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Questions and Answers

Which actions should the nurse take for a client experiencing a postpartum hemorrhage? (Select all that apply)

Administer methylergonovine (correct)

Provide emotional support (correct)

Administer oxygen at 12 L/min via nonrebreather face mask (correct)

Firmly massage the uterine fundus (correct)

Weigh the perineal pads (correct)

Insert an indwelling urinary catheter (correct)

Which data collection findings should the nurse report to the provider prior to surgery? (Select all that apply)

Allergy (correct)

Blood pressure

Hemoglobin level (correct)

Family history of malignant hyperthermia (correct)

To which interprofessional team member should the nurse refer a client who is experiencing difficulty using eating utensils?

Occupational therapist

Which client condition should be reported to a regulatory agency?

A client who is newly diagnosed with tuberculosis Signup and view all the answers

What should the nurse include with the discharge report for a client recovering from a cerebrovascular accident?

List of potential complications to report Signup and view all the answers

What statement by the parent indicates an understanding of teaching about lactose intolerance?

I should offer my child yogurt that has a probiotic as a snack. Signup and view all the answers

What indicates that a client understands the teaching about managing type 1 diabetes?

I should check my blood sugar if my appetite is decreased. Signup and view all the answers

What finding should the nurse expect in a client with iron deficiency anemia?

Difficulty concentrating Signup and view all the answers

Which immunization is contraindicated for an immunocompromised client?

Measles, mumps, and rubella (MMR) Signup and view all the answers

What method should the nurse use when communicating with a client who has expressive aphasia?

Provide a picture board. Signup and view all the answers

What action should the nurse take after accidentally brushing the needle on the counter's surface?

Prepare a new dose of insulin for injection. Signup and view all the answers

Which technique should the nurse use to elicit the Babinski reflex in a newborn?

Stroke the sole of the newborn's foot upward and toward the great toe. Signup and view all the answers

What should the nurse do first when a client questions an unfamiliar medication?

Verify the prescription in the client's medical record. Signup and view all the answers

What therapeutic response should the nurse make to a client accusing them of stealing?

Tell me how you decided who took your money. Signup and view all the answers

What instruction should the nurse give about safe lifting technique?

You should hold a box close to your body when lifting it up. Signup and view all the answers

What infection control precautions should be instructed for a client with hepatitis A?

Contact Signup and view all the answers

What finding should the nurse expect in a client who has multiple sclerosis?

Ataxia Signup and view all the answers

What response should the nurse provide to a client stressed about a tumor diagnosis?

What have you done to help yourself get through stressful situations before? Signup and view all the answers

What factor should the nurse consider when using the FLACC scale for an infant's pain level?

Level of activity Signup and view all the answers

What manifestation indicates increased intracranial pressure in a school-age child?

Confusion about knowing their own name Signup and view all the answers

What position should the nurse place a client undergoing thoracentesis?

Upright with arms resting on the overbed table Signup and view all the answers

What statement indicates understanding of the DASH diet?

I will keep my intake of sodium less than 2,300 milligrams per day. Signup and view all the answers

What action should the nurse take for a client in labor with spontaneous rupture of membranes?

Apply the external fetal heart rate monitor. Signup and view all the answers

What information should the nurse share about puberty with prepubescent female clients?

You will likely gain weight before you start to get taller. Signup and view all the answers

What priority action should the nurse take for a client experiencing a situational crisis?

Determine if the client is experiencing psychotic thinking. Signup and view all the answers

When bottle feeding a newborn with formula, how often should the newborn be fed?

Feed the newborn at least every 3 to 4 hr. Signup and view all the answers

Which food contains the highest amount of protein that the nurse should recommend for a client with HIV?

1 Tbsp peanut butter Signup and view all the answers

What statement indicates effective coping by a family of a client with terminal cancer?

Dad, I remember the time we all went fishing at the lake. Signup and view all the answers

What action should the nurse take for a terminally ill client practicing Orthodox Judaism?

Assure the client that a family member will stay with the body after death. Signup and view all the answers

Which strategies should be included for managing pediculosis capitis? (Select all that apply)

Dry bed linens and clothing in a hot dryer for at least 20 min. Signup and view all the answers

What adverse effect should the nurse monitor in a client postoperative following a cholecystectomy after receiving morphine?

