NURSING 201: HESI Version 3- Fundamentals, Complete guide (2019/2020) ; Columbia University.

NURSING 201 HESI Version 3- Fundamentals. A client who has a prescription for fluid restriction asks the nurse for a mid-afternoon snack. What is the best snack to bring to the client The nurse is developing a teachi ...

NURSING 201 HESI Version 3- Fundamentals. A client who has a prescription for fluid restriction asks the nurse for a mid-afternoon snack. What is the best snack to bring to the client The nurse is developing a teaching plan for a client who was recently diagnosed with pernicious anemia and requires vitamin B12 replacement therapy. Which precaution is most important for the nurse to include in the clients plan of care. In preparing to administer an intravenous medication, the nurse notes that the drug is listed in drug reference guide as being incompatible with the currently infusing intravenous solution of Ringer’s Lactate. What action should the nurse take? A client with an overactive bladder receives a prescription Oxybutynin (Ditropan) an anticholinergic agent. Which information should the nurse include in this client teaching plan. A female client who is receiving chemotherapy asks the nurse if she can have a fresh green salad because she is nauseated. Which response should the nurse provide. The health care provider telephones the nurse and provides a verbal prescription for a client’s persistent cough and pulmonary wheezing. The prescription includes a chest x-ray and antibiotic and a nebulizer treatment now and PRN, in what order should these interventions be implemented? (Arrange the first action on top, and the last action on the bottom) Based on the Braden Risk Assessment Scales, Which client is at highest risk? Prior to removing surgical wound staples, what assessment is most important for the nurse to complete? Which technique should the school nurse use to assess a group of children with pediculosis capitis (head lice). A nurse assesses a client’s care after receiving a report from the practical nurse, who is leaving the unit. The PN report that the clients’ dressing was changes, and the dressing change and wound appearance were documented in the nurses’ note. The nurse later observes that the date on the clients dressing is from the previous day and was initialed by the nurse who cared for the client the previous day, What action should the nurse take? Because a client with Bells’ palsy is at risk for impaired nutrition, which action should nurse include in the clients plan of care? A new employee in a long term care facility for clients with Alzheimer’s tells the nurse that an elderly male client constantly asks for his mother who died many years ago. The UAP asks the nurse for advice on how to respond to the client. Which response should the nurse provide? A client with metastatic cancer and a very limited prognosis is being discharged from the hospital, when developing a plan for this client, which goal has the highest priority? A nurse is observing the appearance of an older clients eyes. Which finding warrants immediate intervention? 15 A client with type 2 diabetes mellitus (DM) receives a new prescription for sitagliptin (januvia) In providing client teaching, the nurse should emphasize the importance of reporting which problem to the healthcare provider immediately? When analyzing objective data obtained during a physical assessment, what action should the nurse perform first? The nurse is assessing the reflexes of a 35 year old male client who came to the clinic for his annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next? A charge nurse overhears a practical nurse (PN) tell unlicensed Assistive personnel (UAP) to apply sequential Compression devices to the legs of a postoperative client. What action should the charge nurse take? The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non English speaking client. The client gives verbal consent and the healthcare provider ?????? ?????? the nurse to witness the signature on the consent form. The client and interpreter then speak together in the foreign language for an additional (3?) minutes, until the interpreter (?????) “she says it is OK”, What action should the nurse take now? The healthcare provider prescribes several medications for a client diagnosed with myasthenia gravis (MG) Which medication would the nurse expect to use to differentiate a myasthenic crisis from a cholinergic crisis? A client’s right to give informed consent is based on which ethical principle? When establishing isolation supplies……for a shunt A male client is scheduled for a cardiac Catheterization? In the morning, which interventions should the nurse plan for implementing prior to this procedure? An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insists that an elaborate alarm system needs to be installed in his home. The nurse knows that the client is exhibiting which sign or symptom? While preparing a sterilized field prior to doing sterile dressing change, the nurse drops a sterile gauze pan on the edge of the sterile field. What is the best nursing action? A client who is receiving peritoneal