Test 1 -Womens Health

Test 1-women’s health 1. A patient at 8 weeks gestation reports urinary frequency without burning and nausea in the afternoon. What Is the nurse most appropriate response 2. A nurse is teaching a group of adolescents ...

Test 1-women’s health 1. A patient at 8 weeks gestation reports urinary frequency without burning and nausea in the afternoon. What Is the nurse most appropriate response 2. A nurse is teaching a group of adolescents about sexual transmitted infection. She knows learning has been achieved when one of the group members state the most common s/s of sexual transmitted disease 3. Assessment finding of a post partum pt who delivered vaginally 10 hours ago include Pulse 56 BP 100/62 Temp 99.8 Res 16 having to urinate freq 4. the nurse completed teaching in preparation for a pap smear which client indicates the understanding of the nurse teaching 5. a pt who is breastfeeding calls the clinic and reports temp of 102.4 and unilateral redness and tenderness what should the nurse tell pt 6. a pt report lst menstration dec 5 use negle’s rule (subtracting three months, and adding seven days) 7. given rx for hormone replacement tx; what should u expect from taking HRT (hormone replacement tx) 8. Which nursing inventions for a post partum pt will be appropriate for relieving discomfort from hemorrhoids 9. When performing vaginal examination a pt partner ask why a pelvic exma needed to be done the best answer would be A -SATA ) 10. when caring for a ct with primary genital herpes with lesion on the her vulva an peraneal area , the nurse instructs that when lesions are present you must 11. a person who’s pre-prenatal weight is 105 and weighs 109 at her 12 week visit, which statement by the nurse isn’t appropriate 12. the nurse is teaching a prenatal class about false labor. The nurse should teach pts that false labor will include which of the following : which statement by post menopausal clt determines understanding of breast exam The pt states that the pt has positive Chadwick’s sign when the patient ask the nurse what that means the best answer would be 13. a pt is admitted into the L&D unit, the nurse preforms a vaginal exam and determines the client’s cervix is 5 cm dilated with 75% effacement. Based on this assessment the pt is in which phase of labor 14. a patient is 38 weeks gestational, calls the clinic to report that her baby has not moved today. Which statement should the nurse 15. the nurse just completed teaching of chlamydia to a group of young women, which statement indicates that the nurses teaching was successful 16. nulliparous women in active phase of labor, has a cervix has progressed to 6mm dilated, the nursing caring for this woman evaluates the external monitoring tracing and notes the following :decrease in FHR shortly after onset of cervical uterine contractions returned to baseline rate by the end of contractions, shape is uniform. based on this finding the nurse should: 17. when instructing a group of prima gravida woman on the onset of labor the nurse tells the woman to be alert for 18. what client would be the best candidate for an intra uterine device (IUD) A client married with 2 kids, that doesn’t want any more kids for another 3 yrs 19. which should the nurse consider as presumptive (possible) signs of pregnancy SATA 20. a pt delivers a 9lb5oz baby two days ago what aid should the nurse recommend for episiotomy discomfort 21. a nurse is monitoring a pt receiving oxytocin to induce labor, the nurse should be prepared for which adverse reaction A SATA abruption Hypertension x-bradycardia-slow heart rate (will be tachycardia than anything) 22. a nurse is caring for a pt who states she has smoked in other pregnancies and did not have any problems, which is the nurse best response 23. what is the priority nursing assessment with the 4th stage of labor (they’ve already had the baby) caring for a patient 24. the nursing is providing contraceptive counseling for a 36 y.o. woman who has two sexual partners, smokes 2 packs of cigarettes a day, which method is best suited for this client 25. A primigravida at 39 weeks of gestation is observed for 2 hours in the L&D unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: 26. primary HCP has ordered an injection of Rhogam the nurse understands that it is given to prevent the formation of a art antibodies which assessment will be performed by the nurse with each prenatal visit : 27. The client is being taught about the care of diaphragm which comment by the client shows that the client understands the teaching 28. A patient is at the prenatal clinic for her first visit for this pregnancy. She had an elected abortion 5 years ago, she has a 5 year old son how would the nurse record obstetric history 29. Which assessment is most important for the nurse to obtain prior to administering a PRN analgesic to a pt in labor 30. The