Respiratory rate 10/min Signup and view all the answers

What laboratory result should the nurse report before administering gentamicin?

Creatinine 2.5 mg/dL (0.5 to 1.1 mg/dL) Signup and view all the answers

What snack should the nurse offer to an older adult client experiencing difficulty sleeping?

Whole grain crackers Signup and view all the answers

What instruction should the nurse give a client about self-administering epoetin alfa?

Administer the medication subcutaneously. Signup and view all the answers

Which client should the LPN ask to have reassigned to an RN?

A client who has a new colostomy and requires the development of a teaching plan. Signup and view all the answers

What communication technique lets the client know that their concerns and feelings are heard?

Active listening Signup and view all the answers

What should the nurse maintain to keep the urine diluted to a reddish-pink color after a transurethral resection of the prostate (TURP)?

Drainage flow rate Signup and view all the answers

Which action by a newly licensed nurse demonstrates sterile technique when applying sterile gloves?

Puts a glove on their dominant hand first Signup and view all the answers

What is a recommended choice for reducing solid fat consumption?

Purchase beef that is a loin cut Signup and view all the answers

What task should the charge nurse delegate to the LPN regarding a stroke patient?

Administering an initial NG tube feeding Signup and view all the answers

What statement indicates possible financial maltreatment?

"My child took my wallet so they can keep track of what I'm spending." Signup and view all the answers

What diagnostic test should a nurse expect for a client with symptoms of bacterial meningitis?

Cerebrospinal fluid analysis Signup and view all the answers

What are advance directives?

Written instructions regarding end-of-life care Signup and view all the answers

What should be done when washing hands with soap and water?

Remove rings Signup and view all the answers

What statement by a client indicates a delusion?

"My doctor's glasses have lasers that will burn holes in my brain if I look at them." Signup and view all the answers

What position should a nurse keep a client in after a tonic-clonic seizure?

Side-lying position Signup and view all the answers

What is the first action a nurse should take for a client after a bronchoscopy?

Check for a gag reflex Signup and view all the answers

What position should a client be assisted into for a lumbar puncture?

Lateral recumbent Signup and view all the answers

What type of precautions should a nurse initiate for a client with rubeola?

Airborne Signup and view all the answers

What finding indicates digoxin has been effective in a client with heart failure?

Cardiac workload decreases Signup and view all the answers

What urine specific gravity should a nurse expect from a client with diabetes insipidus?

1.002 Signup and view all the answers

What should a nurse instruct a client to do during a 12-lead ECG?

Remain still Signup and view all the answers

What is the appropriate method for inserting a rectal suppository in a school-age child?

Use one finger to insert it past the anal sphincters Signup and view all the answers

What heart rate finding should the nurse report to the provider for a preschooler?

146/min Signup and view all the answers

What statement indicates a client understands the use of an ipratropium inhaler?

I should wait 1 minute before taking a second puff. Signup and view all the answers

What finding should a nurse report when inspecting a newborn's skin?

Generalized petechiae Signup and view all the answers

What equipment should be placed in a client's room who has a history of seizures?

Suction catheter Signup and view all the answers

What position should a chest tube drainage system be in relative to the client's chest?

Below the level of the client's chest Signup and view all the answers

What factor increases a person's risk of experiencing partner violence?

Threats to leave the relationship Signup and view all the answers

What is a recommended strategy for managing anxiety?

Say the word 'stop' when upsetting thoughts occur Signup and view all the answers

What is a common adverse effect following a lumbar puncture?

Headache Signup and view all the answers

What question should a nurse ask first when a client is in severe pain?

"Where is your pain located?" Signup and view all the answers

What medication should be readily available for a postpartum client with a deep-vein thrombosis?

Protamine sulfate Signup and view all the answers

What is an example of assault in a healthcare setting?

Informing a client of an injection despite their refusal Signup and view all the answers

What priority finding should be reported for a school-age child with cystic fibrosis?

Lack of appetite Signup and view all the answers

When transferring a client with right-sided weakness to a wheelchair, where should the nurse place the wheelchair?

On the client's left side Signup and view all the answers

What therapeutic effect should a nurse teach about low-dose aspirin in a client with coronary artery disease?

Antiplatelet Signup and view all the answers

Which raw food contains the highest amount of water per 1 cup serving?

Cherry tomatoes Signup and view all the answers

What statement should the nurse make regarding fat intake for weight loss?

Keep fat intake to no more than 30 percent of your daily caloric intake. Signup and view all the answers

What type of client should a nurse recommend for discharge during a natural disaster situation?

A client who has pneumonia and is currently receiving oral antibiotics. Signup and view all the answers

What should a nurse provide to a client scheduled for a nonstress test (NST)?

A handheld event marker to record fetal activity Signup and view all the answers

An LPN is allowed to reinforce teaching once the plan has been established.

True Signup and view all the answers

What should a nurse tell a client with type 2 diabetes about weight gain during pregnancy?

Your weight gain should be the same as for someone without diabetes. Signup and view all the answers

What action should a nurse take with a client who has Alzheimer's disease?

Encourage the client to reminisce about the past. Signup and view all the answers

What information should be included in a weekly nursing care summary for an older adult client?

Hydration status Signup and view all the answers

What indicates a client's understanding of taking ferrous sulfate elixir?

I will rinse my mouth after taking this medication. Signup and view all the answers

What should the charge nurse do regarding an assistive personnel's repeated failure to provide oral care?

Discuss this behavior with the AP while reinforcing expectations. Signup and view all the answers

What is the first step a nurse should take for a child with a minor burn?

Clean the burn with mild soap and tepid water. Signup and view all the answers

What intervention should be included in the care plan for a client following a TURP?

Irrigate the bladder using sterile technique. Signup and view all the answers

What should the nurse advise regarding a newborn's crib placement?

Place it away from heat vents. Signup and view all the answers

What should a client with tuberculosis understand about the people they live with?

The people I live with should be tested for TB. Signup and view all the answers

Which client should the nurse recommend for treatment first?

A client who is experiencing shortness of breath after taking amoxicillin. Signup and view all the answers

What should a nurse do when performing postmortem care for a client?

Gently close the client's eyelids. Signup and view all the answers

What should a nurse do for a client with viral meningitis?

Place the client in a private room. Signup and view all the answers

What instruction should be given to a client with severe left-sided heart failure?

Rest for 15 minutes between activities. Signup and view all the answers

Which over-the-counter medication should a client taking captopril avoid?

Ibuprofen Signup and view all the answers

What ECG finding should the nurse report for telemetry monitoring?

PR interval 0.24 seconds Signup and view all the answers

What finding indicates a urinary tract infection?

Presence of dysuria Signup and view all the answers

Which urinalysis results indicate follow-up for a urinary tract infection?

Positive leukocyte esterase Signup and view all the answers

What is a leading cause of urosepsis in a client with a history of catheterization?

Prior catheterization Signup and view all the answers

What advice should a nurse give to prevent urinary tract infections?

Clean the perineum from back to front. Signup and view all the answers

What prescriptions should the nurse anticipate for a client with a urinary tract infection?

Phenazopyridine 200mg PO three times daily. Signup and view all the answers

What findings indicate treatment has been effective for a urinary tract infection?

Client drinks 1.5 L of water daily. Signup and view all the answers

What should a nurse document if a patient doesn't meet critical pathway goals?

Document the findings as a variance. Signup and view all the answers

What adventitious lung sound should a nurse document when hearing a high-pitched, crowing sound?

Stridor Signup and view all the answers

Where should a nurse look to find information about a client's personal health insurance?

Admission sheet. Signup and view all the answers

What should a nurse say to prepare a preschooler for an IM immunization?

Let's give the medicine to your doll first. Signup and view all the answers

Which client should a nurse see first?

A client who has pneumonia and a new onset of confusion. Signup and view all the answers

The nurse will administer _____ mL of amoxicillin for each dose if the prescription is 875 mg PO every 12 hr.

11 Signup and view all the answers

What component of a Tourette syndrome prescription should the nurse question?

Dosage Signup and view all the answers

What action indicates a client understands how to use an incentive spirometer?