dialysis is assigned to a nurse who has not performed this procedure previously. Which actions should the nurse implement before beginning the procedure? A client has a prescription for azithromycin 500mg diluted in 250 ml of normal saline IV q24h for three doses. What action should the nurse implement? After performing a focused assessment for a male client with Addison’s disease, the practical nurse reports to the charge nurse that the clients’ mucus membranes are moist and he has strong peripheral pulses and his blood pressure is 132/88. The client verbalizes understanding of his illness and importance of taking his medication daily, which action should the nurse implement? What instruction should the nurse include in the teaching plan of a client who is beginning to take the prescription drug Atabuse (Disulfiram) The nurse identifies physical signs of Trisomy 21- Down syndrome in a 3 month-old infant during a well child visit. Which focused assessments are most important for the nurse to complete? The nurse is planning care for an assigned group of clients in a small nurse care facility, which client should the nurse see first? Which self-care measure is most important for the clinic nurse to emphasize when teaching a client who was recently diagnosed with osteoporosis A mother brings her 4 month old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child’s hernia. Which explanation should the nurse provide? The nurse begins an oral medication prescription to be given daily to a male client who tells the nurse that he will take his medication later. What action should the nurse implement? Following a left above the knee amputation, the client voiced several complaints. What statement should serve as a warning to the nurse that the client may be experiencing complications? A child is brought to the clinic complaining of fever and joint pain and is diagnosed with rheumatic fever. When planning care for this child what is the primary goal of nursing care? In caring for a 9 month old child following surgical correction of a clubfoot. Which intervention should the nurse implement to determine the child’s need for analgesic administration??? When the charge nurse presents a change in unit procedure to the nursing staff. One of the nurses states “it’s never going to work” Which response by the charge nurse is likely to be most effective. MATH Q The healthcare provider prescribes 250mg/hr of magnesium sulfate. The pharmacy delivers 500 ml IV that contains 4 grams of the drug. The nurse should set the IV infusion pump to deliver how many ml per hour. Round to the nearest whole number if needed. An 8 year old child weighs 60 lbs receives 25mg/kg/day every 8 hrs. The medication is labeled 125mg/5ml. How many ml should the nurse administer? While assessing the nasogastric tube drainage, the nurse discovers rust colored flecks, which action should the nurse take? A male client sustained a burn injury to more than 25% of this total body area in an industrial fire. Which nursing intervention is most essential to be implemented during the emergency phase? A male client with chronic kidney disease is involved in a motor vehicle collision and is brought to the emergency department with a rapidly hemorrhaging leg fracture. The healthcare provider inserts a central venous catheter (CVC). To promote rapid volume expansion, which equipment should the nurse obtain? To identify a client’s learning needs prior to surgery, what action should the nurse implement? An older female is admitted for a 24 hour observation after suffering several broken ribs as a result of a fall in her home. Which finding should the nurse report to the healthcare provider immediately? A mist tent and intravenous fluids are prescribed to a 6 month old with respiratory syncytial virus (RSV) is a virus that causes respiratory tract infections. It is a major cause of lower respiratory tract infections and hospital visits during infancy and childhood. When the parent inquire why there child is not receiving antibiotics. A client with a history of recurrent atrial fibrillation is taking amiodarone (cordarone) and warfarin (Coumadin). Which meal should the nurse provide for the client? The nurse is preparing to transfer a client who I receiving a primary infusion of normal saline and a secondary infusion of an antibiotic??? Peak and trough levels need to be obtained after transfer. What information is most important for receiving when the client arrives? Following an episode of bacterial endocarditis, a client develops Mitral valve stenosis. The nurse recognizes that the client is at risk of pulmonary hypertension as a result of what process? The nurse is measuring the input for an infant admitted for vomiting and diarrhea. During a 12 hr shift the infant drinks 4oz….vomits 25ml and voids twice. The dry diaper weights 50 grams, and one wet diaper weights75 grams, the other one weighs 50 grams. Which …documentation should the nurse enter in the client’s record. When should the nurse conduct an Allen’s test? Which equipment should the nurse use to administer a liquid iron preparation to an infant with an iron deficiency anemia? When caring for a client on a ventilator, which finding provides the greatest indication that the client has an open airway? When entering a client’s room, the nurse discovers, that the client is unresponsive and pulseless. The nurse starts CPR and calls for assistance. Which action should the nurse take next. A client is admitted in the labor and delivery unit in early labor and the nurse assesses the status of her condition. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner. What might the nurse suggest to a patient who has fibrocystic breast in attempt to help her relieve her symptoms? A UNP report to the nurse that a patient’s right hand and fingers spasm when she takes his blood pressure using the same arm. After confirming the spasms, what action should the nurse take? A male infant born at 20 weeks gestation in an outlying hospital is being prepared for transport to a level IV facility. His respirations are 97 breaths/min and his heart rate is 156/beats per minute. What drug will the transport team most likely administer to the infant? A pediatric client is taking beta adrenergic blocking agent Inderal (propranolol hydrochloride). In developing a teaching plan. The nurse should teach the parents to report which sign of an overdose. A client admitted with hepatitis A and dehydration. Subjective symptoms include fatigue, anorexia,…. What additional assessment should the nurse collect during the preicteric Phase. The charge nurse of the Intensive care unit is making assignments for the permanent staff and RN who was floated from a medical unit. The client with which conditions is best to assign to the float nurse. A mother comes to the pediatricians’ office complaining that her 9 month old infant is experiencing, fever, diarrhea, and irritability. When taking the history, which information is most important for the nurse to obtain? In assessing a client 12 hrs following Transurethral resection of the prostate (TURP). The nurse observes the urinary draining tubing contains a large amount of clear, pale, pink urine and the containers bladder irrigation is infusing slowly The nurse needs to add medication to a liter of 5% dextrose in water (D5W) that is already infusing into the client at what location should the nurse inject the medication. Picture of hanging IV bag Which self-care measure is most important for the clinic nurse to emphasize when teaching a client who was recently diagnosed with osteoporosis A mother brings her 4 month old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child’s hernia. Which explanation should the nurse provide? The nurse begins an oral medication prescription to be given daily to a male client who tells the nurse that he will take his medication later. What action should the nurse implement? An adolescent receives an injection for 4mg subcutaneously of Imitrex for migraine headaches. Using a vial labeled 6mg/0.5ml, How many ml should the nurse administer? Round to the nearest hundredth A female nurse who took drugs from the unit for personal use was temporary released from duty. After completing mandatory counseling. The nurse asks administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurses request. What action is best for the charge nurse to take. A client at the healthcare clinic reports a new onset of pyrosis and dyspepsia to the nurse. Which nursing action has the highest priority. Which nursing intervention has the highest priority for a multigravida client who delivered vaginal 12 hours ago. The mother of a one month old boy born at home brings the baby to his first well-baby exam. The mother tells the nurse that he was born 2 weeks after his due date, and he is a good quite baby, who almost never cries. In screening for hypothyroidism what questions are most important to ask the mother. In preparing a nursing care plan for a client admitted with Guillain Barre Syndrome. Which nursing problem has the highest priority? A client who recently received a prescription for R ? to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effects should the nurse report to the health care provider. What statement by a client 24hrs post subtotal thyroidectomy requires an immediate intervention by the nurse. A 6- week old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which preoperative nursing action has highest priority A college student recently diagnosed with (ADD) and is taking adderall 10mg PO daily. Which information should the teaching plan for the client A male client had a TURP today has a continuous bladder irrigation. The client requests pain meds for abdominal pain 9/10. What action should the nurse take? The mental health nurse takes several adolescent clients to the inpatient school room. Teacher asks nurse to stay and help male client with ADHD with spelling assignment. Which goal is most reasonable for this client to attain during the 1 hour class? Client receiving a standard solution of heparin 25,000units/250ml of NS. HCP prescribes increase current infusion to 700units/hr. How many ml/hr should the nurse program the infusion pump? lient receiving IV Dobutamine (Dobutrex). In evaluating client reaction, which