PEDS
The nurse is teaching the parents of a four-month-old who had developed positional plagiocephaly ( flat head syndrome). Which statement by the parents indicates a need for further teaching?
A. “I should alternate head positions when the infant is supine.”
B. “ I should place the infant in the prone position during naps.”
C. “ I will minimize the amount of time that the infant is in a car seat.”
D. “ I will place interesting toys opposite the affected side.”
B. “ I should place the infant in the prone position during naps.”
The nurse receives handoff report on 4 clients. Which client should the nurse assess first?
A. Client with chronic anxiety disorder taking buspirone and diphenhydramine who has dry mouth
B. Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up
C. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache
D. Client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea
C. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache
The nurse is providing education to a client diagnosed with trichomoniasis vaginal infection who has been prescribed a one-time dose of oral metronidazole. Which of the following statements by the nurse are appropriate? Select all that apply.
A. “Abstain from sexual intercourse until the symptoms are cleared.”
B. “Avoid drinking alcohol for at least 3 days after taking the last dose.”
C. “Inform your sexual partners that they need to be treated.”
D. “Metronidazole may temporarily turn your urine a dark, brownish color.”
E. “Vaginal douching after intercourse may prevent recurrence of infection.”
A. “Abstain from sexual intercourse until the symptoms are cleared.”
B. “Avoid drinking alcohol for at least 3 days after taking the last dose.”
C. “Inform your sexual partners that they need to be treated.”
D. “Metronidazole may temporarily turn your urine a dark, brownish color.”
A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. the nurse should teach the client to report which side effect to the health care provider(HCP) immediately?
A. Abdominal discomfort
B. Insomnia
C. Morning headaches
D. Muscle aches or weakness
D. Muscle aches or weakness
The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse?
A. Glucose 200 mg/dL (11.1 mmol/L)
B. Hematocrit 38% (0.38)
C. Potassium 3.4 mEq/L (3.4 mmol/L)
D.Troponin 0.7 ng/mL (0.7 mcg/L)
D.Troponin 0.7 ng/mL (0.7 mcg/L)
The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
A. Avoid excessive caffeine
B. Immerse hands and cold water
C. Practice yoga or Tai Chi
D. Refrain from using tobacco products
E. Wear gloves when handling cold objects
A. Avoid excessive caffeine
C. Practice yoga or Tai Chi
D. Refrain from using tobacco products
E. Wear gloves when handling cold objects
A nurse is caring for a school-age client with fever, somnolence, and a skin rash from suspected meningococcal meningitis. Which of the following interventions should the nurse plan to implement for this client? Select all that apply.
A. Elevate head of bed at 30 degrees
B. Implement seizure precautions
C. Keep a mask on the client at all times
D. Minimize environmental stimuli
E. Place client in a room with negative-pressure airflow
A. Elevate head of bed at 30 degrees
B. Implement seizure precautions
D. Minimize environmental stimuli
The office nurse receives 4 telephone messages. Which client should the nurse call back first?
A. 28 year old female client who fell on ice sister day and has low back pain and spasm
B. 42 year old male client who developed sharp burning leg pain radiating from buttocks to knee after lifting heavy weights
C. 65 year old female client 10 days post spinal fusion was increased persistent back pain and fever at 101.2 F (38.4 C)
D. 7 year old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back
C. 65 year old female client 10 days post spinal fusion was increased persistent back pain and fever at 101.2 F (38.4 C)
The 28 year-old client is seeking advice from the nurse about why she has not been able to conceive. The client is discouraged and states that she has been “trying to get pregnant for 4 months.” Which statement by the nurse is best?
A. “Adoption or surrogacy are options for those who are unable to conceive.”
B. “Consider talking to your healthcare provider about fertility-enhancing medications that can help you conceive more quickly.”
C. “There is no cause for concern unless you haven't been able to conceive for 1 year.”
D. “Using an over-the-counter urine ovulation detector kit two times sexual intercourse May improve your chances of conceiving.”
D. “Using an over-the-counter urine ovulation detector kit two times sexual intercourse May improve your chances of conceiving.”
The nurse is assessing a 70 year old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially?
A. Food poisoning
B. Influenza
C. Myocardial infarction
D. Stroke
C. Myocardial infarction
The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply.
A. "Avoid drinking alcoholic beverages."
B. "Do not abruptly stop taking your phenytoin."
C. "Go to the emergency department every time a seizure occurs."
D. "Wear an epilepsy medical identification bracelet."
E. "You may need to start using a nonhormonal birth control method"
A. "Avoid drinking alcoholic beverages."
B. "Do not abruptly stop taking your phenytoin."
D. "Wear an epilepsy medical identification bracelet."
E. "You may need to start using a nonhormonal birth control method"
The nurse is reinforcing discharge teaching for the parents of a one-year-old with a newly diagnosed cow's milk allergy. Which nutrients normally provided by milk should be obtained from other sources? Select all that apply.
A. Calcium
B. Fiber
C. Iron
D.Vitamin D
E. Vitamin K
A. Calcium
B. Fiber
D. Vitamin D
The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first?
