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LYME EXAM NURSING WITH COMPLETE SOLUTIONS!!
A home health nurse is caring for a child who has lyme disease. Which of the following is an appropriate action for the nurse to take?
- Ensure the state department has been notified
A nurse is caring for a client who has been admitted to the hospital. (Case study with 3 exhibits) 1200 lab results show Hgb, Hct, Bilitubin, creatinine, platelet count....select the 5 actions the nurse should take?
Provide frequent rest periods for the client.
Restrict the client's sodium intake
Advise the client to avoid the use of soap and alcohol based lotions.
Instruct the client to avoid blowing 4)their nose forcefully.
- Assess the client's level of orientation.
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?
Evaluate functioning of the suction device.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
Remove the device from the room.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
Remove the cap and place it sterile-side up on a clean surface
A nurse is creating a plan of care for a female client who has recurrent urinary infections. Which of the following interventions should the nurse include in the plan?
Wear loose-fitting underwear.
A nurse is caring for a newborn. (Case study with 3 exhibits). Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing ________ and _________.
Transient tachypnea of the newborn
Hypoglycemia
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
Sunken fontanels and dry mucous membranes
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
Hypertension
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates
A nurse is caring for a 2yr old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
Banana slices
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
Determine the medical needs of incoming clients through the emergency department
A nurse has just received change of shift report for four clients. Which of the following clients should the nurse assess first?
A client who was just given a glass of orange juice for low blood glucose level.
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
Hold the client's eyes shut for a few seconds.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
"What are the voices telling you?"
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?
weight loss
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
- Turn on the suction and set the pressure.
- Don sterile gloves.
- Insert the catheter during the client's inspiration.
- Apply suction while rotating the catheter.
- Rinse the catheter to remove secretions.
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2hr earlier. Which of the following statements should the nurse make?
"I can start the medication 30 min earlier"
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
Offer fluids every 2 hours
click on the finding again.
- Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
- Client reports lower back pain and pinkish vaginal discharge.
- Uterine contractions every 8 min, palpate strong, duration 30 seconds.
- Cervical exam indicates 2cm, 50% effaced, 0 station
A nurse is caring for a client who has ben admitted to the antepartum unit. (Case study 3 exibits). Complete the following sentance by using the list of options. The nurse should recognize the client is experiencing _______ due to _________.
Preterm labor
Previous preterm birth
A nurse is caring for a client who has been admitted to the antepartum unit. (Case study 3 exhibits). The client is at risk for developing which of the following two complications? Select 2 complications the client is at risk for developing.
Sepsis
Preterm pre-labor rupture of membranes (PROM)
A nurse is caring for a client who has been admitted to the antepartum unit. (Case study 3 exhibits) for each potential provider's prescription, click to specify if the potential prescription is anticipated or unanticipated for the client.
Unanticipated:
Place the client in supine position
Administer oxytocin
Anticipated:
Limit fluid intake to 3,000 mL/day
Maintain bed rest with bathroom privileges
Administer betamethasone
Administer terbutaline.
The nurse continues to care for the client. (Case study 4 exhibits) which of the following actions should the nurse take? SATA
1.Urine culture
- Obtain provider prescription for antibiotics
- Obtain provider prescription for phenazopyridine
The nurse continues to care for the client. (case study 4 exhibits) click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.
1.Client rates lower back pain a 0 on a scale from 0 to 10.
2.No reports of vaginal discharge.
3.No uterine contractions noted.
4.No further reports of burning with urination.
- WBC 12,
- Platelet count 188,
- Temperature 98.
- Blood pressure 120/
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
Wear clean cotton socks every day.
going forward with the treatment. Which of the following statements by the nurse is appropriate?
You don't have to go through with the treatment.
A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching?
"The more my baby is at the breast sucking, the more milk I will produce."
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
Evaluate the client's ability to help with repositioning.
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
I can lift objects that are less than 10 pounds
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
Speak directly to the client.
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
acetaminophen (tylenol)
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
A client who has a hip fracture and a new onset of tachypnea
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A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
Palms of the hands
A charge nurse is teaching new-staff members about factors that increase a client's risk to become violent. Which of the following factors should the nurse include as the best predictor of future violence?
Previous violent behavior
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
FHR baseline 170/min
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
Digoxin 0.25mg PO daily
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A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
How to operate portable suction machine
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?
Provide humidification of the room air.
A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse take?
Provide anticipatory guidance classes to parents through public schools.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
malaise
A nurse in an emergency department is caring for a client. (Case study) 57-yr-old male client presents to the ED with severe abdominal and epigastric pain that began about 12 hrs ago. Click to highlight the findings that require follow-up.
- Client presents for evaluation of severe pain in upper abdomen that radiates into his back.
- States pain began approximately 12hr ago and is worse when he is supine or after he eats.
- Sclera noted to be yellow.
- Abdomen firm, bowel sounds hypoactive.
- Client guards abdomen and grimaces during palpation.
A nurse in an emergency department is caring for a client. (Case study) 57-yr-old male client presents to the ED with severe abdominal and epigastric pain that began about 12 hrs ago. For each finding, click to specify if the finding is consistent with pancreatitis or peritonitis.
Pancreatitis:
Hyperbilirubinemia
Abdominal pain
Elevated WBC
Peritonitis:
Bloody stools
Abdominal pain
Elevated WBC count
A nurse in an emergency department is caring for a client. (Case study) 57-yr-old male client presents to the ED with severe abdominal and epigastric pain that began about 12 hrs ago. Complete the following sentence by using the list of options. The nurse should first assess the client's _______ followed by the client's _______.
Lung sounds
blood pressure
A nurse in an emergency department is caring for a client. (Case study) 57-yr-old male client presents to the ED with severe abdominal and epigastric pain that began about 12 hrs ago. The nurse is preparing to notify the provider about the client's current condition. For each potential provider prescription click to specify if it is anticipated or contraindicated.
A nurse is assessing a 2-yr-old toddler. Which of the following findings should the nurse expect?
Non-tender, protruding abdomen.
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
Document the client's condition every 15 minutes.
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
The estimated blood loss was 250 milliliters
A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?
Determine the client's Glasgow Coma Scale score.
A nurse in an emergency department is caring for a client following an MVA. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect?
The client is oriented times 3.
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35. Which of the following dysrhythmias is the client displaying?
First-degree atrioventricular block.
A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
Hypertension
A nurse is caring for a client. (Case study) client reports a 3-month history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 12 pounds in 3 months. For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or crohn's disease.
Ulcerative colitis:
Fever
Weight loss
Diarrhea
Diverticulitis:
Fever
Anemia
Diarrhea
hypertonicity
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which of the following actions should the nurse take?
Administer dextrose 10% in water
A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate?
C on the diagram under the pectoralis muscle
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
You can receive the immunization for influenza at any time during your pregnancy
A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?
Avoid using nail polish remover around the client.
A nurse is introducing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching?
Blow into the meter as hard and quickly as possible.
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
Magnesium hydroxide 30mL PO
A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include?
Perform chest percussion and postural drainage at least twice daily
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
A non-coring needle
A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
Hematoma over the insertion site.
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
Deep tendon reflexes 2+
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