The client attempts to elevate the cylinder by inhaling deeply. Signup and view all the answers

What is the nurse's response to a client doubting surgery will help?

You're saying that you are doubtful that this procedure will benefit you. Signup and view all the answers

Study Notes

Postpartum Care and Hemorrhage

Large amounts of lochia rubra and a boggy fundus indicate possible postpartum hemorrhage.
Actions for nurse: massage the uterine fundus, administer methylergonovine, weigh perineal pads, provide emotional support, insert urinary catheter, and administer oxygen at 12 L/min via nonrebreather mask.
Immediate intervention is crucial to prevent hemorrhagic shock.

Preoperative Considerations

Important data to report prior to surgery includes hemoglobin level, any allergies (especially latex), and family history of malignant hyperthermia.
Hemoglobin levels below normal might necessitate blood products during surgery.
All latex products must be removed if the client has a latex allergy.

Interprofessional Referrals

Clients with difficulty using eating utensils post-stroke require a referral to an occupational therapist for adaptive strategies.

Reportable Conditions

Tuberculosis is a communicable disease that must be reported to local health authorities.

Discharge Instructions

Include a list of potential complications in discharge instructions for safe home care post-cerebrovascular accident.

Lactose Intolerance

Probiotic-rich yogurt is beneficial for children with lactose intolerance, aiding in lactose digestion.

Diabetes Management

Clients with type 1 diabetes must check blood sugar levels during decreased appetite to prevent hyperglycemia.

Anemia Symptoms

Difficulty concentrating is a common finding in clients with iron deficiency anemia due to impaired oxygen delivery caused by low hemoglobin levels.

Immunization Guidelines

The MMR vaccine is contraindicated for immunocompromised clients due to the live virus.

Communication Techniques

For clients with expressive aphasia, using a picture board aids communication by providing a non-verbal means to express needs.

Medication Preparation

If a needle touches an unsterile surface, a new dose of insulin must be prepared to ensure sterility.

Reflex Testing in Infants

Elicit the Babinski reflex by stroking the sole of the newborn's foot upward towards the great toe.

Medication Queries

Always verify medication prescriptions in the client's medical record when there is uncertainty about a drug's identification.

Therapeutic Communication

Encourage the client to discuss their feelings and perceptions regarding accusations, validating their concerns.

Safe Lifting Techniques

Advise clients to hold objects close to their body to prevent injury while lifting.

Infection Control

Use contact precautions for clients with hepatitis A who are incontinent of stool.

Multiple Sclerosis Expectations

Expect ataxia in clients with multiple sclerosis, alongside other symptoms like fatigue and memory issues.

Coping with Grief

Reminiscing about positive past experiences can aid family members in coping with terminal illness.

Orthodox Jewish Practices

Ensure that a family member will remain with the deceased until burial, respecting cultural and religious practices.

Pediculosis Capitis Management

Effective strategies include storing clothing separately at school, boiling combs for sanitation, and drying linens at high temperatures.

Postoperative Monitoring

A respiratory rate of 10/min indicates respiratory depression, a potential adverse effect of morphine administration.

Renal Function Monitoring

Report a creatinine level of 2.5 mg/dL prior to gentamicin administration due to nephrotoxicity risks.

Sleep Disturbances in Older Adults

Offer carbohydrate-rich snacks like whole grain crackers before bedtime to promote better sleep.

Epoetin Alfa Administration

Reinforce that epoetin alfa should be self-administered via the subcutaneous route.

Scope of Practice for Nursing Staff

LPNs should not develop teaching plans, such actions should be reassigned to registered nurses.

Weight Gain during Pregnancy

Advise clients with diabetes that recommended weight gain during pregnancy remains the same as for clients without diabetes.

Alzheimer's Disease Care

Facilitating reminiscence about the past can help clients with Alzheimer's cope with memory loss.

Weekly Nursing Care Summary

Hydration status should be closely monitored and documented in older adults to prevent dehydration.