nurse is caring for a client with a hx of HIV which nursing Dx formulated by the nurse is highest priority for this client A: risk for infection 31. Which woman in her 3rd trimester should the nurse suspect for psychological difficulty adjusting to the pregnancy 32. A client on a OB?? has been diagnosed with endometriosis and asked the client to describe this condition. The nurse tells the client that endometriosis is A: tissue outside the uterus that resembles the endometrium (it grows on the intestines, kidneys, ) When caring for a client in labor the nurse should plan to 33. Which method should the nurse instruct the mother to use in order to illicit a response from her infant The woman's periodic health screen provides the bases for The most common sexual transmitted infection in women in the US is chlamydia 34. The nurse admitted the post partum patient to the room; during the initial nursing assessment the client reports she is a lesbian with a supportive female partner; which nursing action should be included in the client’s care 35. Rh immunoglobin, RBG indicated for which patient 36. for a prima gravida who is 12 weeks, which prenatal test labs would the nurse report to the HCP A: reactive BDRL (syphilis –the one positive you want) 37. For her first prenatal visit the patient ask the nurse about possible physiological changes she can expect during pregnancy the nurse responds 38. A patient is having contractions every 2 minutes lasting 90 secs and strong intensity. Vaginal exam reveals that the cervix is at 9cm dilated and 100% effaced. Which part of labor is the patient experiencing 39. labor and delivery unit. Which assessment would the nurse perform before notifying the healthcare provider SATA Test 2 – Cancer,Neoplastic ABG’s Men’s Health *** don’t have; review alone Test 3 –Mental Health ECT Change of memory is a common side effect. It is an expected finding the nurse does not have to be notified. Patient may not remember events leading up to the procedure. Retrogade amnesia If memory was already altered ECT will not improve. Brief disorientation is common, it may be hard for them to remember things leading up to the procedure. Intracranial pressure is contraindications Nursing Care mangages medications, decreases physical activities, increase food and fluid intake insure 4-6 hours of sleep per night, intervene so that self care needs are met Defense Mechanism Patients drinks excessive amounts of alcohol and refuses to seek treatment, the patient states "I work hard everyday to provide for my family i dont see why i cant relax a litte"- Rationalization "I apologize for being late my wife didn't wake me up"- Projection Medications Lithium 0.6-1.2 maintanence above 1.5 toxicity Toxicity- nausea, vomitting, diarrhea, First line of tx for mania is Lithium Carbonate SSRIs- Fluoxetine (Prozac) can treat bulimia nervosa Escitalopram (Lexapro) -when an individual has been taking this medication for @ least 2 weeks monitor for suicide ideations because mania could arise which would give them enough energy to do it. blocks the synaptic uptake of serotonin. the outcome should be IMPROVED MOOD. Involuntary Commitment If an individual is involuntary committed they still have ALL THEIR RIGHTS THEY DONT LOSE ANY. Culture Eastern culture focuses on ying and yang (Asia)- balance Western culture - science Indigenous culture (tribes)- harmony Therapies CBT- system of techniques that produces positive thinking Foods for acute manic HIGH PROTEIN. HIGH CALORIE. HIGH FIBER. FINGER FOODS SUCH AS A TURKEY SANDWICH Bipolar Disorder Bipolar 1 is manic (week) Bipolar2 is hypomanic (4days) Olazapine (Zyprexa) - lightheadedness, dizziness, fainting muscle rigidity- hold medication contact doctor Antichollinergic Constipation, urinary retention, blurred vision Therapeutic Communication "Can you tell me why you are here" NOT THERAPEUTIC "I'll go first then you go" NOT THERAPEUTIC "Would you tell me why you are here" NOT THERAPEUTIC "What would you like to discuss" NOT THERAPEUTIC "Tell me why you are here " THERAPEUTIC "Describe what you are feeling" THERAPEUTIC "Are the voices telling you to hurt yourself" THERAPEUTIC Silence as therapeutic communication provides comfort and support. Can be meaningful for the patient. If a patient says that they dont want to talk, as the nurse just sit with the patient MH nurse have to examine their own feelings values and beliefs so it wont affect the outcome of the treatment that you give that patient. Nursing Evaluation for Bipolar Disorder Mood, Affect, Grooming/Hygiene, Able to verbalize During group therapy with multiple patients if another patient is being disruptive set limits and remove them from the group. The disruption can increase anxiety for the other individuals. 