assessment finding indicates that he med is effective? Client misses breakfast because of 2 hr hand washing ritual. What plan is most therapeutic for the nurse to implement? Which DC instruction should the nurse provide client with HF taking Digoxin? Charge Nurse in ICU needs to transfer client to the med unit from the ER can be admitted to ICU. Which client is best to transfer? Nurse stops to render aid at scene of MVA and finds child 6mos old strapped in car seat in back. After calming with pacifier, what action should nurse take? Unresponsive female victim of MVA brought to the ED and it is determined that immediate surgery is needed to save life. The client is accompanied by close friend, but no family. What intervention should the nurse implement? Confused and combative male placed in bilateral wrist restraints to keep from pulling NG out. Client developed abrasions both wrists. Morning abrasions found, client record contained nursing documentation stating skin and circulation …..every 6-8 hrs When nurse auscultates anterior chest just above right nipple, moderate pitched breath sounds heard and equal on inspiration and expiration. Which statement best describes the finding? Client is seen in clinic with acute gastritis. Which nursing diagnosis is highest priority? Nurse encourages male over age 45 to get what test for prostatic cancer? Male tells nurse does not want to receive blood that is needed for internal hemorrhage. What action should the nurse implement? Nurse is caring for laboring client whose membrane ruptured 24 hrs prior to admit. Based on record and current fetal monitor, which action should the nurse implement? Nursing intervention with highest priority when completing DC teaching for H. Pylori induced peptic ulcer Dz? A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement The nurse is developing a teaching plan for a client who was recently diagnosed with pernicious anemia and requires vitamin B12 replacement therapy. Which precaution is most important for the nurse to include in the client’s plan Which technique should the school nurse use to assess a group of children for pendiculosis capitus Client diagnosed with HTN has goal of “will be able to verbalize ways to decrease BP” What statement by client indicates outcome is met? A client comes to the prenatal clinic on September 10th and reports her last menstrual period (LMP) was May 1st. Identify the location where the nurse should expect to locate the fundus 75yr old female had total hip replacement 2 days ago. Never been in hospital before, and just called for bedpan. How should nurse place pan under her? Day 3 hospital for depression, male client tells nurse feeling better and believes the antidepressant meds at working. He participates in activities and agrees to take on assignments. What action is most important to implement at this time? Client experiencing intracranial HTN from traumatic brain injury, admitted to trauma unit. How should the nurse position him? Parents of 4wk old male infant reports eats well but vomits after feeding. Which assessment finding should nurse expect to exhibit if inadequate nutrition? Planning DC teaching for female with frequent urinary infections, in teaching how to prevent which recommendation? Meds causing photosensitivity Infusion 500ml D5 with 25,000 units heparin at 1,000 unit/hr with PTT of 110 sec. Sliding scale Rx reads: PTT less than 65 sec, increase by 200 units/hr; PTT greater than 95 sec decrease by 200 units/hr Teaching preconception preparation class and discussing ways to improve dietary folic acid intake. Which snack contains the most? 8 mo old boy with TOF periodic Tet spells with paroxysmal dyspnea. Which intervention is most effective? 21 yr old developed splenomegally secondary to infectious mono. What factor in the history is most important for DC teaching? Monitoring an infant with pulmonic stenosis. Which finding is important for nurse to report to HCP? Nurse planning care for newborn with bladder extrophy. During preop which intervention should implement? After positioning client on the side to administer rectal suppository, observes incontinent of a large amount of liquid stool which soaked through gauze pad covering stage 3 pressure ulcer. Which action should take? Nurse assessing 48 yr old with Guillian-Barre. What symptom is client most likely to have? ED notifies charge nurse at 3am of transfer of client being admitted with multiple lacerations that are from self-destructive behavior. Policy says client admitted to a safe room with windows locked but the only room on unit is currently occupied. Nurse caring for a 2 day post-op client. What assessment indicates wound healing? ABG are ph 7.5, PaO2 94, PacO2 30, HCO3 24. What action? “Code pink” announced over intercom….what action should nurse on med/surg unit implement first? Client experiencing paranoid ideation admitted to psych unit. First 48 hrs which intervention? Surveillance clues specific potential indicators of bioterrorism attack? Client in acute renal failure has serum potassium 6.3. What med? Nurse finds client 33 weeks gestation in cardiac arrest. What adaptation