NUR 1234 HESI MED SURG REVIEW QUESTIONS AND ANSWERS SATISFACTION GUARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+

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NUR 1234 HESI MED SURG REVIEW |NUR1234 HESI MED SURG REVIEW HESI MED SURG REVIEW • An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night... to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake • An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. blood ph of 7.30 b. glucose of 350 mg /dl c. white blood cell count of 15000mm d. potassium of 2.5 meq/l • A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f • An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma • A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a. collect a clean catch specimen b. palpate the suprapubic region c. instruct to wipe from front to back d. inquire about recent sexual activity • A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a. offer the client reassurance that this information indicates that the clients cancer cells are benign b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client in the healthcare provider has giving her any information about the classification of her cancer d. help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly • A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first? a. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5%albumin IV • A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr? =9 • The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis? a. upper mid abdominal gnawing and burning pain b. severe abdominal cramps and diarrhea after eating spicy foods c. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion • The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. the xenograft is taken from nonhuman sources b. grafting increases the risk for bacterial infection c. as the burn heals the graft permanently attaches d. grafts are later removed by debriding procedure • A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss • During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited • When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate • A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants • A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg • After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take? a. obtain stool specimen to evaluate for occult blood and fat content b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days d. advice the client to stop taking the drug and contact the healthcare provider • Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies ( POSSIBLE ANSWER TOO) d. obtain samples for complete blood count and cultures • A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain • A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the client’s central venous catheter. When the client’s respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) (POSSIBLE ANSWER) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload • When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch • A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nitroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute • An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? a. BUN creatinine specific gravity b. White blood count, hemoglobin hematocrit c. PH,PCO2, HC03 d. LDH OR LD, SGOT OR ALT, SGPT OR AST • An elderly post-operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone? a. her respiratory rate is 7 breath/minute b. she indicates that she feels as if she cannot get enough air to breath c. she has intercostal retractions and bilateral wheezing is auscultated d. her pulse oximeter is 89% on room air • Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention? a. urinary output equal to intake b. no terminal urinary dribbling c. denies stress incontinence d. absence of xerostomia • Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)? a. Lorazepam (Ativan) 2mg IM b. Chlorpromazine (thorazine) 50 mg IM c. Prochlorperazine (Compazine) 5 mg IM d. Hydromorphone (Dilaudid) 2 mg IM • Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? a. call the healthcare provider f you develop gynecomastia b. Take the medication in the morning c. Avoid caffeine and smoking d. Increase your consumption of bananas and oranges • A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon? a. after meals to increase endogenous insulin secretion b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur d. when unable to eat during sick days • A client with hyperthyroidism is being treated with radioactive iodine (I- 131). Which explanation should be included in preparing this client for this treatment? a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately • A female client is being treated for tuberculosis with rifampin (rifadin) which statement indicates that further teaching is needed? a. I will take my usual contraceptive for birth control • A client is discharged with a prescription for warfarin (Coumadin). What discharge instructions should the nurse emphasize to the client? a. take a multi vitamin supplement daily b. use an astringent for superficial bleeding c. avoid going barefoot especially outside d. include large amounts of spinach in the diet • In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasal which serum lab test is most important for the nurse to monitor? a. osmolality b. calcium c. platelets d. glucose • After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame? a. 2 hours b. 5 minutes c. 1 hour d. 15 minutes • A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain? a. capillary refill b. body temperature c. muscle strength d. breath sounds • A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field ( possible answer) c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision • What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. Sexual activities may be resumed upon return home b. Light housekeeping is permitted but avoid heavy lifting c. Use a metal eye shield on operative eye during the day d. Administer eye ointment before applying eye drops • A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound • A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. toasted wheat bread and jelly b. cheese and crackers c. cold cereal with skim milk d. fruit flavored yogurt • The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? a. Facilitates transport of glucose into the cell b. Increases intracellular receptor site sensitivity c. Stimulates function of beta cells in the pancreas d. Delays carbohydrates digestion and absorption • The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription? a. Eszoplicone (Lunesta)10 mg orally at bed time b. Zolpidem 10 mg orally at bed time c. Temazepan orally at bed time d. Ramelteon orally at bedtime • A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the client’s statement what nursing action is most important for the nurse to take? a. Encourage the client to take medication with food to decrease GI distress b. Advice the client that the medication should be stopped gradually rather than abruptly. c. Review the clients dosing schedule to ensure he is taking the prescribed amount d. Assess the client for other indication of adverse effects of corticosteroid • Fifteen minutes after receiving sulfa athenozole. A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement? a. Auscultate lung sounds for wheezing b. Review the clients list if drugs allergies c. Add sulfamethinozole to clients allergies d. Check neurological vital signs • Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients? a. stop taking prescribed antibiotics when symptoms decrease b. avoid using antibiotics when suffering from colds or the flu c. ask the healthcare provider to prescribe the newest antibiotic when needed d. request a prescription for first time vancomysin for a sore throat • A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide? a. Advise the client once symptoms occur is too late to receive an influenza vaccination b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza d. Instruct the client that over the counter medications are sufficient to manage influenza symptoms • Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement? a. stop medication infusion and notify the healthcare provider of the adverse effect b. increase the rate of the infusion to complete the dose of the medication more rapidly c. continue the infusion and administer a prn antiemetic prescription d. reassure the client that the nausea is not related to the iv infusion • The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimer’s disease as an intervention for which client problem? a. fluid volume excess b. disturbed thought processes c. chronic pain d. altered breathing patterns • To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse? a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) b. Hematocrit 45% c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) d. Platelet count of 100,000/mm3 or 100x10??/ L (SI) • A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral hypoglycemic agent. The primary health care provider prescribes ad additional medication injected exenatide (byetta). Which information is most important for the nurse to teach this client? a. Administer subcutaneously after meals b. Consume additional sources of potassium c. Notify the healthcare provider if anorexia occurs d. Watch for signs of jitteriness or diaphoresis ( POSSIBLE ANSWER) • A client is who is diagnose with schizophrenia receives a prescription for an atypical antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical antipsychotic agents? a. observe the client hallucinatory behaviors b. obtain the client finger stick glucose levels c. measure the clients lying and standing blood pressure d. determine the clients abnormal involuntary movements scale (AIMS) 1- A client with pheocromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain first? Blood pressure 2- The drainage in the chest tube of a client with emphysema has changed from clear watery fluid. What action would be best for the nurse to take/ Maintain the current IV antibiotic schedule 3- A client is admitted with a sudden onset of right sided the nurse complete first? Observe for peripheral edema 4- When planning care for a client newly diagnose with open angle glaucoma, the nurse identifies a priority nursing diagnosis of “ Visual sensory/perceptual alterations”. This diagnosis is based on which etiology? Decreased peripheral vision 5- A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement? Call the PACU nurse to prepare for prolonged ventilatory support Also know that PACU is BP, Respiration and Pulse 6- A client who is receiving packed red blood cells develops nausea and vomiting. What action should the nurse take first? Stop the infusion of blood Te lo pueden poner como hemodialysis y tambien es STOP transfusion 7- A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat, and feeling shaky. What should the nurse do first? Determine the client current glucose level 8- After suctioning the patient with an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective? Increase in breath sounds 9- The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? Provide additional oral fluid intake Also with TURP you must know that 3l of water a day is needed 10- Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction? Risk for injury related to effects of thrombolysis 11- The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange? The client demonstrates effective coughing and deep breathing exercises 12- When caring for a client with nephrotic syndrome which assessment is most important for the nurse to obtain? Daily Weight 13- A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse? Gastroccult positive emesis 14- A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? • No specific nursing action is required • Instruct the client to empty the bladder • Collect a clean catch urine specimen • Obtain vital signs and breathe sounds 15- The nurse positions a male client for a lumbar puncture by placing him in the side-lying position with his knees flexed and pulled toward his trunk. What action should the nurse implement next? • Call another nurse to assist the healthcare provider • Provide a small pillow for the client to curl around • Instruct the client to perform a Valsalva maneuver • Support the client’s head bent forward to the chest 16- When teaching a client with osteoporosis to increase weight-bearing exercise, how should the nurse explain the purpose of this activity? • Strengthen leg muscles • Promote venous return • Increase bone strength • Restore range of motion 17- A male tells the clinic nurse that he is experiencing burning on urination, and assessment that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? • Observe the perineal area for a chancroid-like lesion • Obtain a specimen of urethral drainage for culture (POSSIBLE ANSWER) • Identify all sexual partners in the last four days • Assess for perineal itching, erythemia, and excoriation 18- An older female client with long term type 2 diabetes mellitus (DM) is seen in the doctor routine health assessment. To determine if the client is experiencing any long-term complications of DM, which assessments should the nurse obtain? Select all that apply: • Visual acuity • Serum creatinine and blood urea nitrogen (BUN) • Signs of respiratory tract infection • Sensation in feet and legs • Skin condition of lower extremities 19- Which laboratory test result is most important for the nurse to report to the surgeon prior to a client’s scheduled abdominal surgery? • Potassium level of 4 mEq/liter • Blood glucose of 90 mg/dl • Serum creatinine of 5 mg/dl (POSSIBLE ANSWER) • Hemoglobin level of 13 grams 20- A client who has a history of long-standing back pain treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this client’s pain management during the postoperative period? • Use minimal parenteral opioids for surgical pain, in addition to oral methadone • Maintain client’s methadone, and medicate surgical pain based on pain rating • Consult with surgeon about increasing methadone in lieu of parenteral opioids • Make no changes in standard pain management for this surgery and hold methadone 21- The nurse applies an automatic external defibrillator (AED) to a client who collapsed in an exam room at a community clinic. What action should the nurse take next? • Determine the defibrillator reading • Assess the client’s oxygen saturation • Bring a crash cart to the exam room • Measure the client’s blood pressure 22- Which change in lab values would indicate to the nurse that treatment for gout is successful? • Decreased serum uric acid • Decreased serum purine • Increased serum uric acid • Increased serum purine 23- The nurse reports that a client is at risk for a brain attack (stroke) finding? • Jugular vein distention • Palpable cervical lymph node • Carotid bruit • Nuchal rigidity 24- The nurse is assessing a group of older adults. What factor in a male client’s history puts him at greatest risk for developing colon cancer? • Is excessively exposed to sunlight • Eats a high-fat diet • Smokes cigars (POSSIBLE ANSWER) • Has intestinal polyps 25- While taking routine vital signs at 0400 AM, the nurse notes that a client who had a total knee replacement the previous day has a heart rate of 126 beats/minute. What action should the nurse take first? • Compare heart rate trends with blood pressure trends ( POSSIBLE ANSWER) • Review the medical record for a history of cardiac disease • Check surgical drainage system and bandage for bleeding • Determine current pain level using