1 on 1 therapy might be a better choice. Suicide Constant supervision is needed for these clients Don't leave them alone If a client is active or fidgety exercise will be the best activity. The goal of MH Patients stability and transitioning back into the community PT 1 gets disruptive and slaps pt 2 what does the nurse need to do. PT1 should be placed in the seclusion room and placed on close observation. Initial Phase Rapport is being established. Developing a trusting rapport. This is a desireable outcome. Information is collected and organized. Terminmation Phase Give approriate resources for them to seek out Working Phase "lets develop a tx plan" "lets discuss my strength and weaknesses" DX according to DSM 5 When a person can not carry out daily functioning a nurse is able to identify that a mental illness has been diagnosed. Maladaptive behaviors. Advocate to MH patient assist the patient access to adequate MH resources to keep them on track Anxiety (Severe) Symptoms: Nauseated, palpatation, sometimes I cant concentrate The nurse is admitting a patient to an inpatient MH facility what is your goal during the initial assessment? Collect data or information -may be through family, patient, EHR During your assessment your patient shifts the gear from them to you, what do you do? -Redirect. State that this time is set aside to discuss your concerns. Let the patient know that you are here for them and that this there time. Interventions for major depression promote attendance in group therapy planning activities of daily living listen for covert messages of suicide claims ****Never isolate these patients Manipulative Patients The nurse should set limits. Use concise concrete words and let the patient know you expecatations. Establish a behavior contract. Test 4–IV 1. The nurse reviews preadmission lab results for a patient scheduled for surgery which lab value would cause concern 2. normal saline 0.9% is noted as which type of solution- 3. the nurse is continuing a client’s iv line, upon withdrawing the cannuli from the peripheral site the nurse notices that tee tip of the cannula is missing. The first action is 4. a 16 year patient with a fractured leg Is preparing for surgery. He states that he is living with a friend and is an emancipated minor he has a court statement which a client with 0.9 normal saline infused in the right vasilic vien. After reviewing the following information the nurse should first 5. A post operative client why leg exercises need to be performed every hour 6. SATA-Which preoperative client should the nurse assess the glucose level assess findings for a surgerical client reveal a temp of 95.2 pulse 80% and shivering 7. The client had an orthopedic surgery enoxaparin. What will the nurse teach the patient and family about the molecular weight heparin before discharge 8. The hcp has ordered a peripherial iv to be inserted before the client goes to surger what should the nurse do when selecting an iv site on the hand or arm 9. The preoperative nurse is planning the surgical care of a 6-month old infant which Nursing assessment of a client of surgery reveals a pulse of 160 bp 90/50 resp 22 and jaw rigidity what should the nurse do first Admin dantrolene sodium 10. General anesthesia is the choice of the patient of a client who is having surgical procedure that is of a significant duration prolonged muscle relaxation becuawse of the location of the surgical site 11. the nurse is preparing a surgical insertion site , the site has now been chosen the nurse must apply to the site using friction matter A: chlorhexidine 12. Prior to the administration of enoxoparin sodium 30 mg subq the nurse should A: asses the client for any signs of bleeding 13. the nurse is preparing to initiate intravenous fluid for a client and notices the infuse pump has a frayed cord what should the nurse do A: remove pump and place a damage tag on the handle 14. pediatric drop factor is 60 15. the patient is admitted into PACU what is the priority intervention for nursing asses the patency, quality of respirations, and obtain vs 16. the nurse primary resposbility for the care of a patient undergoing surger a: develop an idiviualized care plan for the patient 17. surgical attire- reistricted zone of surery eye protective gear 18. which patient in the Pacu meet critera to transfer to a unit room the nurse enters the post surgical pt room and notices the patient’s family touching the button of the PCA pump. which intervention should the nurse take 19. The nurse understands that 20. 11 year old needs surgery – no parents in site for consent form 21. nurse discovers that the patient an incorrect iv solution what should the nurse do hang the appropriate solution –write an incident report asses vitals 22. a client is experiencing nausea vomiting duringn surgery, the nurse expects the surgeon to order 23. four clients are receiving the d5n5 at 25ml/per hour which client should the nurse see first 24. in the pacu the nurse notices the pt is having difficulty breathing and suspects uppoer airway obstruction what should the nurse do first 25. while assessing the client peripheral iv site they notice edema at the insertion site, how will they document these findings? 26. a client and significant other are provided discharge teaching post surgical procedure with conscious sedation, which statement buy the client requires additional teaching 27. a nurse asses for a pt scheduled for surgery which pt requires the nurse contact the anesthesiologist 28. during a medication reconciliation prior to same day surgery the client reports taking the last dose of clopidogrel (Plavix) yesterday preop meds the hcp prescribes an infusion of D5NS at 25 ml/hr to a 2year old. Which interventions should the nurse implement (checking every 4 hours is too long to wait to asses) 29. when the circulation nurse calls for the surgical team time out. The team SATA 30. Client 31. A client is scheduled for the removal of fibroids tumors this is classified as a 32. The circulating nurse is planning care for 80 year old patient scheduled for a total hip replacement . Which interventions should be implemented A: pressure points should assessed and padded prior to the procedure 33. The clinic nurse prepares to assess a patient who is 6 days post operative for abdominal surgery. Suddenly the patient coughs and reports feeling a popping sensation. A focused assessment of the surgical site reveals wound evisceration. Which intervention should the nurse implement obtain the vital signs every 5 min, document results 34. The assesses a recovery patient’s surgery site and notes approximately around 1cm of bright red drainage of the dressing. Which should the nurse do first Test 5- diabetes 1. the provide therapeutic communication with a patient the nurse should 2. the school nurse primary preventative education on ringworm to elementary school teachers the nurse should 3. a school nurse is collaborating with other community resources to develop a safety course for an elementary school. This level of health services is an example of 4. which activity by the occupational health nurse would be identified as preventative care 5. the best strategy for the nurse to initially take to reduce obesity risk in middle age adults includes 6. a 57 yyear old patient with an new onset of type 2 diabetes has an order of serum glycated hemoglobin (A1c) the nurse explains that it indicates 7. to assist a 75 year old diabetic patient to engage in daily exercises which action by the nurse best 8. a patient is considering an insulin pump appropriate teaching includes a patient demonstrates adequate knowledge of endogenous insulin secretin when stating 9. a patient in a clinic is diagnosed with pre diabetes when impaired fasting glucose levels are 10. A patient with type 2 diabetes usually controlled with an oral antidiabetic agent develops a UTI. Due to the stress of the infection, 11. The priority foot care instructs the nurse should teach the patient with type 1 diabetes is to 12. A diabetic client has become unresponsive with rapid shallow respirations 13. A patient with type 2 diabetes takes metformin for glucose control and is scheduled for a cardiac cauterization what is the best action by the nurse 14. Which information is appropriate in teaching a patient with diabetes about foot care SATA You don’t want to you use commercial remedies to remove callouses and corns (go to a podiatrist) 15. A patient with type 2 diabetes present to the clinic complaining of burning and tingling sensation in the feet what is the next action by the nurse 16. the nurse administers 28 units of MPH insulin to a patient at 1600 what is the best action by the nurse 17. the nurse can best assess the patient ‘s ability to prepare and give insulin doing a discharge process by 18. the nurse is preparing a discharge teaching plan regarding self injection of insulin which concept is priority and should be enforced by the nurse 19. the patient who has type one diabetes demonstrates appropriate interventions to prevent hypoglycemia by 20. which action made by the patient indicates good understanding of the nurse teaching about the administration of aspart insulin 21. a client with type 1 diabetes receiving treatment via an insulin pump presents with a decreased level of consciousness and a finger stick glucose 39mm the family reports that the client has been skipping meals in an effort to lose weight .which nursing intervention is priority 22. a patient presents to the clinic with a 16 lb loss , fatigue, and polyuria what should the nurse do first? 23. the nurse gives the patient specific instructions for which intervention as the primary treatment for type 2 24. a nurse performs a physical assessment on a client with type 1 diabetes findings include: a fasting glucose 125, temp 101, pulse 90, resp 22 , bp of 100/72 which of these findings most concern the nurse? 25. a patient with type 1 is given an intermediate acting insulin at 730 am. The patient refused to eat a snack. at 830pm the nurse would access the patient for 26. a patient demonstrates understanding of lispro insulin by stating 27. a patient with type 1 diabetes has a glycosylated hemoglobin test resuling in 7.2 . in discussing results with the patient the nurse most accurate statement is: 28. in determining a client with hypoglycemia, the nurse will look for which manifestation in addition to checking the blood glucose 29. a patient with type I has been self monitoring the blood glucose level . The home health nurse observes the patient technique and should be concerned with safety 30. a home health nurse providing a first time teaching to a patient diagnosed with diabetes the nurse is demonstrating how to currently choose a balanced diet what is the best way for the nurse to evaluate what is learned 31. the patient with diabetes calls and reports flu like symptoms to the nurse in the clinic. The best response by the nurse 32. a nurse is teaching a patient how to administer insulin which statement by the nurse indicates teaching was effective : 33. a client how long a vial of insulin can be stored at room temperature before it goes bad 34. a nurse expects findings of early hyperglycemia order 1.inject cloudy 2. Inject clear 3. Draw clear 4. Draw cloudy 5. Verify with staff 35. a client has a blood glucose of 160 since they are on a sliding scale they meet the req for 4 units of reg 36. an adolescent patient diagnosed w/ type 1 diabetes demonstrates understanding of stating which action will decrease the need of insulin 37. which patient will the nurse see first: 38. the nurse observes a student with tachycardia diaphoretic and complains of feeling nervous and hungry. Which action by the nurse. 39. a nurse is preparing a client with type 1 diabetes for discharge. The nurse concludes additional teaching is needed when the client says 40. which statement indicates that a client with diabetes understands monitoring the long term complications 41. a patient with Afrezza (inhaled insulin) is contradicted for contradicted for a paitent with 42. the nurse is teaching a client to administer injections . the client starts crying, “I will not be able to do this, this is overwhelming “ which is the best statement by the nurse 43. which the appropriate tx for patients with diabetes complications Test 6- GI 1. When assessing a client for perforation of an ulcer, the nurse would expect to find? 2. The Nurse is teaching family members of a client with Hepatitis A virus. Family members that were exposed to client should? 3. When assessing the patient’s abdomen, the nurse should? 4. The nurse anticipates that the care of a newly admitted client with a diagnosis of peritonitis should include 5. What is a priority for a liver biopsy 6. An appropriate menu selection for a client with a gallbladder disturbance would include? 7. The nurse is instructing a client on colon preparation that would include polyethylene glycol electrolyte lavage prior to colposcopy is aware that the use of the solution This is contraindicated for Patients with? 8. Nursing actions for a client scheduled with EGD SATA verify that the consent form for the procedure is signed 9. The nurse is providing care for a child with (GERD) reflex the nurse should 10.A client with chirrosis has had pancreatitis two hours ago. Which best indicates a client is progressing as expected 11.The nurse would expect to collect assessment data on a client admitted with ulcerative colitis, 12.A 38 year old client who has had radical neck dissection one month ago states “I will never find a woman to marry me now” what is the best response by the nurse 13.A client is 3 days post operative following a colostomy the nurse is changing the dressing and notes the stoma is pink in color. What is the priority? 14.A client with cirrhosis is prescribed spironolactone (potassium sparing) 100mg PO twice a day. which finding show the expected outcome (will be something positive) 15.The client returns to a nursing unit following the radical neck dissection for oral cancer. What is a priority nursing intervention? 16.A hallmark clinical manifestation of intentional obstruction include 17. The Nurse is calculating the 12 hour intake and output for a client who is post op abdominal colectomy. Which finding should be reported to the HCP? 18. The client has had diarrhea vomiting for two days priority assessments are 19.A client with chirrosis of the liver is receiving lactulose the lab value indicates that the medication is effective 20. A client has prescribed ranitidine (antiacid/antihisteme-heartburn). Which statement would indicate that this client understood the action of this medicine. 21. the nurse is caring for a client who has had surgery for gallbladder dieasese. Which finding would the nurse immediately report to the health care provider 23.A what instruction is given to a client who is taking omeprazole (PPI) client is admitted with a small bowel obstruction and a NG tube is inserted. Select the appropriate nursing actions. 24.The client is scheduled to have a urea breath test. The nurse should ask the client about 25.A client is scheduled for a colonoscopy. Nursing measures on the day of procedure include? SATA 26.A nursing is caring for a client who underwent a subtotalgastrictomy to manage dumping syndrome. The nurse should the client 27. The nurse is caring for a client diagnosed (GERD) the client should be advidsed to 28. Which intervention is appropriate when planning care for a client who just returned to the nursing unit after having a endoscopic retrograde (ERCP) 29.a client diagnosed cirrhosis and ascites is found bleeding profusely from mouth and nose. The assessment BP 72/40 PULSE 138 RESP 36 skin cold and clammy . appropriate nursing actions: 30. Which should be a priority focus of care for a client experiencing an exacerbation of Crohn’s disease? 31. a client diaginosed with peptic ulcer disease. Which order should the nurse question? 32. A nurse is teaching a client about colorectal cancer. Which should the nurse encourage the paitent to report to the HCP 33.A priority nursing intervention during and after a paracentesis is to? 34.A client has a new order for omeprazole (PPI) which instruction should the nurse include 35.A client is experiencing pain nausea and rebound tenderness in the lower right quadrant. What additional assessment findings might the nurse expect 36.A client is 2 hours post EGD and begins to complain of abdominal pain at a level of 10. What action by the nurse should be done first 37.The nurse is teaching a client with a new colostomy how to apply an appliance to the colostomy. The leaves a ½ inch of skin exposed between the stoma and the ring of the appliance. What teaching is indicated here. 38.A patient is two days post op after a gastrojejunostomy (billroth 2). Advise to SATA 39.In planning dietary instructions for the client with diverticulitis disease without symptoms of diverticulitis instruct the client to i 40.A client with frequent complaints of dyspepsia is encouraged to? • 41. The client is admitted with Hepatitis C. Which precautions will the nurse implement? 42.5year old diagnosed with Celiac disease attends daycare. Which food would be an appropriate snack 43. Which nursing interventions are appropriate for clients with infectious acute Hepatitis? 44.A patient has been prescribed pantoprazole (PPI) the nurse should provide patient teaching to include 45.The client is being treated with esophageal variance has a sengstaken blakemore tube inserted. The most important assessment for the nurse to perform is Respiratory 1. A patient with pulmonary tuberculosis is ready to return to work when 2. The nurse reassess the client following a lower lobectomy, the client is dyspneic (difficulty breathing) respiration 40 o2 sat 89, faces mask at 50%. the trachea is deviated to right with right side of the chest not expanding with respirations. The nurse should first 3. What pt is most at risk for a pulmonary embolism had a baby two weeks ago 4. The nurse obtains a pulse ox reading of 90% in a client with pnemounia what should the nurse do next 5. The nurse is preparing to give theophylline 300mg and metaprolol orally .the client complains of nausea. What should the nurse do next 6. A nurse is caring for a 2 year old child who is placed in a crib under an oxygen tent. Which toy is most appropriate for the child to have in the crib. 7. Which measure should receive priority for a client with pneumonia The nurse discovers a client with respirations of 30 , semi conscious , with circumoral cyanosis(blue around the mouth). What should the nurse do next of sudden shortness of breath. The client states that he has difficulty breathing and wheezing is audible. After an inhaled levabulterol tx the wheezing cannot be auscaltated the pulse is 120 and resp 40 02 84 the client is oriented only to person . what should the nurse do next. 8. A 53 yo dx with chronic bronchitis; blood gas analysis reveals PH 7.32 PacCo2 55 O2 86 the nurse applies oxygen nasal cannula at 2L/min . What should the nurse do 9. The nurse is carrying for a client with ineffective airway clearance. What findings indicate the nursing interventions were successful 10. Which client should be placed in a private room Priority goals of clients in stage two lung cancer should include What are significant data from a client who has been dx with pneumonia A client mantoux test (tb test) is flat and red around the injection site the nurse should 11. A community health nurse is assessing the home of a child with asthma . what indicates a need for concern 12. What is the most important preventive measure to avoid pulmonary embolism in a client who just had a surgical procedure 13. 