COVID Brain
A nurse is providing a change of shift report to oncoming nurse. Which of the following information should the nurse include?
A. subjective comments the patient made
B. Routine morning care they completed
C. Patient insurance
D. Time last patient's pain medication was
D. Time last patient's pain medication was
In which step of the nursing process does the nurse analyze data and identify client problems?
1) Assessment
2) Diagnosis
3) Planning outcomes
4) Evaluation
Answer:
2) Diagnosis
Rationale:
In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client's health status. In the planning outcomes phase, the nurse formulates goals and outcomes. In the evaluation phase, which occurs after implementing interventions, the nurse gathers data about the client's responses to nursing care to determine whether client outcomes were met.
Which of the following clients should have an apical pulse taken? A client who is:
1) Febrile and has a radial pulse of 100 bpm
2) A runner who has a radial pulse of 62 bpm
3) An infant with no history of cardiac defect
4) An elderly adult who is taking antianxiety medication
Answer:
3) An infant with no history of cardiac defect
Rationale:
An apical pulse should be taken if the radial pulse is weak and/or irregular, if the rate is <60 or >100, if the patient is on cardiac medications, or when assessing children up to 3 years. It is difficult to palpate a peripheral pulse on infants and young children.
When assessing a clients abdomen which finding should the nurse report as abnormal
a) dullness over the liver
b) bowel sounds occurring every 10 seconds
c) shifting dullness over the abdomen
d) vascular sound over the renal arteries
c) shifting dullness over the abdomen would indicate ascites which is abnormal
dullness over the liver, bowel sounds every 10 seconds and vascular sounds over the renal arteries are all normal sounds in the abdomen
After a stroke the client develops aphasia. The nurse expects to see which assessment finding?
a) arm and leg weakness
b) absence of a gag reflex
c) difficulty swallowing
d) inability to speak clearly
d) aphasia is loss of language skills
Which factor(s) in the patient's past medical history place(s) him at risk for falling? Select all that apply.
1) Orthostatic hypotension
2) Appendectomy
3) Dizziness
4) Hyperthyroidism
Answer:
1) Orthostatic hypotension
3) Dizziness
Rationale:
Orthostatic hypotension, cognitive impairment, difficulty with walking or balance, weakness, dizziness, and drowsiness from certain medications place the patient at risk for falling. A history of right appendectomy and hyperthyroidism do not place that patient at risk for falling.
The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following?
1) Team nursing
2) Case method nursing
3) Functional nursing
4) Primary nursing
Answer:
3) Functional nursing
Rationale:
With team nursing, an RN or LVN is paired with a NAP. The pair is then assigned to render care for a group of patients. In case method nursing, one nurse cares for one patient during her entire shift. Private duty nursing is an example of this care model. This medical surgical floor is following the functional nursing model of care, in which care is partitioned and assigned to a staff member with the appropriate skills. For example, the NAP is assigned vital signs, and the LVN is assigned medication administration. When the primary nursing model is utilized, one nurse manages care for a group of patients 24 hours a day, even though others provide care during part of the day.
The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has:
1) Crackles
2) Rhonchi
3) Stridor
4) Wheezes
Answer:
3) Stridor
Rationale:
Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are potentially serious but do not necessarily indicate respiratory distress that requires immediate medical attention.
A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing?
1) Phantom
2) Visceral
3) Deep somatic
4) Referred
Answer:
3) Deep somatic
Rationale:
Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site.
A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next?
1) Apply a vest restraint.
2) Move the patient to a quieter room.
3) Ask another nurse to care for the patient.
4) Provide comfort measures.
Answer:
4) Provide comfort measures.
Rationale:
Patients sometimes become agitated because they are uncomfortable or in pain. Providing comfort measures may decrease agitation. If the patient continues to be agitated, the nurse should encourage a family member or friend to sit with the patient. Applying a physical restraint should be kept as a last resort for use only when less restrictive measures fail. The patient should be placed in a room near the nurses' station so he can be checked frequently if there is no one available to provide one-on-one supervision. A quieter room would probably not help.While teaching a health promotion group of adults, the nurse notices one person who is clutching his throat with both hands. What should the nurse do first?
1) Call 9-1-1.
2) Encourage the person to cough vigorously.
3) Ask, "Are you choking?"
4) Give five back blows.Answer:
3) Ask, "Are you choking?"
Rationale:
Clutching the throat is the universal sign of choking. The first action when you suspect airway obstruction is to ask, "Are you choking?" If the person indicates "yes," or if the person cannot cough, speak, or breathe, that indicates choking. You must first be certain the person is choking because you can cause harm when you perform the choking maneuver. You would not call 9-1-1, encourage coughing, or give five back blows until you first establish that the person is choking. The client appears to be giving the universal sign for choking, but the nurse must validate the client's meaning before acting.
The nurse is assisting a male client to the bathroom. When 5 feet from the bathroom door, the client states, "I feel faint." Before the nurse can get him to a chair, he starts to fall. What is the priority action for the nurse to take?
Lower patient to floor then assess
Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?
1) Hepatitis B
2) Occasional alcohol use
3) Allergy to aspirin
4) Gastric irritation with bleeding
Answer:
1) Hepatitis B
Rationale:
Even in recommended doses, acetaminophen can cause severe hepatotoxicity in patients with liver disease, such as hepatitis B. Patients who consume alcohol regularly should also use acetaminophen cautiously. Those allergic to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) can use acetaminophen safely. Acetaminophen rarely causes gastrointestinal (GI) problems; therefore, it can be used for those with a history of gastric irritation and bleeding.
Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate.
Answer:
3) Assess the patient's respiratory status.
Rationale:
Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's respiratory status because opioid analgesics can cause respiratory depression. It is not necessary to clarify the order with the physician because morphine 4 mg IV is an appropriate dose. It is not necessary to monitor the patient's heart rate.
the nurse is caring for clients in the outpatient clinic. which of the following phone calls should the nurse return FIRST?
1. a client diagnosed with hepatitis A who states: my arms and legs are itching
2. a client with a cast on the right leg who states: i have a funny feeling in my right leg
3. a client diagnosed with osteomyelitis of the spine who states: i am so nauseous that i can't eat
4. a client diagnosed with rheumatoid arthritis who states: i am having trouble sleeping
"a client with a cast on the right leg who states: i have a funny feeling in my right leg"
physical stability is the nurse's first concern. the most unstable client will be seen first (think ABC's). the client stating that their right leg (that is in a cast) feels funny may have neurovascular compromise and requires immediate assessment of circulation. the client with hepatitis A is experiencing itching due to the accumulation fo bile salts under the skin and can be treated with calamine lotion and antihistamines. difficulty eating and sleeping both require assessment, but are not top priority.
A client who is blind is admitted for treatment of gastroenteris. Which nursing diagnosis is the highest priority for this client?
a) deficient fluid volume
b) risk for injury
c) activity intolerance
d) impaired physical mobility
A) deficient fluid volume
dehyrdation is a sign of gastroenteris
a client reports pain in the right lower extremity, the primary HCP prescribes codeine 60 mg and aspirin 650 mg PO Q4H PRN for pain. Each codeine tablet contains 15 mg of codeine. Each aspirin tablet contains 325 mg of aspirin. Which of the following should the nurse administer?
1. 2 codeine tablets and 4 aspirin tablets
2. 4 codeine tablets and 3 aspirin tablets
3. 4 codeine tablets and 2 aspirin tablets
4. 3 codeine tablets and 3 aspirin tablets
"4 codeine tablets and 2 aspirin tablets"
60 mg codeine = 4 15 mg tabs
650 mg aspirin = 2 350 mg tabs
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?
a) serum albumin level of 3 g/dL
b) HDL level of 90 mg/dL
c) Norton scale score of 18
d) Braden scale score of 20
A
Serum albumin level below 3 g/dL indicates protein deficiency, putting the client at risk for pressure ulcer formation and poor wound healing
B: Normal level-nothing to do with wounds
C: low risk-lower then 10 is considered high risk
D: low risk - lower then 12 is considered high risk
Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply):
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
3) Heart rate was 76 before eating and is 60 after eating
4) Respiratory rate was 14 when standing and is 22 after walking
Answer:
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
3) Heart rate was 76 before eating and is 60 after eating
Rationale:
The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate after exercise.
The nurse has completed the diet teaching of a male client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
A. A peanut butter sandwich with soda and cookies.
B. A tunafish sandwich with chips and ice cream.
C. A salad with three kinds of lettuce and fruit.
D. Vegetable soup, crackers, and milk.
Answer
B. A tunafish sandwich with chips and ice cream.
Rationale
(B) contains the highest amount of protein. Four ounces of tuna contains 11 g of protein, and ice cream 5 g of protein per cup. Chips are a fat with virtually no protein value. (A) contains 4 grams of protein per tablespoon. (C) contains only 1 gram of protein per 1 cup serving. (D) may have beef flavoring but it consist mostly of vegetables and would therefore be low in protein.
While caring for a client with a cervical spine injury, which assessment finding should the nurse report to the healthcare provider immediately?
A. Heart rate 140 beats/minute.
B. Respiratory rate 6 breaths/minute.
C. Average urinary output 20 mL/hour.
D. Sluggish pupillary response.
Answer
B. Respiratory rate 6 breaths/minute.
Rationale
With a cervical spinal injury the respiratory status can quickly become compromised and require mechanical ventilation. A slowing respiratory rate (B) is a critical sign that the client is decompensating. (A, C, and D) are important but do not have the priority of (B).
The nurse is caring for a client with suspected meningitis after a lumbar puncture was performed. Which of the following indicates an expected outcome after the procedure?
A. The client has a small amount of bloody drainage at the insertion site.
B. The client has pupils of unequal size.
C. The client has a small hematoma at the insertion site.
D. The client reports a HA with mild dizziness
The client reports a HA with mild dizziness
(HA is a mild but common complication that occurs in 10-30% of clients in the hours following the procedure, and maybe be accompanied by dizziness, N/V, tinnitus, and visual changes)
The nurse is preparing a client to receive one unit of PRBCs prior to surgery. Which of the following will the nurse ensure is done before the transfusion is begun? (select all that apply)
A A recent type and crossmatch
B A blood band/ID bracelet is in place
C An 18 gauge catheter IV in place
D 1 liter lactated ringers ready to infused with the blood
E Baseline VS performed and documented
A,B,C,E
A recent type and crossmatch, a blood band/ID bracelet in place, an 18 gauge catheter IV in place, and Baseline VS performed and documented.
~ Only NS may be given with PRBCs
For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques?
A. Palpation
B. Auscultation
C. Inspection
D. Percussion
1) D, B, A, C
2) C, A, D, B
3) B, C, D, A
4) A, B, C, D
2) C, A, D, B
Rationale:
Inspection begins immediately as the nurse meets the patient, as she observes the patient's appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving physical touch, the behavior, posture, demeanor, and responses might be altered. Palpation, percussion, and auscultation should be performed in that order, except when performing an abdominal assessment. During abdominal assessment, auscultation should be performed before palpation and percussion to prevent altering bowel sounds.
A patient has a history of DM. When doing your charting the patient calls out on call light and states," I feel dizzy and thirsty". What is your first initial step to take care of this patient? What is your second step to take care of this patient?
Take patients blood sugar
Give 15 grams of carbs (juice, pb crackers)
Check blood sugar again in 15 min
Another round of carbs
A client is diagnosed with deep vein thrombosis (DVT) Which nursing diagnosis should receive the highest priority at this time?
a) impaired gas exchange due to increased blood flow
b) excess fluid volume related to peripheral vascular disease
c) risk for injury related to edema
d) ineffective peripheral tissue perfusion related to venous congestion
d) ineffective peripheral tissue perfusion is highest priority due to clot formation impeding blood flow in DVT