Iron Supplement Instructions

Patients taking ferrous sulfate should be instructed to rinse their mouth after dosage to prevent staining.### Charge Nurse Responsibilities
Discuss inappropriate actions with the assistive personnel (AP) and clarify care expectations.
Evaluate AP performance as part of the nurse's delegation responsibilities.
Teaching and counseling are crucial in nursing leadership.

Pediatric Burn Care

First step: clean the burn with mild soap and tepid water to eliminate possible infectious material.
Remove embedded debris to prevent infection and promote healing.
Apply antimicrobial ointment to minimize infection risk.
Cover with a gauze dressing to keep the area protected.
Educate parents about the dressing change schedule post-discharge.

TURP Care

Irrigate the bladder with sterile technique to lower infection risk post-transurethral resection of the prostate (TURP).

Newborn Safety Instructions

Place the baby’s crib away from heat sources to prevent risks like fire and strangulation.

Tuberculosis Understanding

Family members should be tested for tuberculosis due to its contagious nature.

Prioritizing Treatments in Urgent Care

Immediate treatment is required for clients experiencing shortness of breath, potentially indicating anaphylaxis after amoxicillin intake.

Postmortem Care

Ensure the client’s eyelids are gently closed for proper presentation to family members.

Isolation for Viral Meningitis

Place clients with viral meningitis in private rooms to limit viral transmission.

Heart Failure Patient Education

Advise clients with severe heart failure to rest for 15 minutes between activities to manage fatigue.

Hypertension Medication Guidance

Instruct clients on captopril to avoid ibuprofen as it diminishes the medication's effectiveness.

ECG Interpretation

A PR interval of 0.24 seconds indicates a heart block and should be reported to the provider.

Urinary Tract Infection Indicators

Symptoms indicating a UTI include frequency, dysuria, and urgency.

Urinalysis Follow-Up

Positive nitrites, leukocyte esterase, WBC, and RBC in urinalysis results suggest a UTI and require follow-up.

Urosepsis Risk Factors

Prior catheterization increases the risk of developing urosepsis.

Preventing Future UTIs

Advise clients to avoid irritants like coffee and alcohol and suggest showering instead of bathing to limit bacteria exposure.
Emphasize proper perineal hygiene and regular voiding to prevent bladder distention.

Expected Prescriptions for UTI Treatment

Anticipate prescriptions for phenazopyridine and sulfamethoxazole, along with a urine culture and sensitivity test.

Signs of Effective UTI Treatment

Effective treatment indicated by reports of discomfort-free urination and clear urine.

Postoperative Monitoring

Document any variances in vital signs and patient status that deviate from the critical pathway guidelines.

Stridor Identification

High-pitched crowing sound during inhalation should be noted as stridor in lung assessments.

Health Insurance Information Location

The client's admission sheet contains details about personal health insurance.

Pediatric Injection Preparation

Use play therapy when preparing preschoolers for procedures to reduce anxiety.

Client Prioritization in Care Settings

Attend to clients with pneumonia showing confusion first due to the potential decrease in oxygenation.

Medication Dosage Calculation

For amoxicillin 875 mg, the administration amount is 11 mL based on provided concentrations.

Medication Dosage Confirmation

Query the dosage strength and amount prescribed for haloperidol to ensure accurate medication reconciliation.

Incentive Spirometer Use

Correct use involves inhaling deeply to elevate the cylinder of the spirometer.

Addressing Client Concerns

Reflecting doubt about surgical benefits acknowledges client feelings and promotes therapeutic communication.

Continuous Bladder Irrigation Protocol

Maintain the irrigation flow rate to ensure urine remains a diluted reddish-pink color to monitor for bleeding/clots.

Sterile Technique in Gloving

Donning the glove on the dominant hand first is essential for maintaining sterile technique during procedures.

Reducing Solid Fat in Diet

Instruct clients to choose loin cuts of beef to minimize saturated fats in their diet.

Assigning Tasks to LPN

Administering initial NG tube feeding is within the LPN’s scope and should be reassigned from assistive personnel.

Identifying Possible Financial Maltreatment

Recognizing control over a client's finances indicates potential financial abuse and warrants further investigation.

Diagnostic Tests for Meningitis

Expect cerebrospinal fluid analysis for clients exhibiting signs of bacterial meningitis.