14. Nurse is caring for client with COPD client is pale and SOB the nurse should first 15. A client has had an atherectomy 2hrs ago chest tubes in place, upon initial assessment the nurse finds the chest tube 2cm suction. Light bubbling is seen in the suction chamber. Vital signs are BP140/84 Temp94.4 Pulse 102 RESp 24 ABGs Ph 7.44 PCo2 40 PO2 94 what action should the nurse take? 16. Which intervention is most appropriate for helping a client mobilize secretions The most important teaching for a patient with asthma is 17. Risk factor for pneumonia 18. 19. The client is admitted into the hospital with exascerbation of COPD. The client’s secretions are think and tenacious. From protocol what med should be given 20. What information should be given to a person with asthma SATA Perform peak flow monitoring daily (lets you know how your asthma is doing) Report to the HCP tightness and dyspnea Use a spacer with fluticasone (spacer for those do not know how to use inhaler) 21. Which client should the nurse recommend receive the pneumonia vaccine A: 60 year old with emphysema 22. The client is scheduled for a left pneumonectomy. The position will most likely be ordered for the client 23. The nurse discovers the client is not taking all medications for tx of chronic bronchitis. Which is the most appropriate for the nurse to say to the patient A two year old suspected of having some respatory problems.the infant has just returned to the floor after doing some diagnositic test. Which assessment findings require immediate action by the nure 24. The nurse is planning care for a client with COPD . Which information should the nurse should continue in determining that the client should have supplemental o2 25. what is priority for a client with impaired gas exchange due to pneumonia a client receiving isoniazid (TB med) rifampin (tb med) , pyrazinamide (tb med) tx for 2 months states to the nurse” I feel so much better why do I have to take all this medicine 26. what is included in the POC with a client with COPD Rinse mouth After taking budesonide (steroid for Chrons/ Ulcerative colitis; inhaled; also rinse inhaler) should 27. The nurse is assessing the client at home with asthma monitoring. The nurse knows the following need to be available when notifying the HCP 28. The client had a lobestomy two hours ago. The chest drainage system is connected to the 20 cm suction . what requires immediate action? A: continuous bubbling in the water seal chamber (is this too high a suctin??**) 29. The nurse teaches a client with COPD a client is admitted with pneumonia ABGs reveal PaO2 of 70 Ph 7.30 which are appropriate interventions Xxx anxiety med (this isn’t alkalosis-hyperventilating) 30. what is the most important thing to review first for a client who has had thoracentesis 31. a client with a newly diagnosed asthma should be given instructions to use which medication in case of shortness of breath and wheezing 32. a client receiving chemo for lung cancer. Which indicates the client is at risk for injury 02 94%??? 33. Which client should the nurse see first 34. A client with emphysema has o2 at 2l/min infusing. The client complains of shortness of breath of 20mins duration. After auscultating breath sounds what is the nest action 35. The goal of perched lip breathing is to 36. A client is receiving a combination of isoniazid rafampid and streptomidcyde What requires immediate intervention after a client with a pneumonectomy 37. A client with pneumonia is being discharged from an acute care facility. The most important instruction to give the client is to notify the client of Cardiac Pt with venous insufficiency what is a measure that the nurse should include in the plan? Difficulty communicating Pt with a hx of stable angia presents to the nurse with complaints of chest pain. The best way to differentiate between stable and unstable is? Test 8- Cardiac 1. a client comes into the emergency department with severe chest pains and shortness of breath, suddenly the client collapse what should the nurse do first 2. the nurse is writing a teaching plan for a client with venous insufficiency to prevent complications. What is one measure the nurse should include in the plan? 3. the nurse is caring for a client who had a stroke and is having difficulty articulating speech the nurse documents the client has 4. the client with fluid overload has developed pulmonary edema the nurse will prepare to 5. what action is the highest priority of nursing management for a client with an elevated ST on a 12 lead EKG 6. a thirty two year old client with a new diagnose of heart failure states” I am way too young for something to be wrong with my heart” the most appropriate response: 7. the client with a history of stable angina (chest pain dt activity, exertion) comes to the Emergency