to CPR should implement? Client produced first of a series of sputum samples for cytology. What action? Scheduling home visits, which client is best for HHC nurse to assign to LPN? Hospitalized for pregnancy induced HTN and receiving magnesium sulfate 2g/hr IV. Which med should nurse have immediately avail? Which statement by mom of toddler with croup indicates teaching effective? HCP asks for meperdine (demoral) 25mg IV Q3hr for older adult post-op patient. Nurse prepares dose from cartridge labeled meperdine 75mg/ml and dilutes with 5ml NS for IV. How many mls of total medication? Which assessment indicates resolution of sub-Q emphysema 1 hr after getting cardura, a male client with BPH complains of rapid HB and dizziness. He is sitting at the side of the bed finishing his bedtime snack. Radial pulse is 144bpm. What action take first? Preparing client for thoracentesis, it is essential for nurse to take what action? Nurse is preparing disaster plan for community. When planning for potential bioterrorism which Dz should be considered Completing discharge teaching for client with perineal surgery 1 wk ago. Which statement indicates effective? Male tells nurse experienced acid reflux for several yrs. Nurse recognizes the client has increased risk for Which equipment should nurse use to administer iron to infant with iron deficient anemia? 25 yr old with testicular CA scheduled for unilateral orchiectomy tomorrow. During pre-op prep, he says concerned that scrotum will not look normal after, even though he knows testicular prosthesis will be inserted. What information for nurse to provide? Adult male presents to psych clinic with mother who is concerned that child is going to jail for breaking into a jewelry store. Nurse conducts intake assessment and finds that son is using marijuana. What info should nurse provide to mother? Nurse plans frequent monitoring of skin color, mucus membranes, nail beds of client with ARF. What is the purpose? 7yr old child with Guillian-Barre admitted with ascending paralysis to the C-6. In plan to prevent disuse until the paralysis subsides, which intervention to include? Female client being prepared for HSG informs nurse allergic to shellfish. What implement? After seeing homebound clients, HHC nurse ahs telephone messages from case load. Which call should be returned? Client with HTN scheduled for dose of carvedilol (coreg). Which vital sign warrants notification to HCP prior to giving? 45 yr old client had hysterectomy 1 wk ago and asks when can start to experience hot flashes. Before responding what info is needed? After sitting outside elderly male develops uticaria and a macular rash with raised wheals over trunk. He is slightly dyspneic, and furiously scratching with both hands. What action 1st? Indwelling urinary catheter develops hematuria in last 4 hrs. What action? Nurse observes male HCP viewing his sister’s med record on computer. What do? While receiving the first of 2 prescribed units of Packed red blood cells (PRBC), develops a low-grade fever, flushing, uticaria; so nurse stops transfusion. What next? Nurse working with UAP to prepare client with hip surgery for transfer to rehab unit. A PN enters room and reports that a patient with pneumonia has been confused and combative. What action? 2 yr old well-child visit, toddler parent tells nurse child who is youngest of 5, rarely talks spontaneously. What intervention? 82 yr old female hospitalized with fractured femur. During assess repeatedly asks nurse to “speak up”. What action? 79 yr old female with COPD asks why she has round chest. Nurse correctly responds that typical “barrel- chest” appearance of an emphysema client is caused by? Vaginal exam is admitted early labor reveals cervical dilation 2 cm 50% effacement, and -3 fetal station. Client tells nurse that friend bag of water was ruptured by Dr to make faster and she is concerned because her Dr didn’t do it. Response? Nurse plans to administer 0.5ml IM to 18 month old in vastus lateralis. What is rationale? “Social Isolation” identified by nurse for 16 yr old experiencing facial edema. What behavior indicates positive outcome? Planning strategies to promote rest and sleep during night shift. Nurse should encourage staff to adhere to which guideline? Planning for client newly diagnosed with type 1 DM. What intervention? The nurse is evaluating pre-op teaching. What statement indicates understanding of need for NPO prior to surgery? Resident of long-term care falls in night. After determining has obvious wrist injury and blunt head trauma nurse is unable to reach HCP despite numerous attempts. Which action? New plaster cast is applied to arm for fracture of ulna. Sixty minutes after pain med, pt reports pain in arm 10/10. Which action? Which assess finding contraindicates removal of staples? Pt in ED with acute abdominal pain and provisional diagnosis of pancreatitis. Assessment and results from lab are obtained. Which is most valuable in reporting status to HCP? Pt with dementia describes imagined experiences that have no basis of fact so “altered thought process R/T confabulation”. What does confabulation serve in