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| Question | Answer |
|---|---|
| AP task postoperative | measure drainage |
| noncompliance with advance directives | administration of enteral tube feedings who has end-stage dementia who has advanced directive that say comfort measures only |
| how to identify true labor | cervix transitions to an anterior position |
| above the knee amputation plan of care | assist the patient to the prone position NO ELEVATION |
| AP assist with meals | demonstrating aphasia |
| chemotherapy further teaching needed regarding precautions | fresh fruits and veggies |
| radiation therapy, prostate cancer, expected side effects- understanding of teaching | I can wash the irradiated area with a mild soap and water |
| indwelling catheter for male- sterile technique | set catheter tray on the overhead table at waist height |
| prescribed home oxygen therapy understanding of teaching | wear cotton fabrics oxygen in use smoking outside |
| grapefruit and verapamil what are the s/s | tachycardia |
| assessment of a newborn following a vaginal delivery | nasal flaring? overlapping of sutures |
| fire safety | RACE |
| current staffing issues, acceptance of change the nurse manager should | encourage staff to offer possible solutions |
| gestational diabetes- include in teaching | at birth your baby will be at risk for hypoglycemia |
| lorazapem- which antidote would you give for respiratory depression | flumazenil |
| severe preeclampsia following s/s | blurred vision facial edema proteinuria |
| intervene which HIPAA violation | chaplain and client diagnosis |
| clients rights and informed consent- ethical principles | autonomy |
| hepatitis A cleaning | 1:100 chlorine solution |
| discharge teaching who has a new diagnosis of TB | remain on medications for 6 months |
| unconscious following an injury | proceed with medical care "implied consent" |
| acute exacerbation of asthma | peak expiratory flow rate |
| ICP medication | mannitol |
| CVA referral to OT | difficulty performing personal hygiene |
| tracheostomy final step | change trach ties |
| RA moderate to severe pain in multiple joints | allow frequent rest periods |
| informed consent nurses role | witness |
| child safety measures | always wear a helmet |
| fecal impaction | insert a lubricated gloved finger |
| glomerulonephritis expected finding in urine | protein |
| dietary teaching for 7 month | introduce new foods 4-7 days at a time |
| patient has not voided for more than 8 hour. abdomen is distended and restless | latex allergy |
| apnea monitoring at home, what should you include in the teaching? | ensure alarm can be heard, avoid co-sleeping with the newborn |
| ECT side effects | short term memory loss |
| bipolar disorder alterations of speech | flight of ideas |
| schizophrenia problem- solving skills | alone in a room with the fire alarm |
| teaching to the parents of a newborn | zinc oxide |
| clozapine | weight gain |
| elective cardioversion for a-fib | cardiac compression |
| IVP abnormal response | itching |
| hypoglycemia s/s | irritability? vomiting |
| assessment of which child first | appendectomy- sudden relief of pain |
| 4 month old infant- failure to thrive | the mother smiles at the infant |
| newborn need for intervention | temperature 97.2 |
| LPN scope of practice | preparation of post-op bed? collection of stool sample |
| CVA is preparing for d/c. the nurse should anticipate the following actions | identify community resources contact with home health agency verify that arrangement have been made for supplies occupational therapy services |
| GI bleeding and NG tube | instill 75 mL of 0.9% NaCl |
| uric acid based urinary calculi formation the foods to include in the diet | oranges |
| prevent heat loss via conduction by what interventions | pad a scale with paper prior to weighing infant |
| infectious gastroenteritis-requires intervention by nurse | ensuring the child BRAT diet |
| history of aggressive behavior requires intervention to prevent escalation to the client's anger | pacing around the chair in which his wife is sitting |
| DM type I- highest priority | medication regimen |
| new prescription for TPN | monitor blood glucose |
| ABGs | paCO2 - 33 |
| active pulmonary TB | private room- negative pressure |
| triaging four clients | unstable vital signs |
| codeine every 4 hours for a client who is being d/c from hospital. proper administration of codeine- a need for further teaching | urinary frequency |
| client in crisis- in what sequence in order to assist the client to cope | safety relationship development of an action plan coordinate with support plan and provide |
| daughter of Alzheimer's pt, I don't know why I bother to visit my mother anymore - therapeutic communication | it seems like you feel your visits are a waste of time |
| diaphragm- need for further teaching | removal right after sex |
| funding for an educational program | identify |
| case manager for mental health clients | arranging transportation |
| implanted permanent pacemaker | I will be able to use BATHS AND SHOWERS |
| pulmonary embolism receiving heparin 1200 units/ hr and warfarin 5 mg, aPTT 98 sec and INR 1.8 | hold heparin |
| implanted venous access device | palpate skin to locate the body septum of the port |
| skeletal traction for fractured femur highest priority | upper chest petechiae- sign of embolism |
| AV fistula in right arm, include in the plan of care | auscultate extremity for bruit |
| parents of toddler which foods recommend? | steamed carrots |
| s/s fluid overload | dyspnea |