department with complaints of chest pain. To best differentiate stable vs unstable the nurse ask the client in the recent past 8. which nursing action is best for a client who is having difficulty following instructions following a stroke 9. checking apical heartrate prior to administering digoxin .125mg the nurse places the stethoscope on the patient’s 10. the client with the greatest risk for decrease cardiac output with this finding during a nursing assessment : 11. a client was admitted with left heart failure prescribed furosemide 80 mg, twice a day for two days. Which serum lab test would the nurse monitor to assess the effectiveness of the furosemide 12. the nurse is instructing a client on how to take BP using an automated device for home use . which is appropriate 13. Priority discharge teaching of a patient with fluid volume excess is 14. The nurse is caring for a patient admitted with a MI . While the nurse is doing admission assessment the patient ask for a laxative. The patient tells the nurse he suffers from constipation. What should the nurse tell the patient concerning constipation 15. Which is priority intervention for a patient who is 3 days post op 16. A nurse is teaching a client about the effects of cholesterol in the body the client demonstrates an understanding of when he states: 17. A patient with heart failure is experiencing severe dyspnea and feels anxious. To improve cardiac output and relax the patient the nurse will administer 18. Who should the nurse see first 19. A patient is being discharged with the new prescription of nitroglycerin SL tablets. Instructions by the nurse should include 20. Patient with fluid overload has developed pulmonary edema, the nurse should A: prepare to 21. Which information given by a patient admitted with chronic stable agina will help the nurse confirm the diagnoses 22. Which statement by the client validates the diagnoses of right heart failure A client with peripheral artery disease is sitting up in a chair; which statement made by the client requires follow up(correction) 23. An expected outcome (EO=positive) for a client with hypertension is: A patient presents in the emergency room with symptoms of stroke. What is the most import information the nurse can obtain: 24. Which assessment findings by the nurse caring for a patient who has had a percutaneous coronary intervention using a right radial artery is most important to communicate with the HCP (Question isn’t understanding asking most important to report to the provider, this is a focused Q) 25. A patient is 4 hours post op after a femoral popliteal bypass surgery. Most important to assess is 26. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? 27. For a client with known Corarnary heart disease having chest pains you would first 28. A nurse is caring for a patient who had a carotid endarterectomy two hours ago which findings would cause the nurse to call the health care provider 29. The nurse is obtaining a health history on a patient with hypertension what is the most concern to the nurse? When the client says 30. Instructions the nurse would include for client with a new diagnose of heart failure include: 31. A patient is scheduled for a cardiac stress test. A clear liquid diet was served and now the patient is npo. The client had these present lab values Creatinine 0.8 Potassium 4.0 Glucose 52 HR 60 BP 132/ 64 32. In caring for a patient with hypertension the registered nurse delegates the LPN to a 60 year old pt with a diagnosis of acute MI is having chest pains. 8 on a 0-10 scale. 33. The nurse is administering the first dose of metaprolol extended release to the client (metaprolol wont affect F&E; it won’t pull or add fluids to the body) 34. Patient presents to a client with complaints of a headache and dizziness. The patient does not take any home medications and states he has not had an OTC med in over 2 months. To accurately access the client’s BP, the nurse: 35. The patient is demonstrating symptoms of the Broca aphasia. Which intervention would you implement 36. A nurse is teaching a patient with home blood pressure monitoring. The nurse should teach the patient 37. The nurse is planning care for a client with global aphasia. Which intervention should be included in the plan of care 38. The occupational nurse is presenting and educational evident about hypertension to the employees of a company. When talking about a hypertensive crisis the nurse list the type of patients in whom a hypertensive crisis might occur. What type of patients are these: SATA 39. Which nursing action is best when initiating bladder training for a patient who had a stroke 40. The nurse prepares to administer propranolol 40mg by mouth to a patient. Which medical hx requires the nurse consult the HCP 41. Which action should the nurse include when providing care to a client who is experiencing hemianopsia (2 vision)