dementia? Man trapped for 2 days on the roof during weather related disaster spent several wks in shelter. During this time he said he wondered if he was going to die like friends and relatives. Now several months later reports feeling numb and cannot relate well with others. He sometimes relives the event. Assess pt who had a laparotomy previous day, notices that 300ml of dark red fluid drained from NG tube in last hr. What action? After injection, nurse observes bleeding at site. In what sequence should nurse perform actions? Nurse overhears 2 employees discussing confidential pt info in cafeteria. Breach of which ethical principle? Preparing to administer liter of IV solution to toddler with gastroenteritis who is dehydrated. Which action to prevent overload? Assessing a 6 yr old, notices several elevated 1-3 mm white spots in the buccal mucosa. What other signs to look for? Teaching using a Holter monitor, which statement indicates understanding the procedure? Female diagnosed with major depression admitted to psych unit. Refuses to take a bath, dress, eat, and wants to sleep during day. Which intervention? Pt with chronic controlled A-fib develops symptoms of PE. What intervention? School-aged child with OM receives Rx for Azithromycin 300mg once, then 150 mg daily for 4 days. Med is avail in solution containing 200mg/5ml. How many mls should nurse administer on the 1st day of Tx? Nurse is concerned about type of legal consequence that resulted from breaching confidentiality. What source states legal requirements nurses must follow to protect Pt in nurse-patient relationship? Nurse performing intake interview at prenatal clinic. Which planned activity by client, who is 6 wks gestation should be investigated first? Young adult male admitted to the psych unit because of overdose. Which intervention during initial withdrawal? What area of the body should be palpated to assess Heberden’s nodes for osteoarthritis? Infant receiving gavage feedings via OGTube. At beginning of feeding infant HR drops to 80bpm. Action? 40 yr old with type 1 developed CKD 6 mos ago from secondary complications associated with this illness. Nurse carefully assesses for? Nurse developing plan of care for Pt returning from surgery after total cholectomy and ileostomy. Which diagnosis has the highest priority for the client in immediate post-op period? Which approach is best for the nurse to use when communicate with a client with ALS? Client diagnosed with schizophrenia looks frightened and tells nurse “keeps hearing voices telling me to hurt somebody” Don’t you hear them?” Nurse response? Newly diagnosed type 1 D receives 28 units of Humulin N at 0700. Nurse is making rounds at 1330. Which client statement requires immediate follow-up intervention? During breath sound auscultation of Pt being mechanically ventilated, nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. What implement? At community health fair, 50 yr old tells nurse she has an annual physical exam that includes a clinical breast exam and annual mammogram. How to respond? Adult woman and live-in boyfriend are seen in the ED following MVA. Based on which finding should further assess for domestic violence? Nurse knows the pt with a mechanical valve replacement understands the DC teaching. When states? While reporting BG results to nurse, LPN states the glucometer was not calibrated prior to use because the report given by the night shift staff ran late. What action? Female client instructed to do kegel exercises. What statement indicates the client understands how to perform? Charge nurse should intervene when what behavior is observed? Client who has L AKA 2 days ago has a soft stump dressing. To prevent the development of contracture on the left leg, which intervention? ACE inhibitor is prescribed for male with diabetes whose BP is 120/60. He asks the nurse why he is getting the med when his BP is normal. Response? When irrigating an occluded NG tube, what action should the nurse include? Nursing diagnosis, “high risk for infection” is most relevant for client with which hematologic problem? 36hrs after delivery, nurse assesses client’s fundus just above the umbilicus and displaces to the right of midline. What action? In assessing client diagnosed with left- sided HF, nurse observes new findings of Jugular venous distension (JVD) and pedal edema. What action? Identify location of tragus on the outer auricle. Pt with AV graft for hemodialysis in left forearm and an infiltrated IV in right arm. After disconnecting the IV, where to start the next IV? 10 yr old boy reports words on teacher powerpoint presentations are blurry even though sits in front row of classroom. Based on this, which problem? After phenobarbitol to infant with ICP, which response should nurse expect? HCP prescribes etanercept (enbrel) 50mg Sub-Q weekly for rheumatoid arthritis. Nurse should evaluate effectiveness of med within what time frame? Male pt with history of generalized tonic-clonic seizures tells nurse he feels like about to have seizure. What do? Nurse gives pt daily dose of Rx for captopril 12.5mg PO Q AM. Shortly after, med the HCP instructs nurse to give another dose to reach the newly Rx dose of 50mg PO daily. Med is avail in 12.5 mg tabs. How many additional tabs should nurse give? Pt receiving intermittent infusion of erythromycin lactobionate inj, USP 1 gram in 250ml of NS over 2 hrs. Nurse programs infusion pump ml/hr? 1 day old neonate awaiting surgical correction of myelomeningocele. During pre-op what is priority? Female pt just completed full chemo cycle for CA, lost 15 lbs from anorexia, N/V. BMI is 19. Nurse reinforces nutrition during DC. What dinner selection? Nurse caring for dyspneic pt whose O2 sat of 90%. What position? Obtaining a health history, male client tells nurse become impotent. What part of info is likely to be significant to the dysfunction? Mother of hospitalized 2 yr old boy asks the nurse if her child is ready to potty-train. Response? Nurse agrees to work double because of shortage, but requests another nurse be assigned to care for demanding client. Response? Nurse evaluating teaching about short-acting insulin coverage to newly diagnosed with type 1. Which statement indicates understanding? Pt admitted to inpatient psych unit and antipsychotic drug clozapine is Rx. Which intervention? Nurse assessing Pt 8 hrs postparathyroidectomy. Assessment findings include a negative trousseaus sign. Action? Nurse preparing a native-American for surgery In 1 hr. client says “I want to have my med man called before surgery.” Response? Nurse calculating 1 minute Apgar score for newborn male infant. HR 150 bpm, vigorous cry, muscle tone good with total flexion, quick reflexes, irritability, and color is dusky and cyanotic. Score? Administering IV med through central venous catheter with hep lock. Which sequence? After change of shift report on psych unit of general hosp, which client see first? Nurse caring for Pt being treated for fever. Intervention to prevent chills? To assess with meningitis for meningeal irritation, how to position head? Diagnosed with severe acute diverticulitis and being admitted to med unit. Priority Q? Nurse notes that a depressed adolescent fluoxetine (Prozac) cannot be given because the mother refuses to sign consent. Do? Child injured at sporting event and a nurse attending the event evaluates the child. What is the most accurate method to determine fracture? Nurse working in health clinic assessing need for Hep A vaccine. Which client has greatest risk of contracting? Client with depression remains in bed most of day, declines activities, refuses meals. Dx? Which intervention would nurse expect to decrease discomfort and muscle spasms in elderly pt with fractured left hip? In performing the admission assessment for pt experiencing complications of long-term PD, which Q provides best info about progression? 18 yr old female with primary dysmenorrheal does not want to take meds for symptoms, asks nurse which herbals likely to help alleviate the pain. What supplement? Assessment intervention should the psych nurse implement when performing mental status exam? Nurse is conducting routine assess of 24 hr old AA infant delivered vaginally. At birth weight was 5 lbs 5 oz, HR 150 bpm, R 88bpm, temp 97.7. Which needs further assess? Following vaginal delivery of a 10 lb infant, nurse assesses new mother’s vaginal bleeding and finds that she has 2 pads in 30 min and boggy uterus. What action? Angina experiences chest pain after morning care. First? Gravida 3, Para 2 at 31 wks gestation admitted to hosp with suspected HELLP syndrome. CC- N/V malaise, epigastric pain, BP 116/74. What assessment? 60 yr old male admitted complaining of R knee pain for past week; knee and calf are warm and edematous, history of diabetes and arthritis. What info obtain? Nurse observes client standing with use of crutches and notes that arms are fully extended and tops of crutches are securely pressed into axillae. What intervention? Parents of a child with CF ask about their chances of having another CF child? 12 yr old male diagnosed with idiopathic hypopituitarism based on plasma growth hormone studies. Sub- Q injection of the hormone somatotropin (HGH), are Rx TID. When to promote the most natural physiological release? Planning care for a group of pts on a med unit; which task delegate to UAP? To administer saline enema, nurse inserts the enema tubing 3 inches into rectum, elevates saline container 6 inches above body. After nurse opens clamp, saline does not infuse. What action? Client receiving chemo for lung CA with brain Metastasis scheduled for cranial radiation therapy today. Provide what info? Inserting an indwelling catheter for female and notes catheter in vagina. Steps? Assessing both lower extremities with chronic venous insufficiency; identifies bilateral stasis dermatitis and an ulcer n the medial surface of left ankle. To promote effective self-care what teaching? 40 wks gestation admitted in active labor, labs indicate HIV positive. Action? Toddler with hemophilia discharged from hosp. What teaching? Nurse is preparing a male client for a bilateral adrenalectomy. Which info in preop teaching? Nurse with a history of drug impairment returns from rehab, best initial action by charge nurse?