a 10-point scale 26- A client who suffered an electrical injury on the left foot is admitted to the burn include in this client’s plan of care? (incomplete) • Assess lung sounds q4 hours • Perform passive range of motion • Evaluate level of consciousness • Continuous cardiac monitoring 27- The nurse is taking a client’s blood pressure sphygmomanometer cuff is inflated. What (incomplete) • Administer a prescribed PRN antianxiety (POSSIBLE ANSWER) • Assess the client’s recent serum calcium • Notify the healthcare provider of the • Prepare to implement seizure precautions 28- A client with eczema is using an over-the-counter (OTC) topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response? • Decreased weeping of ulcerations in affected area (POSSIBLE ANSWER) • Healing with a return to normal skin appearance • Reduced pain in eczematous areas • Hydration of affected dry skin areas 29- During an annual health check, the clinic nurse updates an adult female’s health history. When discussing the woman’s history of lactose intolerance, the client reports that it has been years since she last consumed dairy products. What dietary suggestions should the nurse recommend to help ensure that the client receives an adequate intake of calcium? Select all that apply: • Increase intake of salmon, sardines, tofu, and leafy green vegetables • Sip a half-cup of mil during a mid-day meal at least every other day • Eat at least six servings of citrus fruits weekly • Include 2 to 3 servings of yellow and green squash weekly • Take a calcium supplement with vitamin D daily 30- A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse’s assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? • Review client’s history for possible exposure to TB • Instruct the client to return for a repeat test in 1 week • Refer client to a healthcare provider for isoniazid (INH) therapy • Document negative results in the client’s medical record 31-A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement? • Inform the client that it is the nurse’s responsibility to reposition • Provide an overhead trapeze to the bed for the client to use • Place a draw sheet under the client to assist with repositioning • Administer an intravenous PRN anti-anxiety medication 32- In planning care for a client with pneumonia, which nursing problem should the nurse identify as the priority? • Impaired gas exchange related to the effects of alveolar-capillary membrane changes • Acute pain related to the effects of inflammation of the parietal pleura • Deficient fluid volume related to fever, infection, and increased metabolic rate • Disturbed sleep pattern related to pain, dyspnea, and hospitalization 33-A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? • Encourage frequent mouth care • Administer a topical analgesic per PRN protocol • Cleanse the tongue and mouth with glycerin swabs • Obtain a soft diet for the client 33- A client returns from surgery following a hiatal hernia repair via Nissen fundoplication. Which position should the nurse implement for this client? • Right side-lying to promote stomach emptying • Prone to apply external pressure to the suture line • Left side-lying to reduce stress on the suture line • 30 degree semi-Fowler’s to drop the diaphragm 34- An adult woman with Grave’s disease is admitted with severe dehydration is currently restless and refusing to eat. Which action is most important for the nurse to implement? • Keep room temperature cool • Determine the client’s food preferences • Maintain a patent intravenous site • Teach the client relaxation techniques 35- The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? • Administer initial dose of broad-spectrum antibiotic • Instruct the client to force fluids hourly • Obtain results of culture and sensitivity of CSF • Assess the client for symptoms of hyponatremia 36- A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? • Schedule an appointment for the client to see the healthcare provider • Advise the client to apply plastic wrap over the ointment to promote healing • Explain that the client needs to complete all prescribed doses of the medication • Instruct the client to continue the ointment until all erythema is relieved 37- During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement? • Palpate for abdominal distention • Clamp drainage tube for 5 minutes • Continue to monitor the fluid output • Send fluid to the lab for analysis 38- The nurse assesses the dressing of a client who has just returned from post-anesthesia and finds that the dressing is wet with a moderate amount of bright red bloody drainage. What action should the nurse take? • Replace dressing with a new sterile dressing, and monitor the wound hourly until bleeding is stopped • Call surgery and request that the surgeon see the wound prior to leaving the hospital • Reinforce the dressing and document that a moderate amount of sanguineous drainage was on the dressing • Document that the dressing was saturated with serious drainage, and do not change the dressing 39- While the home health nurse is making a home visit, a client with a history of seizures demonstrates tonic-clonic seizure activity. What action should the nurse implement first? • Direct a family member to call emergency services • Ascertain the trigger event • Protect the client’s head with a pillow • Observe the postictal breathing pattern 40- A client who weighs 176 pounds is admitted to the intensive care unit with a serum glucose level of 600 mg/dl and a serum acetone level of 50 mg/dl. Regular insulin at a rate of 0.1unit/kg/hour is prescribed. The pharmacy provides a solution of Regular insulin 100 units/100 ml of normal saline. The nurse should set the infusion pump to deliver how many ml/hour? (Enter numeric value only) = 8ML/H 41- A client whose history includes IV drug abuse is admitted to the intensive care unit (ICU) with Kaposi’s sarcoma associated with Acquired Immune Deficiency Syndrome (AIDS). Which intervention is most important for the nurse to include in the client’s plan of care? • Observe for adverse medication reactions • Assess for signs of AIDS dementia • Identify signs of opportunistic infections • Locate local HIV support groups 42-(Photo) The charge nurse observes a newly employed nurse gathering equipment to obtain a venous blood sample from a client’s implanted port. The nurse has obtained the equipment seen in the photo. What actions should the charge nurse take? (Select all that apply) • Guide the nurse in inserting the needle at a 45 degree angle • Remind the nurse to wear sterile gloves for this procedure • Instruct the nurse to obtain several red-topped tubes • Determine if the nurse has ever performed this skill • Assist in obtaining the correct needle to access the port 43- After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Send another nurse for an emergency tracheotomy set B. Call respiratory therapy to give a breathing treatment C. Review the client's complete list of allergies D. Prepare a dose of Epinephrine (Adrenalin 44- The nurse is reviewing blood pressure readings for a group of client's on a medical unit. Which client is at the highest risk for complications related to hypertension? A. Young adult Hispanic female who has a hemoglobin of 11 gm and drinks beer every day B. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL C. Older Asian male who eats a diet consisiting of smoked, cured, and pickled foods. D. Post-menopausal Caucasian female who overeats and is 20% above ideal body weight 1. Shingles - Teach the pt about phantom pain 2. Shingles Select all the apply - pain - ability - skin integrity 3. PATIENT W/ EZCEMA APPLYING CREAM TTO IS WORKING: - HEALING WITH A RETURN SKIN TO NORMAL APPEARANCE. 4. PT WITH OBESITY HIGH GLUCOSE LEVEL IS AT RISK FOR? - CARDIOVASCULAR DISEASE 5. FOR ANEMIA WHAT DOESN’T HAVE IRON, WHICH FOODS ARE NOT RICH IN IRON? - NO ORANGE 6. PT. W/ RISK OF DVT - PERFORM ROM EXERCISES ALSO LEGS EXERCISE CAN BE OTHER WAY TO ANSWER 7. DISCHARGE FOR VENOUS ULCERS SELECT ALL APPLY? - ELEVATE THE FEET WHEN LAYING DOWN - CHECK BROWNISH SKIN AROUND THE ANKLES - VITAMINS 8. PT W/ SIADH: - HARD CANDY FOR THIRST. 9. PT ARRIVE TO PACU POSTOP MOANING WHAT TO DO: - CHECK PULSE, BP AND RESPIRATIONS. 10. Pt. DIAGNOSED RECENTLY W/ DM HAVE NOT BEEN ABLE TO CONTROL GLUCOSE LEVEL DURING 3 MONTH WHAT SHOULD BE DONE: - CHECK FOR A1C LEVEL - (OTHER SAY ASSESS FOR WHAT SHE HAVE BEEN EATING 3 DAYS AGO). 11. WHEN BP IS HIGH - ADMINISTER (LASIX) 12. PATIENT W/ ESOPHAEGAL VARICES HAVE NOT BE BLEEDING FOR 3 DAYS: - PROVIDE LUKE WARM BROTH, ICE TEA AND LEMON POPSICLE. 13. CALCULO: - 0.75 14. PT WITH OSTEOMALCIA - RISK FOR INJURY 15. SBAR—EXPLAIN SPECIFIC REASON FOR URGENT NOTIFICATON - TEMPERATURE 16. INTESTINAL BOWEL OBSTRUCTION - PLACE THE PT 90 DEGREES SITTING 17. OSTEOARTHRITIS - RISK FOR INJURY RELATED TO JOINT PAIN 18. BONE CANCER TYPE IV: - GIVE OPIODS- NON OPIODS ANALGESICS. 19. HYPOTHYROIDISM - RESTRICT SODIUM NA 122 20. PT ARRIVES TO CLINIC W/ NUCHAL RIGIDITY FEVER FOR 6 HOURS WHAT TO DO: - PREPARE FOR ISOLATION PRECAUTIONS - ( I PUT THIS ONE AND NO LUMBAR PUNCTURE) 21. INTERMITENT CLAUDICATION TEACHING - BANDAGE ELASTIC WRAPED AROUND LEGS - TAMBIEN PUEDE SALIR COMO PAIN TRACTION CAST NOTIFY MD (CAST NO MORE THEN 4HR) 22. PREOPERATIVE NURSING CARE - ASSESS EMOTIONAL PREPAREDNESS - ALSO CAN BE CONCERNS AND ANXIETY FOR SURGERY DEPENDE LA QUE PONGAN 23. TRACHESTOMY CARE: - LEAVE OLD TIES ON UNTIL NEW ONES BE ON PLACE OR SECURE. 24. STERNAL TRACTION COMPLAINS OF PAIN - ADMINISTER PRN MEDS 25. EXTERNAL FIXATION - ADMINISTER PRN MEDS 26. MULTIPLE SCLEROSIS (MS) - ADMINISTER ANTIMEDICS/ PRN AS PRESCRIBED 27. FEMALE PATIENT HOW HAVE EPIGASTRIC PAIN FOR 3 DAYS HAVE BEEN TAKIN ANTACIDS AND NO RESOLVE ARRIVE TO HOSPITAL W/HR;128 BPM, BP110/70 WHAT IS THE MOST IMPORTANT INTERVENTION FINDING IN ASSESSMENT: - ASSESS FOR RADIATING JAW PAIN. 28. Pt. W. RADIACTIVE THERAPY WHAT TO TEACH/ RECOMMEND TO - PROTECT THAT PART OF THE SKIN SPECIALLY FROM THE SUN 29. Pt WITH ALS WHAT TO DO TO PREVENT RESPIRATORY COMPLICATIONS: - TEACH BREATHING TECNIQUES, USES SPIROMETER, AUSCULTATE FOR BREATH OR LUNG SOUNDS. 30. PT WITH LEFT LEF ULCER: - KEEP LEG ELEVATED AS MUCH AS HE CAN. 31. PT WITH AN EXTERNAL DEVICE COMPLAINING OF PAIN: - ASSESS FOR PHERIPHERAL PULSES. 32. CALCULATION 1G/0.4 G - = 2.5 33. EXAMPLES OF DASH DIET: - PEEL FRUITS AND VEGETABLES. 34. CHEST TUBE W/ A DRAINAGE CHANGING FROM CLEAR TO GREEN: - KEEP IV FLUIDS. 35. PT W/ OPEN ANGLE GLAUCOMA SELECT ALL THAT APPLY: - FREQUENT EYE EXAM TO ASSES FOR VISSION, - USE DROPS TO DIMINSH IOP, - AVOID EXTRENOUS EXERCICES LIKE JOGGING OR RUNNING - ( YO PUSE SOLO ESAS 3 RESPUESTAS). 36. PT W/ HYPERTHYROIDISM DEVELOPING EXOSPHTALMUS: - PRESCRIBE TEAR EYE DROPS. 37. PT VOMITING BLOOD LIKE THE PICTURE SAME AS HEMATENSIS: - CHECK VITAL SIGNS ( ASI ESTA EN TODOS LOS PAPELES) - AUSCULTATE LUNGS SOUNDS ( FUE LO QUE PUSO YADIRA) 38. PATIENT W/ ML FELL AND WHEN RECEIVING THE NURSE HE HAVE 2 PROJECTILE VOMITS WHAT SHE DO: - PROVIDE ANTIEMETICS PRN . 39. PT W/ RAYNAUD SYNDROME WHICH WORK AS A DATA ENTRY CLERK: - PROVIDE A SPACE TO WARM THE ENVIROMENT NEXT TO HER - ( ALGO ASI ERA LA RESPUESTA). Y HAY OTRA RESPUESTA QUE SOLO DICE KEEP MONITORING 40. PATIENT THAT HAVE THE K= 6.7 WHAT MEDICATION PROVIDE: - KAYELAXATE (TREATS HYPERKALEMIA). 41. COLON CANCER PT - KAYELAXATE Med 42. RENAL INJURY - KAYELAXATE MED 43. PT WITH A BRONCHOSCOPY AND DRINK A GLASS OF JUICE : - DELAY THE PROCEDURE 6 HOURS 44. NEW PATIENT DIAGNOSES WITH DM TYPE IS RECEIVING TEACHING IN WHICH GLUCOMETER WILL BE THE BEST: - ASSESS FOR VISUAL ACUITY AND ABILITY TO READ OR SOMETHING LIKE THAT. 45. ABG (PH 7.25 PCO2 50 SODIUM 60 - TACHY AND CONFUSION/ RESPIRATORY 46. ACUTE AGN DIET: - RESTRICT NA INTAKE. 47. PT W/ A EXPRESSIVE APHASIA IS ANGER WHAT SHOULD DO THE NURSE: - CVA- COMMUNICATE W/ PICTURE BOARDS. 48. NURSE IS TEACHING THE WIFE IF A PATIENT DIAGNOSED W/ SEIZURE WHAT TO DO: - TEACH HER HOW TO POSITION HIM 49. PT AFTER TTO OF SOMETHING AND WANTS TO EAT: - NURSE ASSESS FOR BOWEL MOVEMENTS. 50. SLE: - ASSESS FOR HEMATURIA 51. PATIENT ALLERGIC TO BANANA (LATEX): - CALL TO MD AND OR STAFF TO BE CHANGE EVERYTHING FOR SINTHETIC MATERIALS, 52. SUBCUT EMPHYSEMA- TORACOTOMY WAS A SELECT ALL THAT APPLY: - ASSESS FOR LUNG SOUNDS, 53. NECK DISTENTION - THINK IT WAS AND OTHER CHOICE THAT I NOT REMEMBER NOW. 54. RESTLESS LEG SYNDROME CON FEOSOL: - ASSESS FOR IRON AND FERRITIN. 55. BNP - ADMINISTRATIVE FUROSEMIDE LASIX IV 56. PARKINSON PT WALKING - REASURE THAT STEPPING ON CRACKLES IS NOT HARMFUL 57. ADDISON DISEASE - TAKE CORTICOSTEROID MEDS 58. CARPO TONIC SYNDROME - WEAR BRACE IN BOTH WRIST 59. PARKINSON AND ALZAIMERS PT - TATICARDIC AND CONFUSION 60. MID ABDOMEN BURNING PAIN - PEPTIC ULCER 61. ANTIBIOTICS - CLEAR DRAINAGE IMPROVE 62. ALLOPRINOL FOR GOUT - TAKE MEDS ALWAYS 63. BLOOD TRANSFUSION HIGH TEMPERATURE - BACK PAIN AND HYPOTENSION - ( ABO- LOW BACK PAIN AND HYPOTENSION) 64. CENTRAL FALL RISK - CARDIOVASCULAR DISEASE 65. RIGHT HIP FRACTURE - O2 SAT LEVEL 66. DESCRIBE PAIN NEUROPATHY - NERVOUS SYSTEM 67. ACUTE ABDOMINAL PAIN, NASUA, PROJECTIBLE VOMITING - SEVERE HEADECHE AND PHOTO Sensitivity 68. UROLITHISIS O LITHOTRIPSY PROCEDURE - RESTRICT PHYSICAL ACTION 69. UAP ( DICE EL PACIENTE QUE TIENE ABD PAIN LARGE TARRY STOOL - TEST STOOL FOR OCCULT BLOOD 70. Insulin for a glucose level of 255 (Pte tmeblando despues que le pusieron insulin.) - Obtain capillary glucose. 71. NGT proper tube procedure - Elevate dead 60 to 90 degree…. 72. RA (rheuma) - Impaired peripheral mobility relate to join pain. 73. Finger stick glucose finding 50 - OC Level of conscious 74. BMI (una persona que pueden tener colon cancer) - Large waist circumference with central fat Review for Hesi: Recopilation: 1. Community Health/Geriatrics/Professional Issues-Leadership-Geriatric syndrome-home health RN needs to go 4 patients and which one needs to see first: A. The patient discharge yesterday and dehydrated B. The patient start a new medication and is incontinence C. The patient that doesn’t want to take a shower 2. Community Health/Medical Surgical-Renal/Reproductive-TURP-home care The nurse is reinforcing home care instructions with a client who is being discharged following transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the clients discharge instructions? A- Avoid strenuous activity for 6 weeks B- Report fresh blood in the urine C- Take acetaminophen for fever 101 D- Consume 6 to 8 glasses of water daily 3. Community Health/Pediatrics/Professional Issues- Leadership/Legal/Ethical-School nurse role The school nurse is implementing standards to manage students and provide a safe and healthy school setting. Which action is most important for the nurse to implement? A- Maintain student immunization records B- Develop an emergency plan for the school C- Ensure that medical supplies are available D- Conduct annual student health assessments 4. Community Health/Psychiatric/Mental Health/Fundamentals/Professional Issues/Medical Surgical- Anxiety/Communications/Basic Nursing Skills/Safety/Teaching- Infection-communication A pt with possible pneumonia come to the hospital and the nurse need to do an assessment but the family don’t want to leave the room, what the nurse need to do first? A –Call the security B- Put the family out of the room C- Put a pneumonia droplet sign in the door D – Continue with the assessment and put mask to the family 5. Critical Care/Fundamentals-Med Administration/Math-IV-mcg/min- dopamine DOPAMINE 198 LBS 7mcg/kg/minute, 500 mg and 400 ml. ml/hour? Answer: 47 198:2.2=90 7x60x90=37800mcg 37800mcg:1000 to mlg=37.8 mlg 500mg:400ml=1.25 37.8:1.25=30.24 6. Critical Care/Fundamentals/Maternity/Pediatrics/Professional Issues- Basic Nursing Skills/Nutrition/Antepartum/Leadership-Community- primary prevention A public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse’s proposal? A. Case management and screening for clients with HIV. B. Regional relocation center for earthquake victims. C. Vitamin supplements for high-risk pregnant women. D. Lead screening for children in low-income housing. 7. Critical Care/Geriatrics/Medical Surgical-Renal-Acute Tubular Necrosis -GERI Diabetic,renal no function,decrease urine or not urine, septic shock, check urine specific Gravity and osmolarity urine. Acute Renal Failure: Low Protein Chronic Renal Failure: NOT Protein at all Asw possible:Urine claude and check input and output 8. Critical Care/Medical Surgical-Cardiovascular? Immune/Hematology/Integumentary/Respiratory-MODS-central line placement NOTE: The Multiple Organ Dysfunction Syndrome (MODS) can be defined as the development of potentially reversible physiologic derangement involving two or more organ systems not involved in the disorder that resulted in ICU admission, and arising in the wake of a potentially life-threatening physiologic insult. Answer: Shock 26. Fundamentals/Medical Surgical-Basic Nursing Skills-Fluid volume overload After receiving IV fluids in the emergency department, an elderly client is admitted to the acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125ml/hr. via a saline lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the nurse anticipates a prescription for what intervention? a. Decrease the rate of the normal saline infusion b. Increase the rate of the normal saline solution c. Change the IV solution to 0.45 saline solution d. Remove the saline lock from the client’s arm 27. Fundamentals/Medical Surgical-Basic Nursing Skills/Elimination- Acute abdominal pain Lower abdominal pain (Order): 1. POSITION BENT KNEES 2. Ask for last food that eat 3. DETERMINE BOWEL MOVEMENT 4. INSPECT ABDOMINAL 5. AUSCULTATE 4 QUADRANTS 28. Fundamentals/Medical Surgical-Basic Nursing Skills/Nutrition- Parkinson’s-meals Answer: Provide privacy and give extra time to eat meals and snack OJO The spouse of a client with Parkinson’s wants to know how to best assist her husband during feeding as he is having "increasing problems with drooling and swallowing." What instruction should the nurse provide to the family member? A) "Use thickened liquids along with upright positioning during feeding." B) "It might be time to switch to enteral feedings if you are afraid that your husband may choke." C) "Increase the amount of fluids he receives to decrease saliva formation and improve swallowing." D) "Use a straw during feedings to facilitate swallowing." 29. Fundamentals/Medical Surgical-Basic Nursing Skills/Nutrition-Visually impaired-feeding-UAP Reloj posisiones manecillas A patient with chemicals in the eyes and is in the hospital. What the nurse tells to the UAP to do to help the patient with the food? A- Give food to the patient in the mouth B- Indicate to the patient where is the tray ( reorient ) C- Look how the patient eat D- Finger food 30. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety- Huntington’s chorea *ANSWER: padding on the side rail Or llevarlo a la cafeteria 31. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety- Hyperglycemia-vomiting TYPE 1 DIABETES MELLITUS BLOOD GLUCOSE 420 BEGINS VOMIT: A- TURN THE CLIENT TO A LATERAL position B- OBTAIN A FINGER STICK GLUCOSE 32. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety-MRI A PATIENT SCHEDULED MRI AND SAID THAT HAS A METAL TOOTH. WHAT THE RN NEED TO DO? A- ASSESS PT FEAR TO THE TEST B- CONSULTS RADIOLOGY C- SEND PT TO X-RAY INSTEAD D- CANCEL THE TEST. 33. Fundamentals/Medical Surgical-Integumentary/Operative-JP drain full POSTOPERATIVE DRESSING: ABDOMINAL WOUND WITH JACKSON PRATT DRAIN. WHAT THE NURSE DO FIRST? (PICTURE) A- ASSESS THE SURGICAL WOUND B- SQUEEZE C- EMPTY 34. Fundamentals/Medical Surgical-Med Administration-IV-gravity infusion flow rate (Question with 4 pictures) Overflow: A- ARM B- ARM AND FOREARM C- IV DRIP D- IV REGULATION 35. Fundamentals/Medical Surgical-Med Administration/Math-IV- Heparin-units HEPARIN SODIUM 25000 IN 5% 500 ml Answer: 36 36. Fundamentals/Medical Surgical-Renal-Diuretic & daily weight Discharge teaching to a patient with heart failure what parameter is most important for weight monitoring *Answer: Weight the patient at the same time, Same Scale, same cloth type) The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. What instruction should the nurse include in this teaching plan? A- Stop taking the medication when the edema in the lower extremities subsides. B- Take the diuretic every day, regardless of weight loss or muscle weakness. C- Limit fluid intake while taking the diuretic to reduce fluid retention. D- Weight yourself daily at the same time and report excessive weight loss. 37. Fundamentals/Pathophysiology-Basic Nursing Skills/Hygiene/Safety- Handwashing HAND WASHING: A- Reduces spread of microorganism. Bio….. B- Lock virus C- Lock in human virus 38. Fundamentals/Pathophysiology/Professional Issues/Medical Surgical- Basic Nursing Skills/Nutrition/Teaching-DM2 and CKD-diet Ketoacidosis Diet A- Banana, whole bread… B- Oatmeal…… C- 6 oz Coffee, strawberry, artificial sweetening D-Egg, butter 39. Fundamentals/Pediatrics-Basic Nursing Skills/Nutrition-infant weight- 1-month AT THE 1 MONTH OLD CLINIC VISIT, AN INFANTS NUDE WEIGHT IS 600 GRAM MORE THAT AT BIRTH. WHICH INTERVENTION SHOULD THE NURSE IMPLEMENT? A. ENCOURAGE GIVING 2 OUNCES OF WATER BETWEEN FEEDINGS. B. RECOMMENDED ADING KARO SYRUP TO EACH FORMA FEEDING C. DOCUMENT INFANT’S WEIGHT ON GROWTH CHART D. CHECK THE INFANT’S WEIGHT USING A METRIC SCALE. NOTE: ANSWER: 600 grams 40. Fundamentals/Pediatrics-Med Administration-Oral susp-resisting- PEDI A child that resists taking the medication: a. Parents help the nurse holding him b. Provide the child juice with the medication c. Explain to the child that if he doesn’t take the medication, he won’t feel better. 41. Fundamentals/Pediatrics-Med Administration/Math-Calculation-PO dose-3x/wk/BSA The healthcare provider prescribes methotrexate 7.5 mg PO weekly, in 3 divided doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given week? Answer: 2.5 42. Fundamentals/Pediatrics-Med Administration/Math-IV-ml/hour-PEDI Vanco 400 mg 6 hours, 100 ml one and half hour Answer: 67 43. Fundamentals/Pediatrics/Professional Issues/Medical Surgical-Basic Nursing Skills/Safety/Leadership-Airborne precautions Un Nino que los Padres lo llevaron al ER A. Mandarlo a la casa B. RN ponerse el precaution C. Ponerle una mascara al nino. B *(Isolated room) * Airborne precautions: 1. Diseases a. Measles b. Chickenpox (varicella) c. Disseminated varicella zoster d. Tuberculosis 2. Barrier protection a. Single room is maintained under negative pressure; door remains closed except upon entering and exiting. b. Negative airflow pressure is used in the room, with a minimum of 6 to 12 air exchanges p hour depending on health care agency protocol. c. Ultraviolet germicide irradiation or high-efficiency particulate air filter is used in the room d. Health care workers wear mask or personal respiratory protection device. e. Mask placed on client when client is out of the room; client leaves the room only if necessary. 44. Fundamentals/Professional Issues-Basic Nursing Skills/Nutrition/Cultural/Spiritual-Hindu diet A Hindu patient… what can the nurse do? A- REMOVE BEEF FROM PT MEAL TRAIL B- ENCOURAGE FAMILY TO BRING FOOD FROM HOME C- SHOW THE CARDIAC MENU TO THE PATIENT D- GIVE TO THE PATIENT WHAT HE WANTS 45. Fundamentals/Professional Issues-Med Administration/Documentation- Bar code scan-med administration When administering a new medication to a client, the nurse uses a scanner to register the nurse? A) Use the scanner to register the bar code on the client’s identification bracelet. B) Document the medication administration on the client’s computerized record. C) Remove the medication from the unit dose packaging while verifying the dose. D) Reconcile the medication to be administered with the initial client prescription. 46. Fundamentals/Professional Issues/Medical Surgical-Basic Nursing Skills/Nutrition/Teaching- Hypertension diet A PATIENT WITH HIGH BP, THE NURSE GIVE A TEACHING FOR WHAT CAN HE EAT FOR LUNCH? A- TOMATO JUICE AND GLUTEN FREE CRACKERS B- BAKED SWEET POTATO 47. Fundamentals/Professional Issues/Medical Surgical-Basic Nursing Skills/Safety/Teaching-Influenza precautions Patient with influenza. Dehydrated and pneumonia: A. Droplet precaution B. Family member wear mask NOTE: Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility. 48. Fundamentals/Professional Issues/Medical Surgical-Med Administration/Teaching-Insulin adm-teaching 1 (PICTURE) The nurse shows the mom of the child how to use insulin for the child that is diabetic: A- ASSIST THE MOTHER IN B- THE CORRECT ANGLE C- LOCATING THE CORRECT SITE Or assess 45 Angle Pen 90 angle 49. Fundamentals/Professional Issues/Medical Surgical-Teaching-Pursed lip breathing 2 VIDEO *Pursed lip Breathing: IN and OUT (Inhale through the nose and exhale by mouth) 50. Geriatrics/Medical Surgical-Integumentary-Skin care-GERI An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement? A) Explain the importance of bathing or showering daily. B) Keep the legs covered as much as possible. C) Apply emollient to affect area at least twice daily. D) Encourage fluid intake of at least 2,000 ml daily. 51. Maternity–Antepartum –Fetal stress - Tachycardia The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider? A) Reports intermittent low back pain. B) Fetal heart rate of 200 beats/minutes C) Complains of early morning heartburn D) Maternal hemoglobin of 11.0 g/ dl or 110 g/l (SI) *Note: Normal FHR pregnant women: 120-160 52. Maternity – Intrapartum – Intrapartum pain management PREGNANT WOMEN WITH 8 CM DE DILATATION Y 100%, SHE WANTS TO GET HYDROCHLORIDE (DON’T REMEMBER THE EXACTLY NAME) FOR PAIN: A- ADMINISTER EPIDURAL B- ADMINISTER HYDROCHLORIDE C- RELAXATION TECHNIQUE 53. Maternity – Postpartum – Hemorrhage postpartum Possible asw: Check for clots and lochia 54. Maternity – Postpartum – Priority management-postpartum After receiving shift report, the nurse working on a postpartum unit should assessment first? A) Vaginal birth today whose infant is refusing to breastfeed. B) Cesarean birth of twin today who is new complaining of pain. C) Post-cesarean birth today with fundus at the umbilicus. D- Multipara vaginal birth yesterday saturating two pads hours. 55. Maternity/Medical Surgical – Antepartum – Barbiturates & pregnancy The nurse is evaluating medication teaching. Which statement by a female who takes a barbiturate for sleep indicates she understands the teaching? a) “I should ensure that I do not become pregnant while taking this medication.” b) “I must take my birth control pill in the morning and my sleeping pill at night.” c) “I will increase the amount I take in small doses if I can’t sleep through the night.” d) “I should take my anxiety pill, alprazolam, only when I really need it.” 56. Maternity/Medical Surgical –Postpartum –Post vaginal delivery- diaphragm Patient that had a vaginal birth, diaphragm. What teaching the nurse need to give to the patient? A- 2 or 6 hours before intercourse B- Re-adapt C- Resisted diaphragm D- Is no anticoncertive 57. Maternity/Professional Issues-Antepartum/Cultural/Spiritual-Pregnancy- cultural awareness Pregnant women first prenatal visit at 12 weeks A - Concern about delivery B - Parenting C - Complication during pregnancy D - CHILDHOOD 58. Maternity/Professional Issues-Antepartum/Leadership-BPP-fetal well- being Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? a) A 41-week multigravida who is scheduled induction of labor today. b) A 38-week primagravida who reports contractions occurring every 10 minutes. c) A 36-week multigravida with a prescription for serial blood pressure. d) A 39-week primigravida with biophysical profile score of 5 out of 8 59. Medical Surgical-Cardiovascular-Angina-exercise A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include to the discharge teaching? a. Engage in physical exercise immediately after eating to help decrease cholesterol levels. b. Walk briskly in cold weather to increase cardiac output. c. Keep nitroglycerin in a light-colored plastic bottle and readily available. d. Avoid all isometric exercises, but walk regularly. 60. Medical Surgical-Cardiovascular-Arterial sheath Saunder 791 Arterial sheath : Pedal pulses and colour, warmth movement and sensation of affected leg & foot Asses insertion site for bleeding, pain, tenderness, swelling or haematoma. No levantarse hasta despues de 8 hrs A patient recovering left femoral atrial sheath. What finding requires immediate intervention (Select all that apply?) A. Tenderness on insertion site B. Left groin egg size C. Quarter size of drainage D. Unrelieved back, flank pain E. Cool/pale left foot The nurse in the outpatient unit is caring for a client who had a right femoral cardiac cauterization two hours ago .What assessment findings requires immediate intervention? A. The client wants assistance walking to the bathroom B. Clients pulse oximeter is 98% C. The client right feed is warn to touch D. The client B/P is 110/70 and pulse 90 OJO CON ESTA NO SALIO PERO HAY QUE VERLA 61. Medical Surgical-Cardiovascular-Atenolol The healthcare provider prescribes atenolol 50 mg PO daily for a client with angina pectoris. Which finding should the nurse report to the healthcare provider before administering the medication? a) Chest pain. b) Urinary frequency. c) Tachycardia. d) Irregular pulse. 62. Medical Surgical-Cardiovascular-Atrial fibrillation-assess Atrial fibrillation, or A-Fib, is the most common heart rhythm disorder in the United States. It’s a condition in which the electrical impulses that control muscle contractions in the upper chambers of the heart become rapid and chaotic. About 160,000 new cases of A-Fib are diagnosed in the U.S. each year–but physicians believe that many people who have A-Fib have not been diagnosed. The likelihood of developing A-Fib increases with age. The majority of people diagnosed with A-Fib are 55 or older. Between three and five percent of people over age 65 and nine percent of people over the age of 80 have A-Fib. Diagnosing and treating A-Fib are important because, left untreated, it can lead to a number of serious heart conditions. Patients with A-Fib are also five times more likely to suffer a stroke. (Although you should see a doctor to diagnose A-Fib, one way to help asses your risk is to take your pulse. Click here for a step-by-step guide–or watch Archie Manning show how it’s done.) One complicating factor is that the signs and symptoms of A-Fib can vary greatly from patient to patient. Some people experience a sudden heart flutter or tremor, or feel their heart “speed up” suddenly; other patients with A-Fib may not feel anything at all. Other symptoms can include: Shortness of breath Fatigue Weakness or difficulty exercising Chest pain Sweating Dizziness Fainting A-Fib is not an emergency–but it is a serious condition. If you suspect you have A-Fib you should see your doctor immediately. Contact your primary care doctor–or find a St.Vincent doctor near you. Or make an appointment to see an A-Fib specialist at the St.Vincent A-Fib Center of Excellence. We can discuss the many treatment options available to treat and cure A-Fib–and help choose the one that’s right for you. 63. Medical Surgical-Cardiovascular-BP-variance in arms *Change the arm or wait 5 min and change the arm 64. Medical Surgical-Cardiovascular-High BP-vasoconstriction A patient is diagnosed with MALIGNANT HYPERTENSION, patient likes skiing and asks if is ok to continue: A. “COLD WEATHER MAY CONSTRICT YOUR BLOOD VESSELS AND INCREASE BP” B. “SKIING MIGHT PRODUCE TOO MUCH EXERTION” C. “SHOULD BE OK AS SOON AS YOU CONFINE SKIING D. “GO FOR IT IS A TERRIFIC WORKOUT 65. Medical Surgical-Cardiovascular-Pitting edema 4+ 66. Medical Surgical-Cardiovascular-SVT-cardioversion-priority Electro shock Posible asw: synchronic 67. Medical Surgical-Cardiovascular/GI/Hepatic-Bariatric surgery-abd pain A patient get to ER and had a week before a bariatric surgery, patient is shortness of breath and has abdominal pain. A. Blood pressure 88/50 B. Left shoulder pain C. Sustained sinus tachycardia D. 101 temperature A woman who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. She states that she is pain free. Which intervention should the nurse include in the client’s plan of care? a. Maintain the client on a NPO status b. Administer daily vitamin supplements c. Determine if the client is over-hydrating to feel satiated d. Encourage positive self-accolades for dietary adherence OJO: ESTA NO SALIO EN ESTE PERO NOS PUEDE SALIR. 