A. A 1-day post tubal myringotomy client with purulent tympanic drainage
B. A 4 day post valve replacement client with the temperature 102 F (38.8 C) and petechiae
C. A 10 day old a old client with patent ductus arteriosus who has a continuous murmur
D. A 6 year old client with epiglottitis who is drooling and has severe sore throat
D. A 6 year old client with epiglottitis who is drooling and has severe sore throat
Which statement is most important to emphasize when teaching a 40 year old female client newly diagnosed with fibrocystic breast changes?
A.“Breast changes that are not related to your cycle should be reported to your provider.”
B.“If your breast become sore during the month, you might take Ibuprofen as needed.”
C.“Schedule yearly clinical breast examinations with your healthcare provider.”
D.“These cyst or benign, and research has shown that they do not increase the risk of cancer.”
A.“Breast changes that are not related to your cycle should be reported to your provider.”
The nurse is preparing to administer 160 mg furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect?
A. Bradycardia
B. Hypokalemia
C. Nephrotoxicity
D. Ototoxicity
D. Ototoxicity
A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.
A. Blood Pressure 82/62 mm Hg
B. Crackles on auscultation
C. Distended Jugular veins
D. Pulse 120/min
E. Shoulder pain
A. Blood Pressure 82/62 mm Hg
D. Pulse 120/min
E. Shoulder pain
The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first?
A. 3-month-old whose posterior occiput appears flattened
B. 4-month-old who has sclera visible above the iris (sunset eyes)
C. 6-month-old who has vomited twice and has had 8 wet diapers in the last 24 hours
D. 9-month- old whose toes fan out and big toe dorsiflexes when plantar surface is stroked
B. 4-month-old who has sclera visible above the iris (sunset eyes)
Several clients check into the emergency department at the same time. Which client should be seen first?
A. 8 month old with persistent vomiting and diarrhea for several days
B. 5 year old who has a foreign body in the right naris
C. 7 year old who is restless after tonsillectomy surgery 3 days ago
D. 9 year old with second degree burn to the arm who's crying inconsolably
C. 7 year old who is restless after tonsillectomy surgery 3 days ago
The Graduate nurse (GN) is assisting the nurse preceptor to provide education to a client diagnosed with a molar pregnancy. Which statement by the GN requires the perception nurse to intervene?
A. “A uterine evacuation procedure is the typical treatment for removing the normal tissue.”
B. “We can provide you with resources for coping with perinatal loss if needed.”
C. “You may start trying to conceive again as soon as you and your partner feel ready.”
D. “You'll need Rh immunoglobulin following a molar pregnancy because you have Rh-negative blood type.”
C. “You may start trying to conceive again as soon as you and your partner feel ready.”
A client is admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg IV. Which action should the nurse take?
A. Adenosine is contraindicated for SVT. Verify the order with the healthcare provider
B. Administer medication only through a central venous access
C. Administer medication rapidly over 1-2 seconds followed by a saline flush
D. Mix medication in 50 mL normal saline and administer over 10 minutes
C. Administer medication rapidly over 1-2 seconds followed by a saline flush
A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis?
A. Impaired social interaction
B. Impaired verbal communication
C. Risk for deficient fluid volume
D. Risk for impact skin integrity
C. Risk for deficient fluid volume
Which discharge teaching instructions should the nurse provide to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply.
A. Complete all the antibiotics even if your child is feeling better
B. Cool liquids and soft diet are recommended
C. Keep your child home from daycare for at least a week
D. Replace your child's toothbrush 24 hours after starting antibiotics
E. Throat lozenges may soothe your child’s sore throat
A. Complete all the antibiotics even if your child is feeling better
B. Cool liquids and soft diet are recommended
D. Replace your child's toothbrush 24 hours after starting antibiotics
The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care?
A. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain
B. Severe lower back pain after lifting heavy boxes
C. Sharp calf ache with ambulation that improves with rest
D. Unilateral leg swelling with 2+ pitting edema after an airplane trip
A. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain
The nurse is caring for a client at 39 weeks gestation and active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply.
A. Administer oxygen via a non-rebreather face mask
B. Change maternal position to the left side
C. Discontinue the oxytocin infusion
D. Notify the healthcare provider
E. Perform a nitrazine test
A. Administer oxygen via a non-rebreather face mask
B. Change maternal position to the left side
C. Discontinue the oxytocin infusion
D. Notify the healthcare provider
A client is being discharged after receiving an implantable cardioverter defibrillator which statement by the client indicates that teaching has been effective?
A. “I'm not worried about the device farting now because I know it won't hurt.”
B.“I will let my daughter fix my hair until my healthcare provider says I can do it.”
C.“I will look into public transportation because I won't be able to drive again.”
D.“I will notify my travel agent that I can no longer travel by plane.”
B.“I will let my daughter fix my hair until my healthcare provider says I can do it.”
The primary care provider’s office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back?
A. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection
B. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration
C. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding
D. 84-year-old man with prostate cancer and spine metastasis is requesting increase pain medication
B. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration