potential indicator of liver damage in clients taking valproic acid for seizures.
Neurological Assessment and Care
- Anticipate monitoring oxygen saturation and blood glucose levels in patients exhibiting signs of increased intracranial pressure.
- Cluster nursing care is contraindicated due to risks of exacerbating increased ICP.
IV Infusion Calculations
- Calculate and set IV drip rates accurately, ensuring proper adjustments for patient needs.
Basal Body Temperature Method
- Educate clients that body temperature may drop slightly before ovulation, assisting them in tracking fertility cycles.
Cystic Fibrosis Care
- High-dose antibiotics are essential due to the metabolic needs of children with cystic fibrosis facing infections.
Recognizing Pulmonary Edema
- Expect pink, frothy sputum in clients with pulmonary edema due to fluid accumulation in the lungs.
Maintaining Sterile Technique
- Keep sterile items within the direct line of vision to uphold aseptic conditions during procedures.
Rheumatoid Arthritis Pain Management
- Encourage rest periods interspersed with activity to manage joint pain effectively in rheumatoid arthritis clients.
Sickle Cell Crisis Management
- Administer IV fluids rapidly to alleviate crisis symptoms and utilize humidification with oxygen therapy to ensure comfort.
Client Prioritization in Nursing
- Address safety concerns first, prioritizing clients who are anxious and attempting to remove IV lines.
Referral to PACE Program
- Initiate PACE referrals for older adults needing adult day care services, which align with comprehensive elder care objectives.
Captopril Adverse Effects
- A persistent cough is a significant side effect of captopril that requires communication to the healthcare provider.
Crutch Training for Fracture Management
- Instruct clients to use a three-point crutch gait to ensure mobility without pressure on the injured limb.
Postoperative Care Priorities
- Encourage deep breathing exercises post-abdominal surgery to prevent complications such as pneumonia and promote lung expansion.### Postoperative Care
- Deep breathing and coughing exercises reduce the risk of postoperative pneumonia.
- Key assessments post laparoscopic cholecystectomy include alertness, incision site status, and auscultation of lung sounds.
- Dressings should be clean, dry, and intact; change when soiled.
- Educate on symptoms to report: swelling, redness, drainage, or warmth at the incision site.
Provider Prescriptions
- Apply heat for abdominal pain related to carbon dioxide retention.
- Encourage deep breathing exercises hourly to aid recovery.
- Ondansetron for nausea should be provided as needed, not on a scheduled basis.
Advance Directives Education
- Client can designate a partner as their health care surrogate, showcasing understanding of advance directives.
- Younger clients may underestimate the importance of planning for future health care.
Postoperative Laryngectomy Care
- Assess reading skills first to tailor communication methods for a patient unable to speak after a laryngectomy.
Risk Assessment Post Thyroidectomy
- Watch for hypocalcemia indicated by muscle cramps and numbness around the lips following thyroid surgery.
- Immediate treatment with calcium gluconate required to prevent complications.
Altruism in Cancer Care
- Proactive behavior, such as starting a community support group, illustrates altruism in patients coping with breast cancer.
Pediatric Assessment Prioritization
- Sudden relief of pain in a child awaiting appendectomy can signal a serious condition like peritonitis; assess this patient first.
Suspected Child Abuse Protocol
- Legally required to report suspected physical abuse to Child Protective Services—do not confront the parents directly.
Intramuscular Injection Guidelines
- Opt for the ventrogluteal site for IM injections in obese clients, as it avoids large nerves and vessels.
Indicators of Thyroid Storm
- Monitor for increased temperature, heart rate, blood pressure changes, and alterations in mental status after thyroid surgery.
New Nurse Performance Evaluation
- Interventions needed when a new nurse starts a task without adequate preparation, compromising time management.
Adverse Effects of Amitriptyline
- Blurred vision should be monitored as an adverse effect of amitriptyline.
Asthma Management Education
- Ensure annual influenza vaccination to reduce infection risk in children with asthma.
Autism Spectrum Disorder Characteristics
- Expect strict adherence to routines and rituals in children on the autism spectrum.