68. Medical Surgical-Cardiovascular/Physical Assessment-Carotid bruit Femoral carotid 69. Medical Surgical –Cardiovascular/Renal-Lasix-outcome PEDI Child taking Lasix. Nurse look for effective of the medicine: Answer: Lose 2 pounds weekly 70. Medical Surgical-Cardiovascular/Trauma/Emergency-Unstable angina Unstable angina is more intense that stable angina. Make a pt awake when they sleep. Made more that 5 min no relies by nitroglycerin. Is a stereo sclerotic plaque rupture. Thrombus formation MI. No always we can see in a elevated ST changes. Stable angina is realize with nitroglycerin and relaxation . OJO: ESTA NO SALIO PERO HAY QUE VERLA Client was admitted to the cardiac observation unit 2 hour ago complaining of chest pain .On admission the client EKG showed bradycardia ,ST depression ,but no ventricular ectopic .The client reports a sharp pain ,telling the nurse ,I feel like an elephant just stepped on my chest .The EKG now shows Q waves and ST elevations in the anterior leads .What intervention should the nurse perform ? A. Administer prescribed morphine sulfate IV and provide oxygen at 2L per minute per nasal cannula B. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzyme levels C. Notify the HCP of the clients increased chest pain and call for defibrillator crash cart D. Increased the peripheral IV rate to 175 ml/hr. to prevent hypotension and shock 71. Medical Surgical-Endocrine-Chvostek’s sign-tetany-POC The nurse is caring for a client with hyperparathyroidism. Which assessment should the nurse include the plan of care? A) Chvostek’s sign B) Brudzinski’s sign. C) Battle’s sign. D) Pupillary response. 72. Medical Surgical-Endocrine-Diabetes-acute confusion A female client with pancreatic cancer is NPO for implantation of a venous sedation. Suddenly, the client becomes unresponsive, and her skin is cool pulse 96 beats/minute, respiratory rate 18 breaths/minute, which are within her outpatient surgery nurse implement first? A- Administer glucagon 0.5 mg IM B- Infuse a 200 ml NS IV fluid bolus C- Obtain a finger stick blood glucose D- Insert a second peripheral IV catheter 73. Medical Surgical-Endocrine-DKA-IV IV insulin: Trade hydration with rapid IV infusion 0.9 a 0.45 normal saline as prescriber, because can elevated edema. Intravenous fluid replacement should start immediately with 1 to 2 L of normal saline over the first 1 to 2 hours of treatment for adults. In children the initial fluid bolus is weight based (5 to 20 mL/kg, dependent on the child’s perfusion status); volume replacement is carefully titrated because of the high risk for cerebral edema in the pediatric population. The adult patient may require up to 8 to 10 L of fluid. Volume is gradually replaced after the initial fluid bolus because rapid infusion of a large volume increases the risk for development of cerebral edema. Close observation of intake and output is essential; placement of a urinary catheter ensures accurate output assessment. A continuous infusion of regular insulin is administered at 0.1 units/kg/hr to stop ketogenesis and achieve a steady decrease in serum glucose level of 50 to 75 mg/dL/hr; an initial intravenous (IV) bolus of 0.15 units/kg of regular insulin may be administered. The short duration of action for regular insulin allows better control of serum glucose levels. After serum glucose level reaches 250 to 300 mg/dL, fluids should be converted to 5% dextrose in normal saline (D5NS) to provide fuel until the patient is able to eat. Resolution of a hyperglycemic emergency occurs when the serum glucose level is less than 200 mg/dL, serum bicarbonate level is greater than or equal to 18 mEq/L, and in DKA, the venous pH is greater than 7.3.[3] Fluid replacement dilutes serum potassium and promotes diuresis. In addition, total body hypokalemia is exacerbated by metabolic acidosis, so potassium replacement should begin after the initial liter of IV fluids is infused, even when initial values are normal. Potassium levels frequently drop precipitously in the first few hours after treatment has been initiated because potassium moves back to the intracellular space along with the insulin and existing glucose. Serum potassium levels must be repeated every 1 to 2 hours during initial management. Cardiac monitoring is essential because dysrhythmias can develop with significant hypokalemia. Acidosis generally corrects with insulin therapy. Insulin allows the cells to use available glucose for energy, leading to decreased proteinolysis and lipolysis, and the ketoacidosis resolves. Insulin infusion should be continued until the pH or serum bicarbonate level has normalized; IV fluids should be converted to D5NS once the serum glucose level reaches 250 to 300 mg/dL to prevent hypoglycemia. Acidosis in DKA is not routinely treated with sodium bicarbonate because sodium bicarbonate administration can cause rebound alkalosis, which can worsen hypokalemia and increases the risk for development of cerebral edema. Controlling nausea and vomiting not only improves patient comfort but prevents worsening dehydration. The patient may require analgesia to relieve abdominal pain, headaches, or other somatic complaints. Providing a quiet, calm environment can improve patient comfort. Stress reduction plays an important part in patient recovery. Thorough explanation of treatment, medications, and plan of care can alleviate stress related to hospitalization. Potential complications include hypoglycemia, hypokalemia, dysrhythmias, and cerebral edema. Monitor capillary/serum glucose levels, electrocardiogram (ECG), laboratory values, vital signs, intake and output, and neurologic status carefully. If the serum glucose level falls rapidly, the resulting fluid shift can lead to cerebral edema, which is associated with a higher mortality rate. Cerebral edema remains the leading cause of death for children presenting in DKA. 74. Medical Surgical-Endocrine/GI/Hepatic-Acute pancreatitis Pancreatitis The pancreas is an organ located behind the stomach that produces chemicals called enzymes, which are needed to digest food. It also produces the hormones insulin and glucagon. Most of the time, the enzymes are only active after they reach the small intestine. When these enzymes become active inside the pancreas, they digest the tissue of the pancreas. This causes swelling, bleeding (hemorrhage), and damage to the organ and its blood vessels. This condition is called acute pancreatitis. Acute pancreatitis affects men more often than women. Certain diseases, surgeries, and habits make you more likely to develop this condition. The two most common causes of pancreatitis in the United States are heavy alcohol use and gallstones. Alcohol use is responsible for up to 70% of cases in the United States. Acute pancreatitis typically requires 5 to 8 drinks per day for 5 or more years. Gallstones are the next most common cause. The condition develops when the gallstones travel out of the gallbladder into the bile ducts, where they block the opening that drains the common bile duct and pancreatic duct (ampulla). Genetics may be a factor in some cases. Sometimes, the cause is not known. Other conditions that have been linked to pancreatitis are: • Autoimmune problems (when the immune system attacks the body) • Damage to the ducts or pancreas during surgery • High blood levels of a fat called triglycerides (hypertriglyceridemia) usually above 1000 mg/dL • Injury to the pancreas from an accident Other causes include: • Complications of cystic fibrosis • Hemolytic uremic syndrome • Hyperparathyroidism • Kawasaki disease • Reye syndrome • Use of certain medications (especially estrogens, corticosteroids, sulfonamides, thiazides and azathioprine) • Viral infections, including mumps, coxsackie B, mycoplasma pneumonia, and campylobacter • Injury to the pancreas after a procedure such as an ERCP (endoscopic retrograde cholangiopancreatography) or EUS (endoscopic ultrasound) with FNA (fine needle aspirate) Symptoms The main symptom of pancreatitis is pain felt in the upper left side or middle of the abdomen. The abdominal pain: • May be worse within minutes after eating or drinking at first, especially if foods have a high fat content • Becomes constant and more severe, lasting for several days • May be worse when lying flat on the back • May spread (radiate) to the back or below the left shoulder blade People with acute pancreatitis often look ill and have a fever, nausea, vomiting, and sweating. Other symptoms that may occur with this disease include: • Clay-colored stools • Gaseous abdominal fullness • Hiccups • Indigestion • Mild yellowing of the skin and whites of the eyes (jaundice) Swollen abdomen 75. Medical Surgical-Endocrine/Integumentary-DM cellulitis 3 eval Cellulitis is a deep infection of the skin that extends to the subcutis. It begins as a painful, tender, erythematous, warm area that spreads rapidly and produces indistinct borders. Fever, chills, rigors, and sweats are frequent. The infection most often begins at the site of antecedent trauma, which may be minor or major. It may also occur as a result of infection associated with closure of non-sterile wounds and at the site of sutures. Cellulitis frequently extends via the lymphatic system and can produce lymphangitis, lymphadenopathy, abscesses, and bacteremia. While taking antibiotics, monitor your condition to see if symptoms improve. In most cases, symptoms will improve or disappear within a few days. In some cases, pain relievers are prescribed. You should rest until your symptoms improve. While you rest, you should raise the affected limb higher than your heart to reduce any swelling. 76. Medical Surgical-GI/Hepatic-GERD-antacid An antacid is prescribed for a client with gastro esophageal reflux (GERD). The client asks to the nurse, “How does this help my GERD? What is the best response by the nurse? A. “Antacids decrease the production of gastric secretions.” B. “It will improve the emptying of food through your stomach.” C. “This medication will coat the lining of your esophagus.” D.“Antacids will neutralize the acid in your stomach.” 77. Medical Surgical-GI/Hepatic/Neurological-Lactulose Asw: Lactulose 78. Medical Surgical-GI/Hepatic/Respiratory-EGD-recovery care Following an esophagogastroduodenoscopy (EGD), a make client is drowsy and difficult to and his respiratory are slow and shallow. Which action should the nurse implement (Select all that apply?) A) Initiate bag valve-mask ventilation. B) Prepare medication reversal agent. C) Apply oxygen via nasal cannula. D) Check oxygen saturation level. E) Begin cardiopulmonary resuscitation. 79. Medical Surgical-Immune/Hematology-Blood transfuse reaction A client receiving a blood transfusion complains of itchy skin and appears flushed. What action should the nurse take first? A- Check the blood type on the bag B- Notify the healthcare provider C- Assess the client’s temperature D- Stop the blood transfusion. 80. Medical Surgical-Immune/Hematology/Integumentary-Sunburn-severe reaction Pt expuesto al sol y no se puso sunblock and blisters. Que s/s vas a ver. Posible asw: headache No es chills and fever Signs of Sunburn. When you get a sunburn, your skin turns red and hurts. If the burn is severe, you can develop swelling and sunburn blisters. You may even feel like you have the flu -- feverish, with chills, nausea, headache, and weakness. 81. Medical Surgical- Immune/Hematology/Integumentary/Trauma/Emergency-Dog bite-adult An adult arrives at the urgent care clinic after being bitten on the hand by an aggressive dog that escaped from a neighbor’s fenced yard. The nurse cleanses the wound with providone-iodine and administers Human Rabies Immune Globulin (HRIG) and the first injection of the rabies vaccine. Which intervention is most important for the nurse to implement? A- Determine if the client has any allergies to antibiotics. B- Send client for a magnetic resonance image (MRI) of the hand C- Schedule administration of remaining rabies vaccine injections D- Notify local Animal Control Bureau about the dog bite 82. Medical Surgical-Immune/Hematology/Musculoskeletal-Myasthenia gravis-findings MYASTHENIA GRAVIS TAKING (MESTINON). WHAT FINDING REQUIRES INTERVENTION BY THE NURSE? A. EYELID DROOPING B.TINGLING EXTREMITIES C.UNCONTROLLED DROOLING 83. Medical Surgical-Integumentary-Rule of nines-estimate Patient with burns. What percent? a. 36% b. 27% c. 50% d.16% 84. Medical Surgical-Integumentary/Reproductive-Burns-monitor A client with superficial burns to the face, neck, and hands resulting from a house fires is admitted to the burn unit. Which assessment finding indicates to the nurse that the client should he monitored for carbon monoxide poisoning? A- Expiratory stridor and nasal flaring B- Mucous membranes cherry red color C- Carbonaceous particles in sputum D- Pulse oximetry reading of 80 percent. 85. Medical Surgical –Musculoskeletal-Fat embolism-S&S hesi pg 134 Fat embolism: A process by which fat tissue passes into the bloodstream and lodges within a blood vessel. Signs and symptoms: include central nervous system dysfunction that may progress to coma or death, irregularities in the heartbeat, respiratory distress, and fever. Anemia and thrombocytopenia (low platelet count) are common. Commonly, small hemorrhages are seen on the neck, shoulders, armpits, and conjunctiva. Posible asw: lowfever 86. Medical Surgical-Musculoskeletal-Gout-stress management Which expected outcome statement should the nurse include in a teaching plan of care. A client with management of an acute attack of gout? A. The client will avoid use of alcohol in managing stress B. The client will implement a high purine daily dietary regimen C. The client will use local heat application for acute pain D. The client will stop antigout medication once pain subsides 87. Medical Surgical-Musculoskeletal-RA-pain management Patient with rheumatoid arthritis joint pain and swelling, taking prednisone and ibuprofen, self management pain what information obtain A. Presence of bruising, weakness B. Amount of protein C.Therapeutic exercise daily D.Existence GI discomfort 88. Medical Surgical-Musculoskeletal-Risendronate teaching Which instruction is most important for the nurse to provide a client who receives a prescription for risendronate sodium to treat osteoporosis? a. Remain upright after taking the medication. b. Begin a weight-bearing exercise plan. c. Increase intake of foods rich in calcium. d. Schedule a bone test every year. 89. Medical Surgical-Neurological-Alzheimer’s-safe In planning care for a client with early stage Alzheimer’s disease, the nurse establishes the nursing diagnosis of, “Risk for injury related to impaired judgment.” Which intervention is most important for the nurse to include in this client’s plan of care? A. Offer the client frequent reassurance that he/she will be safe. B. Assign a UAP to provide the client with total personal care. C. Engage the client in regularly scheduled activities during the day. D. Arrange the client’s environment so the client can move about freely. If the client is aggressive you can use the wrist with doctor’s authorization 90. Medical Surgical-Neurological- Cervical cord injury Asw: Sharp pain Symptoms of a spinal cord injury may include: Head that is in an unusual position Numbness or tingling that spreads down an arm or leg Weakness Difficulty walking Paralysis (loss of movement) of arms or legs Loss of bladder or bowel control Shock (pale, clammy skin; bluish lips and fingernails; acting dazed or semiconscious) Lack of alertness (unconsciousness) Stiff neck, headache, or neck pain 91. Medical Surgical-Neurological-Increased ICP-papilledema Patient involves in an accident… which indicate increase of ICP: A. Nuchal rigidity/dystonia B.Confusion/papilledema C.Periorbital eccymocis D.Increase Glasgow scale 92. Medical Surgical-Neurological/Physical Assessment-Pupil constriction Asw:Pupila accommodation 93. Medical Surgical –Neurological /Sensory-Pregabalin Peripheral neuropathy Pregabalin 4 days, what indicate med is effective? A. GRANULATING TISSUE IN FOOT ULCER B. IMPROVED VISUAL ACUITY C. FULL VOLUME OF PEDAL PULSES D. REDUCE LEVEL OF PAIN 94. Medical Surgical –Oncology/Physical Assessment –Lymphatic cancer The nurse is palpating the lymph nodes of a 10 month old. Which findings should the nurse call to the attention of the health care provider? a. Enlarged, warm, tender preauricular node b. Enlarged no tender mobile occipital node c. Small discrete, mobile, no tender, inguinal node d. Small, firm, mobile nodules in the axial Otra pregunta: pt q le encontraron unos immobility node enlargerged,tender. Asw: maligna 95. Medical Surgical-Oncology/Reproductive-Breast cancer findings A female client with breast cancer who completed her first chemotherapy treatment out-patient cancer treatment center is preparing for discharge. Which behavior the client understands her care needs for the next week? a. Invite friends and family to visit while she is at home for the next week b. Rent movies and borrow books to use while passing time at home c. Schedule a lunch date with her best friend for 2 days from now d. Stock her refrigerator with healthy foods including fruits and vegetables OJO: SI APARECE UNA QUE HABLA DE DIMPLING of the skin ESA ES LA RESPUESTA 96. Medical Surgical-Operative-OR-supine position A patient surgery for more than 2 hours, what implementation or intervention? Answer: Put padding to the bony prominences (ESTO PUSO ANNERY Y LE SALIO BIEN) No es tie the extremity No es blanket and pillow 97. Medical Surgical-Operative-Postop-ambulation At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client’s medical record. Based on data contained in the record, what action should the nurse take before assisting the client with ambulation (click on each chart tab for additional information, be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record) A) Remove sequential compression devices B) Apply PRN oxygen per nasal cannula C) Administer a PRN dose of an antipyretic D) Reinforce the surgical wound dressing 98. Medical Surgical-Physical Assessment-Pain assessment Assessing client’s pain: A- “Tell me more how you respond (I DON’T HAVE ANSWER FOR THIS ONE, IF SOMEBODY GOT CORRECT LET US KNOW) 99. Medical Surgical-Physical Assessment/Respiratory-Pneumonia-priority assessment Patient with pneumonia ABG ph 7.24, CO2 65, CO3 24. Which intervention…plan of care daily A. Hypertension B. Maintain IV C. Check electrocardiogram daily D. Assess lung for increase pulmonary secretion *The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that she will be done before administering the medication. A- Determine which side of the body is weak B- Auscultate and breathe sounds C- Obtain and record client vital sign D- Ask the client about soft food preferences 100. Medical Surgical-Renal-Acute kidney injury (AKI)-POC A female client with chronic pyelonephritis expresses concern that she may have to undergo dialysis. What is the best initial response by the nurse? a. Offer to introduce the client to a dialysis nurse who can provide teaching about dialysis b. Explain the relationship between chronic kidney infection renal failure and dialysis c. Provide assurance that dialysis is not the usual treatment for kidney infections d. Assist the client to reduce anxiety and gain control by using guided imagery exercise 101. Medical Surgical-Renal-Chronic renal insufficiency Which symptoms is a characteristic of urethral colic in the client diagnosed with renal calculi? a. symptoms of irritation associated with urinary tract infection b. Acute, excruciating pain, wave-like pain radiating to the gemnitalia c. intense, deep ache in the cost vertebral region d. chills, fever and dysuria 102. Medical Surgical-Reproductive-Endometriosis A young adult female client with recurred pelvic pain for 3 years returns to the clinic for relief of severe dysmenorrheal. The nurse reviews her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client? A- Oral contraceptives increase the symptoms of endometriosis B- An option to diagnose disease extent and provide therapeutic treatment is laparoscopy C- Infertility is successfully treated with removal of intra-abdominal endometrial lesions D- The symptoms of endometriosis can increase with menopause 103. Medical Surgical-Respiratory-Chest tube-respiratory distress The UAP find a patient (chest tube) with shortness of breath call the RN. What is the first thing that the nurse implements? A- 2 L Oxygen B- Check the tube connection 104. Medical Surgical-Respiratory-Pulmonary function test A client with a 40 pack year history of smoking does not want to have a pulmonary function test conducted. Which of the following should the nurse explain to the client regarding this diagnostic test? A- ¨It is used to diagnose lung cancer so treatment can be started B- ¨It is used to determine the amount of oxygen that is in your lungs with every breath¨. C- ¨It measures your lung functioning¨. D- ¨It identifies the best interventions to help you quit smoking. 105. Medical Surgical-Respiratory-TB precautions ANSWER: AIRBORNE PRECAUTION 106. Medical Surgical-Respiratory-TB activated A male client recently release from a correctional facility arrives at the clinic with a cough, fever, and chills, active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply) A- Administer a purified protein derivate (PPD) test B- Schedule the client for a chest radiograph C- Obtain sputum for acid fast bacillus (AFB) testing D- Place a mask on the client until he is moved to isolation E- Send client home with instructions for a prescribed antibiotic 107. Medical Surgical-Sensory-Cataract extraction-nausea ANSWER: ZOFRAN OR ANTIEMETIC 108. Medical Surgical-Sensory-Pilocarpine-action A client is newly diagnosed with open-angle glaucoma and receives a prescription for the meiotic pilocarpin. The client asks how the eyes pressure will be controlled when the eyes drops are used on the surface. What explanation should the nurse offer when teaching about the therapeutic action of the ophthalmic drops? A- Once the pupil gets smaller, the amount of liquid made inside the eyes is reduced B- It is necessary to open the pupil to allow movement of the fluid from behind the iris C- The drops will reduce eye swelling which is causing increased ocular pressure D- The iris will constrict and contract away from the opening, thereby allowing it to drain 109. Pathophysiology-Neurological/Physical Assessment-Craniotomy-GCS When assessing a client who had a supratentorial craniotomy, what action should the nurse implement when determining the client’s Glasgow coma scale (GCS) rating? A- Determine the intracranial pressure. B- Check the patellar and radial reflexes. C- Inject cold water into the client’s ear. D- Instruct the client to raise an arm. 110. Pathophysiology/Medical Surgical-Immune/Hematology-Antihistamines Which conditions are most likely to respond to the treatment with antihistamines? (Select all that apply) A) Otitis media B) Allergy rhinitis C) Contact dermatitis D) Myocarditis E) Bronchitis 111. Pathophysiology/Medical Surgical-Immune/Hematology-WBC level- patho A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at elementary school this winter. Which question is best for the nurse to ask this client? a) “Do you realize that you will be exposed to many different kinds of germs?” b) “Have you considered that you are putting yourself at risk for developing infections?” c) “Are you aware that you do not have a fully functioning immune system?” d) “Is it possible that you will be in direct contact with the children at the school?” OJO CON ESTA DE ABAJO A client’s morning laboratory test results include leukocytes 3,500/mm3 or 3.5 x 10???/L (SI). Based on this laboratory result, which complaint is this client most likely to report to the nurse? a) Inability to walk without shortness of breath. b) Superficial cuts do not readily stop bleeding. c) A red streak and pain in right calf muscle. d) Persistent cough with yellow-colored sputum. 112. Pathophysiology/Medical Surgical-Musculoskeletal-Osteoarthritis-risk factor The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in the client’s history is a contributor to the osteoarthritis? a. Lactose intolerant since childhood. b. Recently treated for deep vein thrombosis. c. Long distance runner since high school. d. Photosensitive to a drug currently taking. 113. Pathophysiology/Medical Surgical-Neurological/Trauma/Emergency- Head injury-diabetes insipidus Polyuria can be defined as a urine output exceeding 3 L/24 h in adults and 2 L/m2 in children. It must be differentiated from the more common complaints of frequency or nocturia, which are not associated with an increase in the total urine output. Differential diagnosis has to be kept in mind when TBI patients undergoing neurosurgery have huge amounts of urine output because most cases of polyuria, at this time, are not caused by DI (Seckl and Dunger 1989). The more common causes are excretion of excess fluid administered during surgery and an osmotic diuresis, resulting from treatment aimed at minimizing cerebral edema using mannitol or glucocorticoids (Bohn, Davids et al. 2005). 114. Pathophysiology/Professional Issues/Medical Surgical-Nursing Process- Resp acidosis-pneumonia PNEUMONIA IS DIAPHORETIC AND CONFUSED: ANSWER: OBSERVE FREQUENTLY ESTA NO SALIO PERO HAY QUE VERLA A client with a history of upper respiratory symptoms is admitted to the unit with chest tightness, productive cough and difficult breathing. The client ABG is respiratory acidosis. What lab the nurse expects to be high? a. Ph b. Arterial ph. c. HCO3 d. Paco2 115. Pediatrics-Cardiovascular-Left sided heart failure A nurse is assessing a 2 year-old child with left sided heart failure. Which assessment finding should the nurse report to the healthcare provider immediately? a. Penorbital edema noted bilaterally after napping b. Crackles heard in lower lobes of lungs bilaterally c. An apical heart rate of 120 beats per minute d. Liver palpated 2 cm below right costal margin 116. Pediatrics-GI/Hepatic-Diarrhea-specimen Stool Specimens Stool specimens are frequently collected in children to identify parasites and other organisms that cause diarrhea, to assess gastrointestinal function, and to check for occult (hidden) blood. Ideally, stool should be collected without contamination with urine, but in children wearing diapers this is difficult unless a urine bag is applied. Children who are toilet trained should urinate first; flush the toilet; and then defecate in the toilet, a bedpan (preferably one that is placed on the toilet to avoid embarrassment), or a commercial potty hat. Stool specimens should be large enough to obtain an ample sampling, not merely a fecal fragment. Specimens are placed in an appropriate container, which is covered and labeled. If several specimens are needed, the containers are marked with the date and time and kept in a specimen refrigerator. Special care is exercised in handling the specimen because of the risk of contamination. No creo q es la rest*A child with diarrhea: Antibiotics 117. Pediatrics-Gwth & Devlp/Physical Assessment-Child interview-school age Child 9 years old: A- Talk directly to the child B- Ask the child if the parents are saying the true C- Tell the parents to get out of the room 118. Pediatrics-Immune/Hematology- von Willebrand’s disease-POC (Bleeding disorder) A- Decrease exposure to infection B- Decrease contact with other children C- Decrease contact with cold graft D- Guard against bleeding injuries 119. Pediatrics-Integumentary-Burns-hydrotherapy *Answer: Let the child touch the water 120. Pediatrics-Musculoskeletal- Congenital hip-1st action 2 days old infant legs flexed with limited abduction, what is the next action that the nurse take: A- Range of motion exercise B- Notify MD C- Document as an normal finding D- Continue with the care 121. Pediatrics-Neurological-Vegetative state-adolescent Un Nino en estado vegetative hace 5 meses. RN q hacer *Answer: Talk to the child 122. Pediatrics- Renal-Nephrotic syndrome-I&O 2 year old child with nephrotic syndrome taking corticosteroids is edematous and fatigue. What action the nurse implement first. A- Sign and symptom of Cushing B- Restrict sodium C- Intake and output… D- Measure abdominal girth for 2 days 123. Pediatrics-Respiratory-Cystic fibrosis-med The nurse is evaluating the home care teaching of a family who has a child with cystic fibrosis. Which parental action indicates correct understanding of the child’s home care? a. Performs postural drainage after meals b. Supplements diet with water-soluble vitamins and fluids c. Plans a diet high in fat and calories d. Gives pancreatic enzymes before every meal and snack 124. Pediatrics-Respiratory-RSV-isolation *Answer: Contact precautions 125. Pediatrics/Medical Surgical-Respiratory-Theophylline-toxicity PEDI A 4-YEAR-OLD child hospitalized with asthma is receiving theophylline. Which observation by the nurse warrants immediate intervention? A) The child heart rate is 110. B) The child’s breath sounds indicate bilateral expiratory wheezing. C) The child is sitting straight up in bed. D- The child is nauseated and irritable. 