| hemoglobin 7.8, include in the plan of care for a child | observe dyspnea on exertion |
| right modifiable radial mastectomy interventions | presence of one or more surgical drains |
| cardiac tamponade | pericardial friction rub |
| adverse affect of fluoxetine | headache |
| CF receiving O2 therapy- O2 toxicity | bradypnea? restlessness |
| client education about digoxin and furosemide | how to measure pulse rate measure intake need to report muscle weakness importance of obtaining daily body weight |
| misoprostol and NSAIDs | serum pregnancy test |
| pressure ulcer formation | shift weight hourly |
| acute blood loss requires blood transfusion that could potentially save her life, refuses | explore the reasons for refusal? honor the decision |
| transition phase of labor which of the following breathing techniques? | pattern paced |
| client falls more frequently between 0530-0730 while performing a root cause analysis | investigate environmental factors |
| celiac disease foods | baked chicken and wild rice |
| magnesium levels and interventions | 1.3-2.1 initiate continuous cardiac monitoring |
| clonidine adverse effect | dry mouth |
| pneumonia s/s in elderly | acute confusion |
| sickle cell anemia- vaso-occlusive intervention | pain medication |
| PICC line prior to starting infusion | x-ray |
| attend to four client first | confused and attempting to get out of bed |
| COPD and SOB completion of incident report | increasing O2 |
| IM injection to an obese person | ventrogluteal |
| DM and capillary blood testing appropriate | wash the client's hands |
| tape test for pinworms | perform the test 1 hour after child falls asleep |
| adverse reaction to propranolol | heart rate 110 |
| terminal illness thinking about going home to be with loved ones. appropriate intervention | social services |
| medication availability has been an ongoing problem with pharmacy staff | inform nurse manager |
| child of autism | manage behavioral outburst by limiting external stimuli |
| turning right side | pillow |
| potential medication interaction with food | phenytoin who requests a milkshake |
| packed RBC to client- needs to make a correction | D5W- clots form |
| effective breastfeeding indication | 6-8 wet diapers |
| short-leg cast and non weight bearing | three-point gait |
| explosion in a nearby chemical plant. make room for clients | dehydration- 680 mL |
| combative and aggressive client | move client close to the nurses station |
| cancer, client asks nurse to make decision | tell me more about your understanding of the options |
| physical assessment- need for intervention | uses penlight to assess for changes in contour |
| talking about a client in the hallway | tell the nurses to stop the discussion |
| CVA- lower the risk of ICP | quiet environment? HOB 45 |
| cataracts local community center s/s | cloudiness and blurred vision |
| status epileptics medication | diazepam |
| extended time to take a break | I need to talk to you about the unit policies |
| I am going home- following action | clarify notify surgeon AMA document |
| renal failure and received hemodialysis | sodium 148 |
| shaky nervous DM I | give OJ wait 15 min recheck BS provide cheese and crackers |
| narrow QRS irregularly at rate 170/min with no visible P waves | supraventricular tachycardia |
| physiological changes with aging | decreased lung expansion |
| skin cancer- further teaching is needed | I should a sunscreen with a minimal of SPF 10 |
| DKA in emergency room | start insulin therapy |
| do I have cancer? | the provider will be here to talk you later |
| democratic leadership style | seeks input |
| herpes simplex virus- precautions | contact |
| bipolar disorder- increasingly restless, profanities, priority intervention | move client away to a quiet place |
| chronic illness- defense mechanism | hobby to compensate |
| manic phase of bipolar disorder | grandiose thoughts |
| cranial nerve II | clear objects from clients walking area |
| effectiveness of pain medication for a child using visualization to decrease child discomfort | blow the hurt away |
| hyperthyroidism s/s | tremors |
| domestic violence incident- | It sounds as though you are feeling responsible for the violence last night |
| nausea and vomiting for the past two days- lab results | 1.052- urine specific gravity |
| incident reports- need for further teaching | I will document that an incident report in the medical record |
| tracheostomy suctioning | hyperoxygenate with 100% oxygen before suctioning |
| hemianopsia | use scanning techniques |
| colostomy care | skin barrier over the stoma and hold for 30 seconds |
| captopril for htn- AP | obtain BP before or after medication administration |
| statements about omeprazole and metronidazole | the omeprazole will minimize acid in the stomach, and metron will tx infection |
| right to confidentiality | list of family members who can receive info |
| total hip arthroplasty | raised toilet seat |
| PACU report to provider | stridor |
| cardiomyopathy- hospice- need for further teaching | hospital- care is different- no longer tx |
| enteral tube feeding for an infant with cerebral palsy- charge nurse to intervene | stabilize the tube by taping to the cheek |
| medication error | too frequently? no risk |
| refuses to ambulate after abd surgery | ask the patient rate his pain |
| 3 hr oral glucose tolerance test | obtain blood sample every 30 minutes |
| head injury, agitated, confused attempting to pull out IV- appropriate intervention |
Created by:
awill3217
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