Advance Directives Explanation

Advance directives serve as written instructions for end-of-life care when the client can no longer make decisions.

Hand Hygiene Guidelines

Emphasize the importance of removing rings during handwashing for effective hygiene practices.### Schizophrenia
Delusion of persecution: Belief that harm is intended by others using unrealistic means, exemplified by the statement about lasers in glasses.

Seizure Management

Post-ictal care: After a tonic-clonic seizure, keep the client in a side-lying position to allow secretions to drain and prevent aspiration.

Bronchoscopy Aftercare

First priority: Check for the client's gag reflex to minimize the risk of aspiration post-bronchoscopy.

Lumbar Puncture Positioning

Positioning: Assist the client into the lateral recumbent position for optimal needle placement during lumbar puncture.

Rubeola Precautions

Airborne transmission: Implement airborne precautions, including a private room with negative-pressure airflow and N95 respirators for healthcare workers.

Heart Failure Treatment

Effectiveness of digoxin: A decrease in cardiac workload signifies the medication's effectiveness by improving heart conduction and reducing oxygen demand.

Diabetes Insipidus

Expected urinary findings: Anticipate urine specific gravity of 1.002 or lower, with a typical presentation of colorless urine.

ECG Procedure

Client instructions: Advise the client to remain still during a 12-lead ECG to avoid inaccuracies due to motion artifacts.

Pediatric Suppository Administration

Technique for insertion: Use a single finger to insert the rectal suppository past the anal sphincters for proper administration.

Pediatric Heart Rate Monitoring

Reporting vital signs: A heart rate of 146/min in preschoolers exceeds normal limits and requires reporting to the provider.

Asthma Inhaler Use

Ipratropium inhaler instructions: Instruct the client to wait 1 minute between puffs to allow for better medication absorption.

Newborn Skin Assessment

Petechiae significance: Generalized petechiae on a newborn can indicate serious conditions like infection or low platelet count, warranting provider notification.

Seizure Preparedness

Equipment necessity: Ensure suction catheters are available in the room for a client with a history of seizures to manage oral secretions and maintain airway patency.

Chest Tube Care

Drainage system maintenance: Keep the closed drainage system below the client's chest level to prevent backflow of secretions.

Partner Violence Education

Risk factors: Threats to leave a relationship may increase the risk of experiencing partner violence, as it undermines the perpetrator's control.

Anxiety Management

Behavioral technique: Teach clients with generalized anxiety disorder about 'thought stopping' to manage anxiety during distressing thoughts.

Lumbar Puncture Monitoring

Adverse effect observations: Monitor for headaches after a lumbar puncture, and address with prescribed pain medication and hydration.

Pain Assessment

First question for pain management: Ask "Where is your pain located?" to prioritize effective assessment and pain relief measures.

Postpartum Care and DVT

Antidote availability: Have protamine sulfate readily available to reverse heparin's effects in a postpartum client with a deep vein thrombosis.

Legal Issues in Nursing

Assault example: Threatening to administer an injection against a client's refusal constitutes assault and violates patient rights.

Cystic Fibrosis Assessment

Appetite as a concern: A lack of appetite in children with cystic fibrosis signals potential risk for pulmonary infection and requires provider notification.

Patient Transfer Techniques

Transfer safety: Position the wheelchair on the client's stronger side during transfer to minimize falling risks.

Coronary Artery Disease Medication

Aspirin’s action: Low-dose aspirin acts as an antiplatelet agent, inhibiting platelet aggregation to reduce thrombotic events in CAD patients.

Nutritional Guidance

Water-rich foods: Suggest cherry tomatoes as they contain 141 g of water per cup, making them excellent for hydration in fluid volume deficit.

Weight Management Advice

Dietary fat limit: Recommend keeping fat intake below 30% of daily caloric intake to aid in weight loss efforts due to the higher calorie density of fats.

Disaster Response in Healthcare

Discharge recommendations: A client with pneumonia on oral antibiotics may be safely discharged during a natural disaster, freeing up resources for new admissions.

Nonstress Test Procedure

Client involvement: Provide a handheld event marker for the client to document fetal movements during a nonstress test, facilitating better fetal monitoring.

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