Tuberculosis Infection Control
- Assign clients with active pulmonary tuberculosis to a private room with negative air pressure to prevent disease transmission.
Pregnancy-Related Risks
- Monitor for metabolic acidosis in pregnant clients experiencing significant weight loss and inadequate nutritional intake.
Common Pregnancy Discomforts
- Wearing a supportive bra overnight can alleviate discomfort associated with breast changes during pregnancy.
Intestinal Obstruction Identification
- Signs include abdominal distension, hypoactive bowel sounds, and prolonged absence of bowel movements; requires IV fluids and semi-Fowler's positioning for relief.### Bowel Sounds and Urine Output Monitoring
- Assess bowel sounds a minimum of twice daily to check for peristalsis return.
- Monitor urine output closely in clients receiving IV fluids.
- Dehydration is a key manifestation of intestinal obstruction.
Hip Joint Abduction
- Hip joint abduction occurs when the leg moves away from the body's midline during assessment.
Chemotherapy and Neutropenia Care
- Exclude raw fruits and vegetables from the client's diet to minimize bacterial infection risk.
- Limit visits from young children to reduce exposure risk.
- Measure client’s temperature per shift.
Ibuprofen Adverse Effects
- Assess for stomach pain or bloody stools to identify potential gastrointestinal bleeding caused by ibuprofen.
Postoperative Risk Assessment
- Client post CABG at risk for dysrhythmias due to hypokalemia evidenced by lab results showing low potassium levels and muscle cramping.
- Monitor electrolyte levels closely following CABG surgery.
Ginger Tea Effectiveness
- A decrease in episodes of nausea indicates the effectiveness of ginger tea in pregnant clients.
Effectiveness of Packed RBC Therapy
- A hemoglobin level of 14.9 g/dL indicates that packed RBC therapy was successful in elevating low hemoglobin.
Osteoporosis Risk Factors
- Sedentary lifestyle recognized as a significant risk factor for osteoporosis; encourage weight-bearing exercises in older adults.
Alterations in Speech in Bipolar Disorder
- Flight of ideas is characterized by continuous speech with rapid and frequent topic switching.
Neuroleptic Malignant Syndrome Management
- Conditions likely indicating neuroleptic malignant syndrome include muscle rigidity, diaphoresis, and altered vital signs.
- Hold antipsychotic medications and provide cooling interventions; monitor hydration status and temperature.
Intracranial Pressure Mitigation
- Keeping the client's environment quiet helps reduce the risk of increased intracranial pressure.
Hospice Care Understanding
- Expect ongoing support from hospice services post-death; importance of bereavement care.
Advocacy in Nursing
- Advocacy empowers clients to self-actualize; view it as a leadership role encouraging personal growth.
Postpartum Hemorrhage Interventions
- Immediate actions include massaging the uterine fundus, administering methylergonovine, weighing perineal pads, providing emotional support, and administering oxygen.
Continuous Passive Motion Machine Use
- The CPM machine should be switched off during meal times to enhance comfort while eating.
Client Discharge Decisions
- Clients receiving oral antibiotics for cellulitis can be safely discharged, whereas others may need continued hospital care.
Discharge Instructions for Amoxicillin/Clavulanate
- Shake the medication well before administering, store it in the refrigerator, and report diarrhea to the provider.
Monitoring for Violence in Mental Health
- Pacing around a partner during a visit can indicate potential for violent behavior; closer assessment and de-escalation are needed.
Triage Prioritization in Emergency
- Clients with unstable vital signs require immediate treatment due to the risk of severe complications or death.
Cystic Fibrosis and Airway Clearance
- Recommend a high-frequency chest compression vest for children who achieve inadequate results with standard therapies.
Preventing Food and Medication Interactions
- Clients on MAOIs should avoid tyramine-rich foods like cheeseburgers to prevent hypertensive crises.
Adverse Effects of PEEP
- Tension pneumothorax is a potential adverse effect of positive end-expiratory pressure (PEEP); monitoring lung sounds for warning signs is crucial.
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Description
This quiz assesses nursing knowledge on postoperative care, ADHD and intellectual disability, infection control, ovarian cancer signs, and acid-base imbalances.