126. Professional Issues-Cultural/Spiritual/Leadership/Legal/Ethical-Post mortum care PATIENT DIES AND FAMILY WANT TO SEE HIM BEFORE THE HOME FUNERAL ARRIVED, THE NURSE SHOULD ENTER FIRST TO THE ROOM (SELECT ALL THAT APPLY): A- REMOVE THE RESUSCITATION EQUIPMENT B- REMOVE THE DENTURES C- CLOSE HIS EYES D- PUT A PILLOW UNDER THE HEAD E- USE A SHROUD BAG 127. Professional Issues-Documentation/Leadership/Legal/Ethical-Team management-documentation When the nurse manager and the nursing staff review entries into the electronic medical records (EMR), they determine that procrastination is often the reason for late-entries. What recommendation should the nurse manager offer to the nursing staff? A- Document routine care as provided and complex care at the end of shift B- Enter tasks in the EMR as the client's priority needs are addressed C- Document nursing care procedures between time-dependent cares D Keeps notes and enter all documentation at the end of the shift 128. Professional Issues-Leadership-Conflict resolution-arguing staff Two unlicensed assistive personal (UAP) are arguing loudly in the hallway of an extended care facility about who will shower a male resident who defecated in his bed. What action is best for the charge nurse to take? A) Instruct both UAPs are to shower the client immediately. B) Shower the client with the help of a practical nurse. C) Document the conflict in the employee personnel files. D) Reassign the client’s care to another staff member. 129. Professional Issues-Leadership/Legal/Ethical-Decision to strike NURSING STRIKE BARGAINING: A- THE ROLE OF THE NURSE AS A PROFESSIONAL (Esta no me recuerdo las otras opciones pero esa no es la respuesta) (I don’t remember the other options but this is not the answer) 130. Professional Issues-Leadership/Legal/Ethical-Delegate-follow- up As team leader, the nurse is caring for a group of clients with the help of a practical nurse (PN) and experienced unlicensed assistive personnel (UAP). Which nursing actions should the nurse assign to the PN? (Select all that apply) A- Change surgical dressing daily for a client who had an abdominal hysterectomy B- Obtain postoperative vital signs for a client with an epidural analgesic after having a knee arthroplasty C- Start a blood transfusion for client who just returned to the room following a below knee amputation D- Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM) OJO ESTA NO FUE LA QUE SALIO 131. Professional Issues-Leadership/Legal/Ethical-Prescription-poorly written The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are eligible and it appears the healthcare provider used several abbreviations in the prescription. What action should the charge nurse take? a. Report the situation to the house supervisor b. Complete and incident (variance) report c. Call the healthcare provider who wrote the prescriptions d. Contact the healthcare provider review board for instructions 132. Professional Issues-Leadership/Legal/Ethical-Sexual harassment A- “I know you are a good nurse and can handle this client” (Solo me recuerdo de esta opcion xq fue la que puse pero me salio mal) (This is not correct but I just remember this option) Possible asw: cambiar el pt creo q es 133. Professional Issues-Leadership/Legal/Ethical-UAP assign-escort client *Answer: Transfer the patient in the wheelchair to another room 134. Professional Issues-Leadership/Legal/Ethical/Nursing Process-Advocate 135. Professional Issues/Medical Surgical-Documentation-Heart sounds- murmur SOUND A- Murmur B-S1, S2 C- S1, S2, S3 D- Peripheral (No me recuerdo bien esta opcion) 136. Professional Issues/Medical Surgical-Legal/Ethical-Forensic nursing clothing A young adult male is brought to the emergency room with a multiple gunshot wounds in the chest abdomen, and head. After collecting the client’s blood- saturated clothing as forensic evidence or the medical examiner, which action should the nurse implement? A) Drop the clothes in a plastic bag and seal the bag with transported tape. B) Place clothing in a large specimen container and send to the pathology lab. C) Place the folded clothes in a paper bag transfers it to red biohazard bag. D) Roll the clothing in a towel and cover it with an impermeable drape. 137. Professional Issues/Medical Surgical-Legal/Ethical-SBAR-call HCP- femoral stent ABDOMINAL LEFT FEMORAL ANGIOPLASTY: A- SURGEON NEEDS TO SEE B- LEFT PHERIPHERAL PULSES 138. Professional Issues/Medical Surgical-Teaching-Dronedarone-client instructions DRONEDARONE medication and the pt take grapefruit what we need to teach indiet. A- DISCONTINUE B- AVOID C- NOTIFY (WE HAVE TO VERIFY THIS ONE) 139. Professional Issues/Medical Surgical-Teaching-Orchiectomy-wound care Testiculo remove: asw: … Support 140. Psychiatric/Mental Hlth-Abuse-CAGE scoring The questionnaire asks the following questions • Have you ever felt you needed to Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt Guilty about drinking? • Have you ever felt you needed a drink first thing in the morning (Eye- opener) to steady your nerves or to get rid of a hangover? The CAGE questionnaire, among other methods, has been extensively validated for use in identifying alcoholism. CAGE is considered a validated screening technique, with one study determining that CAGE test scores >=2 had a specificity of 76% and a sensitivity of 93% for the identification of excessive drinking and a specificity of 77% and a sensitivity of 91% for the identification of alcoholism. The nurse is with a patient doing a CAGE questionary 3 positive response. What the nurse…. A- Is a questionary for substance abuse B- 1 positive seek help for alcohol dependence C- Al least 2 positive strongly alcohol dependence D- All positive suggest alcohol dependence 141. Psychiatric/Mental Health-Anxiety/Communications-Communication- caregiver support The home care nurse go to visit a patient with Alzheimer’s and find the wife crying, what happen with your husband and the wife respond “watch it with your own eyes”. What action should the nurse…? A- Encourage wife to leave home B- Ask the wife to observe the assessment to learn how to take deal with the situation C- As soon as the client care is completed provide wife with family support group D- Sit with the wife and talk about her concerns 142. Psychiatric/Mental Health-Anxiety/Communications-PTSD-maladaptive behavior ADULT MALE WITNESSED THE MURDER: A- “IT’S BETTER THAN KILLING SOMEONE” B- “TELL ME MORE ABOUT THE MURDERYOU RECENTLY WITNESSED” C- “YOU FEEL GUILTY FORTHE MURDER” 143. Psychiatric/Mental Health-Anxiety/Communications/Psychoses-Manic acting out A group of students along with the nurse are on a tour of the hospital in the area of psychiatry and while they were down the hall one patient says "want to see a crazy patient” and start to jump and scream and make hands like a chicken . What should the nurse do? A- Ignore the patient and continue with a tour B- Give PRN anxiety medication C- Call the security D- shake it and bring it to normal state 144. Psychiatric/Mental Health/Fundamentals-Abuse/Basic Nursing Skills/Mobility/Safety-Restrains-physical harm Chequiar la circulation en la restrains or reposition the restrains 145. Psychiatric/Mental Hlth/Fundamentals-Abuse/Basic Nursing Skills/Nutrition-Bulimia-maintain weight Asw:Scheduled meal and snack Bulimia nervosa is an eating disorder characterized by binge eating and purging, or consuming a large amount of food in a short amount of time followed by an attempt to rid oneself of the food consumed (purging), typically by vomiting, taking a laxative, diuretic, or stimulant, and/or excessive exercise, because of an extensive concern for body weight. 146. Psychiatric/Mental Health/Fundamentals-Anxiety/Communications/Basic Nursing Skills/Safety-Aggression-triggering A client who has a history of aggressive and hostile behavior is in the triggering phase of the aggression cycle. Which action should the nurse implement first? A) Encourage the client to verbalize angry feeling. B) Obtain staff assistance to confront the client. C) Administer a PRN medication to the client D) Physically escort the client to a quiet cooling off area. 147. Psychiatric/Mental Health/Fundamentals/Maternity/Professional Issues- Depress/Grief/Basic Nursing Skills/Nutrition/Postpartum/Nursing Process-PP depression-goals-POC Una pt con postpartun y dejo de comer y perdio peso . Short goal Asw: 100ml and 3 food 148. Psychiatric/Mental Health/Fundamentals/Medical Surgical- Psychoses/Basic Nursing Skill/Safety-Priority-Endocrine Unit A male client, who had a total laryngectomy two days ago, is transferred from the intensive care unit to a private room close to the nurse’s station. The nurse recognizes that the client is anxious. Which intervention should the nurse implement? a. Encourage a family member to stay with the client at all times b. Answer the client’s call signal in person quickly after the calls c. Explain the emergency procedure for loss of airway to the client d. Provide the client with a suction catheter to allow for self-suctioning 149. Psychiatric/Mental Health/Geriatrics/Medical Surgical- Anxiety/Communications-Colostomy-postop confusion . Psychiatric/Mental Health/Maternity-Abuse/Newborn-Neonate-cocaine-withdrawal A neonate whose mother used cocaine during pregnancy is demonstrating excessive shrill cry, and frequent vomiting. What action should the nurse perform first? A. Request a neurology assessment. B. Wrap the infant in warm blankets. C. Obtain a serum screen. D. Burp the infant to eliminate gas. • Psychiatric/Mental Health/Maternity/Anxiety/Communications/Intrapartum-Angry family member The patient was in pain and mom was saying she was ready for cesarean because she knew what had already had 8 children. A- Call the security B- Ask her to leave the room C- Call the charge nurse • Psychiatric/Mental Health /Medical Surgical-Anxiety/Communications- Hip fracture An elderly patient who lives alone and falls, hip fractures and goes to hospital. She was worried about her dog. (Select all that apply): a- Put 2 pillows b- PRN med c- Contact social worker d- Ignore the patient • Psychiatric/Mental Health/Pathophysiology/Medical Surgical-Abuse- Hepatic encephalopathy ( ammonia level alto) A male client with a long history of alcoholism is admitted because of mild confusion and fir motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurse to include in the client’s plan of care? A) Observe for changes in level of consciousness B) Provide grief counseling for client and his family C) Involve the client’s family in healthcare decision D) Determine client’s current blood alcohol level. • Psychiatric/Mental Health/Pediatrics-Depress/Grief-Grief-adolescent The child at school said that had a lot of headache and go to the nurse. What comment made by the child concerned the nurse? Answer: The child says something that wants to see his mom • Psychiatric/Mental Health/Professional Issues- Anxiety/Communications/Leadership/Legal/Ethical-EOL care-fear Patient in hospice care at home fear dying will be painful… A- Encourage to talk about…. B- Explain that pill will be given… C- Provide therapeutic touch with comfort and support • Psychiatric/Mental Health/Professional Issues- Anxiety/Communications/Leadership/Legal/Ethical-Med error- communication 2 nurse discutiendo en el pasillo es el pt escucho que le dieron med mal. Q hacer? Asw: apologies with the pt • Psychiatric/Mental Health/Professional Issues-Depress/Grief/Nursing Process-Depression-nursing problem • Psychiatric/Mental Health/Professional Issues- Psychoses/Documentation/Nursing Process-Delusions-POC Deliria/delusions Delusions are beliefs that guide one's interpretation of events and help make sense out of disorder. The delusions may be comforting or threatening, but they always form a structure for understanding situations that otherwise might seem unmanageable. A delusional disorder is one in which conceivable ideas, without foundation in fact, persist for more than 1 month. These beliefs are not always bizarre and do not originate in psychotic processes. Common delusions are of being poisoned, being followed, their children taking their assets, being held prisoner, or being deceived by a spouse or lover. One older woman persistently held onto the delusion that her son was coming to pick her up and take her home, although her son had been dead for 10 years. • Psychiatric/Mental Health/Professional Issues-Medical Surgical- Abuse/Anxiety/Communications/Legal/Ethical-Date rape-denial The patient from college that was drinking last night with friends. Go to the hospital… A- I’m sorry to hear this B- You remembered if someone put something in the drink or if she remember what she drink C- You know the people who did this D- You feel guilty about what happened to you • Psychiatric/Mental Health/Professional Issues-Medical Surgical -Anxiety/Communications/Depress/Grief/Leadership-Liver transplant-anger The RN sends the UAP to the room to do care to the patient but the patient was anger and yelling to the UAP. What can the UAP do? A- Schedule the care daily B- Not enter more in the room C- Give care earlier D- Give care options participate EXTRA QUESTIONS: 1- A PATIENT WITH CYSTIC FIBROSIS IS… HUMAN DEOXYRIBONUCLEASE. WHAT FINDING REQUIRE THE NURSE INTERVENTION? A- INCREASE MUCUOS THINNED B- INCREASE 2 POUNDS C- DECREASE FREQUENCY STEATORRHEA 2- LARGE BLISTER (BACK) CHEST SOAKED SEROSANGUINIOUS DURING ASSESSMENT. WHAT FINDING REQUIRES IMMEDIATE INTERVENTION? A- HEADACHE B- FEVER/CHILLS C- DECREASE BLOOD PRESSURE D- DIZZNESS 3- TWO RN QUE DISCUTIAN POR UN MEDICAMENTO Y EL PACIENTE ESCUCHA QUE ERA LO PRIMERO QUE HACIA EL CHARGE NURSE: -CHARGE NURSE APOLOGIZE WITH THE PT -LOOK FOR DOCUMENTATION -MEETING WITH 2 NURSES AND REVIEW THE PRIVACY OF THE PT AND POLICY OF THE HOSPITAL Hesi med surge review Package of Pictures 2 of 55 What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. Sexual activities may be resumed upon return home b. Light housekeeping is permitted but avoid heavy lifting c. Use a metal eye shield on operative eye during the day d. Administer eye ointment before applying eye drops ANS: B 3 of 55 A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound ANS: A 4 0f 55 An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake ANS: C 5 of 55 An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. blood ph of 7.30 b. glucose of 350 mg /dl c. white blood cell count of 15000mm d. potassium of 2.5 meq/l ANS: D 6 of 55 A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f ANS: A 7 of 55 An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma ANS: C 8 of 55 A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a.collect a clean catch specimen b.palpate the suprapubic region c.instruct to wipe from front to back d.inquire about recent sexual activity ANS: A 9 of 55 A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a. offer the client reassurance that this information indicates that the clients cancer cells are benign b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client in the healthcare provider has giving her any information about the classification of her cancer d. help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly ANS: C 10 of 55 A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first? a. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5%albumin IV ANS: C 11 of 55 A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr? =9 12 of 55 The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis? a. upper mid abdominal gnawing and burning pain b. severe abdominal cramps and diarrhea after eating spicy foods c. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion ANS: A 13 of 55 The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a.the xenograft is taken from nonhuman sources b.grafting increases the risk for bacterial infection c.as the burn heals the graft permanently attaches d.grafts are later removed by debriding procedure ANS: A 14 of 55 A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss ANS: A 15 of 55 During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited ANS: D 16 of 55 When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching ? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate ANS: B 17 of 55 A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants ANS: D 18 of 55 A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg ANS: D 18a. of 55 Esta es otra 18 que hay en fotos pero es diferente After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take? a. obtain stool specimen to evaluate for occult blood and fat content b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days d. advice the client to stop taking the drug and contact the healthcare provider ANS: C 19 of 55 Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies d. obtain samples for complete blood count and cultures ANS: B 21 OF 55 A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain ANS: A 22 of 55 A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic symdrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the clients central venous catheter. When the clients respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) (POSSIBLE ANSWER) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload ANS: D 22 of 55 ESTA ES OTRA 22 QUE ESTABA EN FOTOS PERO ES DIFERENTE When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the clients upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch ANS: D 25 of 55 A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nytroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute ANS: C 26 of 55 An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? a. BUN creatinine specific gravity b. White blood count, hemoglobin hematocrit c. PH,PCO2, HC03 d. LDH OR LD, SGOT OR ALT, SGPT OR AST. ANS: D 27 OF 55 An elderly post operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone? a. her respiratory rate is 7 breath/minute b. she indicates that she feels as if she cannot get enough air to breath c. she has intercostal retractions and bilateral wheezing is auscultated d. her pulse oximeter is 89% on room air ANS: A 28 of 55 Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention? a. urinary output equal to intake b. no terminal urinary dribbling c. denies stress incontinence d. absence of xerostomia ANS: A 29 of 55 Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The clients blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)? a. Lorazepam (Ativan) 2mg IM b. Chlorpromazine (thorazine) 50 mg IM c. Prochlorperazine (Compazine) 5 mg IM d. Hydromorphone (Dilaudid) 2 mg IM ANS: A 33 of 55 Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? a. call the healthcare provider f you develop gynecomastia b. Take the medication in the morning c. Avoid caffeine and smoking d. Increase your consumption of bananas and oranges ANS: B 34 of 55 A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon? a. after meals to increase endogenous insulin secretion b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur d. when unable to eat during sick days ANS: C 35 of 55 A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately ANS: A 36 OF 55 A female client is being treated for tuberculosis with rifampin (rifadin) Which statement indicates that futher teaching is needed? d- I will take my usual contraceptive for birth control ESTA PREGUNTA ESTABA ESCRITA EN LAS OJAS DE FOTOS 38 of 55 A client is discharged with a prescription for warfarin ( Coumadin). What discharge instructions should the nurse emphasize to the client? a. take a multi vitamin supplement daily b. use an astringent for superficial bleeding c. avoid going barefoot especially outside d. include large amounts of spinach in the diet ANS: C 39 of 55 In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasally which serum lab test is most important for the nurse to monitor? a. osmolality b. calcium c. platelets d. glucose ANS: A 40 OF 55 After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame? a. 2 hours b. 5 minutes c. 1 hour d. 15 minutes ANS: D 41 of 55 A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain? a. capillary refill b. body temperature c. muscle strength d. breath sounds ANS: D 43 of 55 A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision ANS: A 44 of 55 A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. toasted wheat bread and jelly b. cheese and crakers c. cold cereal with skim milk d. fruit flavored yogurt ANS: A 45 of 55 The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? a. Facilitates transport of glucose into the cell b. Increases intracellular receptor site sensitivity c. Stimulates function of beta cells in the pancreas d. Delays carbohydrates digestion and absorption ANS: A 46 of 55 The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription? a. Eszoplicone (Lunesta)10 mg orally at bed time b. Zolpidem 10 mg orally at bed time c. Temazepan orally at bed time d. Ramelteon orally at bedtime ANS: A 47 of 55 A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the clients statement what nursing action is most important for the nurse to take? a. Encourage the client to take medication with food to decrease GI distress b. Advice the client that the medication should be stopped gradually rather than abruptly. c. Review the clients dosing schedule to ensure he is taking the prescribed amount d. Assess the client for other indication of adverse effects of corticosteroid ANS: B 48 of 55 Fifteen minutes after receiving sulfa athenozole . A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement? a. Auscultate lung sounds for wheezing b. Review the clients list if drugs allergies c. Add sulfamethinozole to clients allergies d. Check neurological vital signs ANS: B 49 of 55 Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients? a. stop taking prescribed antibiotics when symptoms decrease b. avoid using antibiotics when suffering from colds or the flu c. ask the healthcare provider to prescribe the newest antibiotic when needed d. request a prescription for first time vancomysin for a sore throat ANS: B 50 of 55 A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide? a. Advise the client once symptoms occur is too late to receive an influenza vaccination b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza d. Instruct the client that over the counter medications are sufficient to manage influenza symptoms ANS: B 51 of 55 Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement? a. stop medication infusion and notify the healthcare provider of the adverse effect b. increase the rate of the infusion to complete the dose of the medication more rapidly c. continue the infusion and administer a prn antiemetic prescription d. reasurre the client that the nausea is not related to the iv infusion ANS: C 52 of 55 The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimers disease as an intervention for which client problem? a. fluid volume excess b. disturbed though processes c. chronic pain d. altered breathing patterns ANS: B 53 of 55 To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse? a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) b. Hematocrit 45% c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) d. Platelet count of 100,000/mm3 or 100x10??/ L (SI) ANS: D 54 of 55 A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral hypoglycemic agent. The primary health care provider prescribes ad additional medication injected exenatide (byetta). Which information is most important for the nurse to teach this client? a. Administer subcutaneously after meals b. Consume additional sources of potassium c. Notify the healthcare provider if anorexia occurs d. Watch for signs of jitteriness or diaphoresis ANS: B 55 of 55 A client is who is diagnose with schizophrenia receives a prescription for a atypical antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical antipsychotic agents? a. observe the client hallucinatory behaviors b. obtain the client fingerstick glucose levels c. measure the clients lying and standing blood pressure d. determine the clients abnormal involuntary movements scale (AIMS) ANS: B 1- A client with pheocromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain first. Blood pressure 2- The drainage in the chest tube of a client with emphysema has changed from clear watery fluid. What action would be best for the nurse to take/ Maintain the current IV antibiotic schedule 3- A client is admitted with a sudden onset of right sided the nurse complete first? Observe for peripheral edema 4- When planning care for a client newly diagnose with open angle glaucoma, the nurse identifies a priority nursing diagnosis of “ Visual sensory/perceptual alterations”. This diagnosis is based on which etiology? Decreased peripheral vision 5- A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement? Call the PACU nurse to prepare for prolonged ventilatory support Also know that PACU is BP, Respiration and Pulse 6- A client who is receiving packed red blood cells develops nausea and vomiting. What action should the nurse take first? Stop the infusion of blood Te lo pueden poner como hemodialysis y tambien es STOP transfusion 7- A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat, and feeling shaky. What should the nurse do first? Determine the client current glucose level 8- After suctioning the patient with an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective? Increase in breath sounds 9- The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? Provide additional oral fluid intake Also with TURP you must know that 3l of water a day is needed 10- Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction? Risk for injury related to effects of thrombolysis 11- The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange? The client demonstrates effective coughing and deep breathing exercises 12- When caring for a client with nephrotic syndrome which assessment is most important for the nurse to obtain? Daily Weight 13-A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse? Gastroccult positive emesis 14- A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? • No specific nursing action is required • Instruct the client to empty the bladder • Collect a clean catch urine specimen • Obtain vital signs and breath sounds ANS: D 15- The nurse positions a male client for a lumbar puncture by placing him in the side- lying position with his knees flexed and pulled toward his trunk. What action should the nurse implement next? • Call another nurse to assist the healthcare provider • Provide a small pillow for the client to curl around • Instruct the client to perform a Valsalva maneuver • Support the client’s head bent forward to the chest ANS: D 16- When teaching a client with osteoporosis to increase weight-bearing exercise, how should the nurse explain the purpose of this activity? • Strengthen leg muscles • Promote venous return • Increase bone strength • Restore range of motion ANS: C 17- A male tells the clinic nurse that he is experiencing burning on urination, and assessment that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? • Observe the perineal area for a chancroid-like lesion • Obtain a specimen of urethral drainage for culture • Identify all sexual partners in the last four days • Assess for perineal itching, erythemia, and excoriation ANS: D 18- An older female client with long term type 2 diabetes mellitus (DM) is seen in the doctor routine health assessment. To determine if the client is experiencing any long-term complications of DM, which assessments should the nurse obtain? Select all that apply: • Visual acuity A • Serum creatinine and blood urea nitrogen (BUN) B • Signs of respiratory tract infection C • Sensation in feet and legs D • Skin condition of lower extremities E ANS: A ; B ; D ; E . 19- Which laboratory test result is most important for the nurse to report to the surgeon prior to a client’s scheduled abdominal surgery? • Potassium level of 4 mEq/liter • Blood glucose of 90 mg/dl • Serum creatinine of 5 mg/dl (POSSIBLE ANSWER) • Hemoglobin level of 13 grams ANS: D 20- A client who has a history of long-standing back pain treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this client’s pain management during the postoperative period? • Use minimal parenteral opioids for surgical pain, in addition to oral methadone • Maintain client’s methadone, and medicate surgical pain based on pain rating • Consult with surgeon about increasing methadone in lieu of parenteral opioids • Make no changes in standard pain management for this surgery and hold methadone. ANS: B 21- The nurse applies an automatic external defibrillator (AED) to a client who collapsed in an exam room at a community clinic. What action should the nurse take next? • Determine the defibrillator reading • Assess the client’s oxygen saturation • Bring a crash cart to the exam room • Measure the client’s blood pressure ANS: B 22- Which change in lab values would indicate to the nurse that treatment for gout is successful? • Decreased serum uric acid • Decreased serum purine • Increased serum uric acid • Increased serum purine ANS: A 23- The nurse reports that a client is at risk for a brain attack (stroke) finding? • Jugular vein distention • Palpable cervical lymph node • Carotid bruit • Nuchal rigidity ANS: D 24- The nurse is assessing a group of older adults. What factor in a male client’s history puts him at greatest risk for developing colon cancer? • Is excessively exposed to sunlight • Eats a high-fat diet • Smokes cigars (POSSIBLE ANSWER) • Has intestinal polyps ANS: D 25- While taking routine vital signs at 0400 AM, the nurse notes that a client who had a total knee replacement the previous day has a heart rate of 126 beats/minute. What action should the nurse take first? • Compare heart rate trends with blood pressure trends ( POSSIBLE ANSWER) • Review the medical record for a history of cardiac disease • Check surgical drainage system and bandage for bleeding • Determine current pain level using a 10-point scale ANS: C 26- A client who suffered an electrical injury on the left foot is admitted to the burn include in this client’s plan of care? (incomplete) • Assess lung sounds q4 hours • Perform passive range of motion • Evaluate level of consciousness . Continuous cardiac monitoring ANS: D 27- The nurse is taking a client’s blood pressure sphygmomanometer cuff is inflated. What (incomplete) • Administer a prescribed PRN antianxiety • Assess the client’s recent serum calcium • Notify the healthcare provider of the • Prepare to implement seizure precautions ESTA NO TIENE RESPUESTA 28- A client with eczema is using an over-the-counter (OTC) topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response? • Decreased weeping of ulcerations in affected area • Healing with a return to normal skin appearance • Reduced pain in eczematous areas • Hydration of affected dry skin areas ANS: B 29- During an annual health check, the clinic nurse updates an adult female’s health history. When discussing the woman’s history of lactose intolerance, the client reports that it has been years since she last consumed dairy products. What dietary suggestions should the nurse recommend to help ensure that the client receives an adequate intake of calcium? Select all that apply: • Increase intake of salmon, sardines, tofu, and leafy green vegetables • Sip a half-cup of mil during a mid-day meal at least every other day • Eat at least six servings of citrus fruits weekly • Include 2 to 3 servings of yellow and green squash weekly • Take a calcium supplement with vitamin D daily ANS: A ; C ; E. 30- A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse’s assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? • Review client’s history for possible exposure to TB • Instruct the client to return for a repeat test in 1 week • Refer client to a healthcare provider for isoniazid (INH) therapy • Document negative results in the client’s medical record ANS: A 31-A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement? • Inform the client that it is the nurse’s responsibility to reposition • Provide an overhead trapeze to the bed for the client to use • Place a draw sheet under the client to assist with repositioning • Administer an intravenous PRN anti-anxiety medication ANS: B 32- In planning care for a client with pneumonia, which nursing problem should the nurse identify as the priority? • Impaired gas exchange related to the effects of alveolar-capillary membrane changes • Acute pain related to the effects of inflammation of the parietal pleura • Deficient fluid volume related to fever, infection, and increased metabolic rate • Disturbed sleep pattern related to pain, dyspnea, and hospitalization ANS: A 33-A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? • Encourage frequent mouth care • Administer a topical analgesic per PRN protocol • Cleanse the tongue and mouth with glycerin swabs • Obtain a soft diet for the client ANS: B 33- A client returns from surgery following a hiatal hernia repair via Nissen fundoplication. Which position should the nurse implement for this client? • Right side-lying to promote stomach emptying • Prone to apply external pressure to the suture line Left side-lying to reduce stress on the suture line 30 degree semi-Fowler’s to drop the diaphragm ANS: D 34- An adult woman with Grave’s disease is admitted with severe dehydration is currently restless and refusing to eat. Which action is most important for the nurse to implement? • Keep room temperature cool • Determine the client’s food preferences • Maintain a patent intravenous site • Teach the client relaxation techniques ANS: C 34- The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? • Administer initial dose of broad-spectrum antibiotic • Instruct the client to force fluids hourly • Obtain results of culture and sensitivity of CSF • Assess the client for symptoms of hyponatremia ANS: C 36- A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? • Schedule an appointment for the client to see the healthcare provider • Advise the client to apply plastic wrap over the ointment to promote healing • Explain that the client needs to complete all prescribed doses of the medication • Instruct the client to continue the ointment until all erythema is relieved ANS: A 37- During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement? • Palpate for abdominal distention • Clamp drainage tube for 5 minutes • Continue to monitor the fluid output • Send fluid to the lab for analysis ANS: C 38- The nurse assesses the dressing of a client who has just returned from post-anesthesia and finds that the dressing is wet with a moderate amount of bright red bloody drainage. What action should the nurse take? • Replace dressing with a new sterile dressing, and monitor the wound hourly until bleeding is stopped • Call surgery and request that the surgeon see the wound prior to leaving the hospital • Reinforce the dressing and document that a moderate amount of sanguineous drainage was on the dressing • Document that the dressing was saturated with serious drainage, and do not change the dressing ANS: B 39- While the home health nurse is making a home visit, a client with a history of seizures demonstrates tonic-clonic seizure activity. What action should the nurse implement first? • Direct a family member to call emergency services • Ascertain the trigger event • Protect the client’s head with a pillow • Observe the postictal breathing pattern ANS: C 40- A client who weighs 176 pounds is admitted to the intensive care unit with a serum glucose level of 600 mg/dl and a serum acetone level of 50 mg/dl. Regular insulin at a rate of 0.1unit/kg/hour is prescribed. The pharmacy provides a solution of Regular insulin 100 units/100 ml of normal saline. The nurse should set the infusion pump to deliver how many ml/hour? (Enter numeric value only) = 8ML/H 41- A client whose history includes IV drug abuse is admitted to the intensive care unit (ICU) with Kaposi’s sarcoma associated with Acquired Immune Deficiency Syndrome (AIDS). Which intervention is most important for the nurse to include in the client’s plan of care? • Observe for adverse medication reactions • Assess for signs of AIDS dementia • Identify signs of opportunistic infections • Locate local HIV support groups ANS: C 42-(Photo) The charge nurse observes a newly employed nurse gathering equipment to obtain a venous blood sample from a client’s implanted port. The nurse has obtained the equipment seen in the photo. What actions should the charge nurse take? (Select all that apply) • Guide the nurse in inserting the needle at a 45 degree angle • Remind the nurse to wear sterile gloves for this procedure • Instruct the nurse to obtain several red-topped tubes • Determine if the nurse has ever performed this skill • Assist in obtaining the correct needle to access the port ANS: D; E 43- After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Send another nurse for an emergency tracheotomy set B. Call respiratory therapy to give a breathing treatment C. Review the client's complete list of allergies D. Prepare a dose of Epinephrine (Adrenalin ) . ANS: D 44- The nurse is reviewing blood pressure readings for a group of client's on a medical unit. Which client is at the highest risk for complications related to hypertension? A. Young adult Hispanic female who has a hemoglobin of 11 gm and drinks beer every day B. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL C. Older Asian male who eats a diet consisiting of smoked, cured, and pickled foods. D. Post-menopausal Caucasian female who overeats and is 20% above ideal body weight ANS: B 1- Shingles--- Teach the pt about phantom pain 2- Shingles Select all the apply - pain - ability - skin integrity 3- PATIENT W/ EZCEMA APPLYING CREAM TTO IS WORKING: HEALING WITH A RETURN SKIN TO NORMAL APPEARANCE. 4- PT WITH OBESITY HIGH GLUCOSE LEVEL IS AT RISK FOR? CARDIOVASCULAR DISEASE 5- FOR ANEMIA WHAT DOESN’T HAVE IRON, WHICH FOODS ARE NOT RICH IN IRON? NO ORANGE 6- PT. W/ RISK OF DVT PERFORM ROM EXERCISES ALSO LEGS EXERCISE CAN BE OTHER WAY TO ANSWER 7- DISCHARGE FOR VENOUS ULCERS SELECT ALL APPLY? - ELEVATE THE FEET WHEN LAYING DOWN - CHECK BROWNISH SKIN AROUND THE ANKLES - VITAMINS HAY OTRA RESPUESTA POR AHI QUE ES SOCKS EN VEZ DE VITAMINS 8- PT W/ SIADH: HARD CANDY FOR THIRST. 9- PT ARRIVE TO PACU POSTOP MOANING WHAT TO DO: CHECK PULSE, BP AND RESPIRATIONS. 10- Pt. DIAGNOSED RECENTLY W/ DM HAVE NOT BEEN ABLE TO CONTROL GLUCOSE LEVEL DURING 3 MONTH WHAT SHOULD BE DONE: I PUT CHECK FOR A1C LEVEL (OTHER SAY ASSESS FOR WHAT SHE HAVE BEEN EATING 3 DAYS AGO). 11- WHEN BP IS HIGH ADMINISTER (LASIX) 12- PATIENT W/ ESOPHAEGAL VARICES HAVE NOT BE BLEEDING FOR 3 DAYS: PROVIDE LUKE WARM BROTH, ICE TEA AND LEMON POPSICLE. 13- CALCULO: 0.75 15- PT WITH OSTEOMALCIA RISK FOR INJURY 16- SBAR—EXPLAIN SPECIFIC REASON FOR URGENT NOTIFICATON TEMPERATURE 17- INTESTINAL BOWEL OBSTRUCTION PLACE THE PT 90 DEGREES SITTING 18- OSTEOARTHRITIS RISK FOR INJURY RELATED TO JOINT PAIN 19- BONE CANCER TYPE IV: GIVE OPIODS- NON OPIODS ANALGESICS. 20- HYPOTHYROIDISM RESTRICT SODIUM NA 122 21- PT ARRIVES TO CLINIC W/ NUCHAL RIGIDITY FEVER FOR 6 HOURS WHAT TO DO: PREPARE FOR ISOLATION PRECAUTIONS ( I PUT THIS ONE AND NO LUMBAR PUNCTURE) 22- INTERMITENT CLAUDICATION TEACHING BANDAGE ELASTIC WRAPED AROUND LEGS TAMBIEN PUEDE SALIR COMO PAIN TRACTION CAST NOTIFY MD (CAST NO MORE THEN 4HR) 23- PREOPERATIVE NURSING CARE ASSESS EMOTIONAL PREPAREDNESS ALSO CAN BE CONCERNS AND ANXIETY FOR SURGERY DEPENDE LA QUE PONGAN 24- TRACHESTOMY CARE: LEAVE OLD TIES ON UNTIL NEW ONES BE ON PLACE OR SECURE. 25- STERNAL TRACTION COMPLAINS OF PAIN ADMINISTER PRN MEDS 26- EXTERNAL FIXATION ADMINISTER PRN MEDS 27- MULTIPLE SCLEROSIS (MS) ADMINISTER ANTIMEDICS/ PRN AS NEEDED 28- FEMALE PATIENT HOW HAVE EPIGASTRIC PAIN FOR 3 DAYS HAVE BEEN TAKIN ANTACIDS AND NO RESOLVE ARRIVE TO HOSPITAL W/HR;128 BPM, BP110/70 WHAT IS THE MOST IMPORTANT INTERVENTION FINDING IN ASSESSMENT: ASSES FOR RADIATING JAW PAIN. 29- Pt. W. RADIACTIVE THERAPY WHAT TO TEACH/ RECOMMEND TO PROTECT THAT PART OF THE SKIN SPECIALLY FROM THE SUN 30- Pt WITH ALS WHAT TO DO TO PREVENT RESPIRATORY COMPLICATIONS: TEACH BREATHING TECNIQUES, USES SPIROMETER, AUSCULTATE FOR BREATH OR LUNG SOUNDS. 31- PT WITH LEFT LEF ULCER: KEEP LEG ELEVATED AS MUCH AS HE CAN. 32- PT WITH AN EXTERNAL DEVICE COMPLAINING OF PAIN: ASSESS FOR PHERIPHERAL PULSES. 33- CALCULATION 1G/0.4 G = 2.5 34- EXAMPLES OF DASH DIET: PEEL FRUITS AND VEGETABLES. 35- CHEST TUBE W/ A DRAINAGE CHANGING FROM CLEAR TO GREEN: KEEP IV FLUIDS. 36- PT W/ OPEN ANGLE GLAUCOMA SELECT ALL THAT APPLY: FREQUENT EYE EXAM TO ASSES FOR VISSION, USE DROPS TO DIMINSH IOP, AVOID EXTRENOUS EXERCICES LIKE JOGGING OR RUNNING ( YO PUSE SOLO ESAS 3 RESPUESTAS). 37- PT W/ HYPERTHYROIDISM DEVELOPING EXOSPHTALMUS: PRESCRIBE TEAR EYE DROPS. 38- PT VOMITING BLOOD LIKE THE PICTURE SAME AS HEMATENSIS: CHECK VITAL SIGNS ( ASI ESTA EN TODOS LOS PAPELES) AUSCULTATE LUNGS SOUNDS ( FUE LO QUE PUSO YADIRA) 39- PATIENT W/ ML FELL AND WHEN RECEIVING THE NURSE HE HAVE 2 PROJECTILE VOMITS WHAT SHE DO: PROVIDE ANTIEMETICS PRN . 40- PT W/ RAYNAUD SYNDROME WHICH WORK AS A DATA ENTRY CLERK: PROVIDE A SPACE TO WARM THE ENVIROMENT NEXT TO HER ( ALGO ASI ERA LA RESPUESTA). Y HAY OTRA RESPUESTA QUE SOLO DICE KEEP MONITORING 41- PATIENT THAT HAVE THE K= 6.7 WHAT MEDICATION PROVIDE: KAYELAXATE (TREATS HYPERKALEMIA). 42- COLON CANCER PT KAYELAXATE MED 43- RENAL INJURY KAYELAXATE MED 44- PT WITH A BRONCHOSCOPY AND DRINK A GLASS OF JUICE : DELAY THE PROCEDURE 6 HOURS 45- NEW PATIENT DIAGNOSES WITH DM TYPE IS RECEIVING TEACHING IN WHICH GLUCOMETER WILL BE THE BEST: ASSES FOR VISUAL ACUITY AND ABILITY TO READ OR SOMETHING LIKE THAT. 46- ABG (PH 7.25 PCO2 50 SODIUM 60 TACHY AND CONFUSION/ RESPIRATORY 47- ACUTE AGN DIET: RESTRICT NA INTAKE. 48- PT W/ A EXPRESSIVE APHASIA IS ANGER WHAT SHOULD DO THE NURSE: CVA COMMUNICATE W/ PICTURE BOARDS. 49- NURSE IS TEACHING THE WIFE IF A PATIENT DIAGNOSED W/ SEIZURE WHAT TO DO: TEACH HER HOW TO POSITION HIM 50- PT AFTER TTO OF SOMETHING AND WANTS TO EAT: NURSE ASSESS FOR BOWEL MOVEMENTS. 51- SLE: ASSESS FOR HEMATURIA 52- PATIENT ALLERGIC TO BANANA (LATEX): CALL TO MD AND OR STAFF TO BE CHANGE EVERYTHING FOR SINTHETIC MATERIALS, 53- SUBCUT EMPHYSEMA- TORACOTOMY WAS A SELECT ALL THAT APPLY: ASSESS FOR LUNG SOUNDS, NECK DISTENTION I THINK IT WAS AND OTHER CHOICE THAT I NOT REMEMBER NOW. 54- RESTLESS LEG SYNDROME CON FEOSOL: YO PUSE ASSESS FOR IRON AND FERRITIN. 55- BNP ADMINISTRATIVE FUROSEMIDE LASIX IV 56- PARKINSON PT WALKING REASURE THAT STEPPING ON CRACKLES IS NOT HARMFUL 57- ADDISON DISEASE TAKE CORTICOSTEROID MEDS 58- CARPO TONIC SYNDROME WEAR BRACE IN BOTH WRIST 59- PARKINSON AND ALZAIMERS PT TATICARDIC AND CONFUSION 60- CHECK SHOES FOR DIABETIC PATIENTS 61- MID ABDOMEN BURNING PAIN PEPTIC ULCER 62- ANTIBIOTICS CLEAR DRAINAGE IMPROVE 63- ALLOPRINOL FOR GOUT TAKE MEDS ALWAYS 64- BLOOD TRANSFUSION HIGH TEMPERATURE BACK PAIN AND HYPOTENSION ( ABO- LOW BACK PAIN AND HYPOTENSION) 65- CENTRAL FALL RISK CARDIOVASCULAR DISEASE 66- RIGHT HIP FRACTURE O2 SAT LEVEL 67- RESPIRATORY ALKALOSIS ( MAIN CONCERN) 68- DESCRIBE PAIN NEUROPATHY NERVOUS SYSTEM 69- BETA 1.6 CALCULO 70- ACUTE ABDOMINAL PAIN, NASUA, PROJECTIBLE VOMITING SEVERE HEADECHE AND PHOTO SENSITIVITI 71- UROLITHISIS O LITHOTRIPSY PROCEDURE RESTRICT PHYSICAL ACTION 72- UAP ( DICE EL PACIENTE QUE TIENE ABD PAIN LARGE TARRY STOOL TEST STOOL FOR OCCULT BLOOD 73- Insulin for a glucose level of 255 (Pte tmeblando despues que le pusieron insulin.)….. Obtain capillary glucose. 74- NGT proper tube procedure…. Elevate Head 60 to 90 degree…. 75- RA (rheuma)… Impaired peripheral mobility relate to join pain. 76- Finger stick glucose finding 50mg… LOC Level of conscious 77- BMI (una persona que pueden tener colon cancer) …. Large waits circumference with central fat….. Med surge Hesi: 1- Q: Parkinson patient walking… Reassure that stepping on walks’ is not harmful. 2- Q: A male client, who is 24hours…… Auscultate bowel sounds in all four quadrants. 3-Q: Beta 1.6 Math calculo 4- Q: Acute abdominal pain, nausea, projectile vomiting…. Severe headache and photo sensitivity 5- Q: Stage IV cancer…… Administration opioids, no opioid meds. 6-Q: Eczema…… Healing with a return to normal skin appearance. 7-Q: Patient with DVT…. Perform leg exercise. 8-Q: Carpal tunnel…. Wear brace on bath wrist. 9-Q Hypothyroidism Sodium 122 mcg/L 10-Q: Epigastric pain-female…… radiating pain to the jaw 11-Q: Ostemalacia Risk for injury. 12- Q: Bronchoscopy (el pte 2 horas antes tomo jugo)… Delay procedure for 6 hours. 13- Q: Pictine (vomito dentro de un emesis)……Obtain vital signs. 14- Q: Cancer cells Benign offer the client reassurance that this information indicates that the clients cancer cells are benign. 15- Q: Cataract ……Light housekeeping is permitted, but avoid heavy lifting. 16-Q: Esophageal varices ……Luke warm bath, cold ice tea, lemon Popsicle. 17-Q: Urolithisi procedure…… Restrict physical action or Stain urine???? 18-Q: A client who took a camping vacation…… Jaundice sclera. 19-Q: External fixation… Administrate PRN med. 20-Q: UAP, (dice el pte tiene abd pain, large tarry stool……Test stool for occult blood. 21-Q: Pheocromocytoma Monitor BP. 22-Q: ABD a client experiences an ABD…… Low back pain and hypotension 23-Q: SBAR …… Explain specific reason for urgent notification 24-Q Primary goal of nursing care for pte pre-op……assess emotional preparedness 25-Q: Intermittent claudication….wrap elastic bandage around legs. 26-Q TURP Drink fluids 3L of water each day. 27- Q: Adult women difficulty time keeping… Hemoglobin A1C level. 28- Q: CVA: ……encourage use of picture chart. (Boards) 29-Q: Diabetes KA Potassium of 2.5 30- Q: Shingles *select all that apply… Pain…Ability…Skin integrity 31- Q: Iron rich, food (pte with anemia cual NO se le va a dar)…..Orange juice 32-Q: MS-multiple sclerosis…… Administration antiemetic. 33-Q: A client diagnoses with stable angina…. Call 911 if pain is unrelieved. 34-Q: BNP…… administrative furosemide Lasix IV. 35- Q: DVT calculo: 9 36- Q: An older male client….. Palpate the bladder above the symphysis pubis. 37- Q: Insulin for a glucose level of 255 (Pte tmeblando despues que le pusieron insulin.)…..Obtain capillary glucose. 38- Q: Pte con stiffness neck……Prepare for lumbar puncture. 39- Q: Shingles…..Check if client was vaccinated for shingles in the past. 40-Q: SIADH: …… Hard candy 41-Q: Tele therapy radiation……Protect skin from sunlight exposure 42-Q: Tracheostomy….. Leave old ties in place, until new one ……. 43-Q: PACU…. Pulse , BP, respiration. 44- Q: Venous legs ulcer (all that apply)…. Elevate the feet when lying down, Check brownish skin around ankles, vitamins. 45- Q: NGT proper tube procedure…. Elevate dead 60 to 90 degree…. 46-Q: Xenograft……The xenograft is from non-human …… 47- Q: Clean water fluid…..Maintain IV fluid 48- Q: RA (rheuma)…….Impaired peripheral mobility relate to join pain. 49-Q Hemodialysy…..Lower the head of the …. And elevate feet. 50-Q: A male adult come Obtain a sputum samples for culture. 51-Q Finger stick glucose finding 50mg… LOC Level of conscious 52- Q: BMI (una persona que pueden tener colon cancer) …. Large waits circumference with central fat….. 53- Q: When explaining dietary guidelines w/ Acute Glomeru. Restrict sodium intake. 54- Q: Renal injury: Koyexalate 15 grams PO ??????? 55- Q: ABG (PH:7.25-PCO2: 50, Sodium 60… Tachy and confunsion. [Show More]

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