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a charge nurse is assisting a newly licensed nurse with the preoperative assessment of a 2-year-old child who has a Wilm's tumor, what actions by the newly licensed nurse require intervention from the charge nurse - anspalpating the child's abdomen A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? - ansI will add rice cereal to my baby's feedings. A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia. Which of the following instructions should the nurse include in the plan? - ansInspect the toddler's toys for sharp edges a home health nurse is providing teaching about post-seizure management to the parents of a school-age child who has epilepsy, what should be included - ans- record the length and character of the child's postictal period following a seizure
- call for emergency medical services if the size of the child's pupils are unequal after the seizure a nurse in a pediatric clinic is discussing the physiology of Reye syndrome with a newly licensed nurse, what statements by the newly licensed nurse indicate an understanding of the disorder - ansReye's syndrome causes fatty changes in the liver a nurse in a pediatric clinic is performing a history and physical for a toddler who is going to receive an MMR immunization, which indicates that it should be withheld - ansreceiving prednisone for nephrotic syndrome A nurse in an emergency department is assessing a school-age child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? - ansSudden decrease in wheezing A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? - ansDetermine the child's breathing pattern. A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? - ansDrooling a nurse in the ED is creating a plan of care for a child who has an acute head injury following a fall from playground equipment, what interventions should the nurse include to initiate - ansseizure precautions for the child a nurse in the emergency department is caring for a preschooler who has epiglottitis, what action should the nurse take - ansinitiate droplet precautions for the child
a nurse is admitting a child who has bacterial meningitis, what actions should the nurse take first - ansinitiate antibiotic therapy for the child A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? - ansPut a "no abdominal palpation" sign over the child's bed. a nurse is assessing a 12m old infant who is immediately postop hernia repair surgery, what pain measurement tools should the nurse use to determine if the infant is experiencing pain - ansFLACC A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? - ansWeight gain of 1.8 kg (4 lb) a nurse is assessing a 3yr old preschooler at a well-child visit, what developmental tasks should be expected uses - ansprimarily two-word phrases a nurse is assessing a 5-month-old infant during a well-child visit, what finding should the nurse report to the provider - ansthe infant does not make consonant sounds a nurse is assessing a 6-month-old infant during a well-child visit, what findings should the nurse report to the provider - ansthe infant does not roll over from his abdomen to his back A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? - ansBP 86/40 mm Hg A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? - ansTachypnea A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? - ansMurmur at the left sternal border a nurse is assessing a child who has acute renal failure, what clinical manifestations are expected - ansedema a nurse is assessing a child who has received the first 50 mL of a blood transfusion, what findings indicate the child may be experiencing an air embolism - anssharp pain in the middle of the chest a nurse is assessing a child who has sickle cell anemia and is experiencing a Vaso occlusive crisis, what manifestations should the nurse expect - anspain
a nurse is caring for a child who has cancer and is receiving chemo, the parent tells the nurse that she wants to d/c treatment and take the child home, what responses should the nurse make - anstell me more about your reasons for making this decision today A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? - ansEncourage the child to use an incentive spirometer A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? - ansFrequent swallowing a nurse is caring for a school-age child who has hemophilia and reports increased bruising, what lab values explain the finding - ansplt count 120, a nurse is caring for a school-age child who has metastatic osteosarcoma, the child asks the nurse "am I going to die?", what should the nurse respond - ans"It sounds like you are worried. tell me what you have been told" a nurse is caring for a toddler who drinks 950mL (32oz) of milk per day and has a poor appetite, the nurse should identify that the toddler is at risk for - ansiron deficiency anemia A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? - ansPeriorbital edema A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? - ansSuction the infant gently with a bulb syringe PRN a nurse is caring for an infant who has GERD, what action should the nurse take to avoid regurgitation - ansthicken the pt's formula and avoid giving the pt citrus juices position the child with the head elevated after meals A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? - ansMonitor the child for increased temperature a nurse is developing a plan of care for a 4yr old who has hemophilia and is experiencing acute hemarthrosis, what interventions should the nurse include in the plan - ansplace ice packs on the affected joints a nurse is instilling otic drops into a toddler's ears, what method is used - anspull the pinna down and back
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following interventions should the nurse include in the plan? - ansMaintain the child on bed rest a nurse is preparing a teaching plan for the parent of a school-age child who has asthma, the nurse should include what manifestation as an "exacerbation" of asthma - anshacking, non-productive cough A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make? - ans"The test shows us if your child had a recent strep infection." A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? - ansIncrease the child's protein intake. a nurse is providing discharge teaching to the parent of a school-age child who has an infection of the throat caused by group A beta-hemolytic streptococci, what instructions should the nurse give to the parent - anscontinue to administer the prescribed antibiotic for 10d give your child acetaminophen or children ibuprofen for fever A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? - ansI will inspect my child's mouth every day for sores a nurse is providing discharge teaching to the parents of a 6-month-old infant following a surgical procedure to repair hypospadias, what instructions should the nurse include in the teaching - ansavoid giving the infant a tub bath until the stent is removed A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?
- ansKeep the child away from people who have an infection a nurse is providing discharge teaching to the parents of a child who has sickle cell anemia and was hospitalized after experiencing a Vaso occlusive crisis. what instructions should the nurse include in the teaching - ansincrease your child's intake of oral fluids A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? - ansScrambled eggs
a nurse is providing teaching to the parent of an infant about care seat safety, what statement by the parent indicates an understanding of the teaching - ansI should place the car seat rear facing until my child is 2 a nurse is providing teaching to the parents of a school-age child who has pediculosis capitis, what instruction should be included - anssoak her brushes in boiling water for 10min A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching? - ansI will make sure my child drinks 240 mL (8 oz) of milk as soon as possible A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include? - ansMassage the anterior area of the infant's ear following administration A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider? - ansPotassium 2.5 mEq/L A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? - ansHg 6g/dL A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? - ans1. a nurse is reviewing the medical record of a 16 yr old brought in by his parents to receive a physical, the record indicates he received his last immunization 10 years ago, what immunizations should the nurse expect to administer to the adolescent - ansTdap a nurse is suctioning the tracheostomy of a child, what assessment findings indicate the effectiveness of the procedure - ansclear breath sounds A nurse is teaching a newly hired nurse about the care of an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications - ansHydrocephalus a nurse is teaching a school-age child and her parents about managing diabetes mellitus during illness, the nurse determines teaching has been effective when they indicate they will provide which of the following when the child is ill - ansincrease fluids
A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first? - ansDemonstrate the injection technique on an orange. A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? - ansBarking cough A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? - ansI will record the highest reading of three attempts. A nurse is teaching the parent of a preschool-age child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? - ansI will give my child a dose of albendazole today and again in 2 weeks a nurse is teaching the parent of an infant about preventing SIDS, what following statement should the nurse make - ansyou should put your infant in bed with a pacifier a nurse is teaching the parents of a toddler about strategies to manage temper tantrums, what instructions should the nurse include in the teaching to establish - ansa structured daily routine for the child a nurse working on an outpatient surgical unit is providing discharge teaching to the parent of a preschooler following the placement of tympanoplasty tubes. the parent asks, what should I do if the tubes fall out. What should the nurse instruct? - ansnotify the provider that the tubes have fallen out a school nurse is assessing a child who fell from playground equipment and landed headfirst, what clinical manifestations should the nurse recognize as indicating increased intracranial pressure - ansreport of diplopia a school nurse is assessing the visual acuity of a school-age child, what finding indicates that the child should be evaluated for strabismus - ansmovement of the uncovered eye during a cover test A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension - ansA, B, D
B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding F. Restrain the client - ansA, B, C, D, E A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception - ansC A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights - ansB A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply) A. Place client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee - ansA, C, D A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side B. Use the incentive spirometer C. Cough at regular intervals D. Perform the Valsalva maneuver - ansD A nurse is beginning a physical assessment of a client who has a new diagnosis of MS. Which of the following findings should the nurse expect? (Select all that apply) A. Areas of paresthesia
B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia - ansA, B, E A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants - ansD A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Crede's method D. Indwelling urinary catheter - ansA A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension - ansB A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise - ansD A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site
B. Hyponatremia C. Hypervolemia D. Oliguria - ansB A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply) A. Induce vomiting B. Instill activated charcoal C. Perform a gastric lavage with aspiration D. Administer syrup of ipecac E. Infuse IV fluids - ansB, C, E A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response - ansC A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body B. Place the bedside table on the right side of the bed C. Orient the client to the food on her plate using the clock method D. Place the wheelchair on the client's left side - ansB A nurse is caring for a client who has MS. Which of the following findings should the nurse expect? A. Fluctuations in BP B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids - ansB A nurse is caring for a client who is postprocedural following LP and reports throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply) A. Use the Glasgow Coma Scale when assessing the client B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake
E. Instruct the client to perform deep breathing exercises and coughing exercises - ansB, C, D A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position B. Document the duration of the seizure C. Reorient the client to the environment D. Provide client hygiene - ansA A nurse is caring for a client who was recently admitted to the ED following a head-on MVA. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized B. Insert NG tube C. Monitor pulse and blood pressure frequently D. Establish IV access and start fluid replacement - ansA A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less" B. "You should avoid the use of CT scans with contrast" C. "You should place a magnet over the implantable device when you feel an aura occurring" D. "It is recommended that you use ultrasound diathermy for pain management" - ansC A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply) A. "I think I might be pregnant" B. "I take warfarin" C. "I take antihypertensive medication" D. "I am allergic to shrimp" E. "I ate a light breakfast this morning" - ansA, B, D, E A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply)
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing - ansA, B, C, E A nurse is providing discharge instructions to a female client who as a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking oral contraceptives when on the medication B. Watch for receding gums when taking the medication C. Take the medication at the same time every day D. Provide a urine sample to determine therapeutic levels of the medication - ansC A nurse is providing education to a client who is to undergo an EEG the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure" B. "Try to stay awake most of the night prior to the procedure" C. "The procedure will take approximately 15 minutes" D. "You will need to lie flat for 4 hours after the procedure" - ansB A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A. Perform defibrillation B. Prepare for transcutaneous pacing C. Administer IV epinephrine D. Elevate the client's lower extremities - ansC A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce the risk of respiratory infection B. The vaccine is administered in a series of four doses C. The vaccine is recommended for adolescents before starting college D. The vaccine is initially given at 2 months of age - ansC
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply) A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet C. Limit looking at flashing lights D. Perform aerobic exercise E. Limit episodes of hypoventilation F. Use of aerosol hairspray is recommended - ansA, B, C A nurse is teaching a client who has MS and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This med will help you with your tremors" B. "This med will help you with your bladder function" C. "This med may cause your skin to bruise easily" D. "This med may cause your skin to appear yellow in color" - ansD A nurse on a med surg unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood glucose is 300 B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D. Client who has dark red coloration of left toes and absent pedal pulse - ansB A client diagnosed with oral candidiasis has received instructions from the nurse about the use of nystatin (Mycostatin) suspension. Which of the following statements made by the client should indicate to the nurse that the teaching has been effective? - ans"I will hold the medication in my mouth for as long as possible." A client is taking ibuprofen (Advil, Motrin) to treat hip pain. The nurse should teach the client that, to minimize gastric mucosal irritation, she should take this medication at which of the following times? - ansImmediately after a meal A client tells the nurse she took a dose of dimenhydrinate (Dramamine) before coming to the health care clinic. The nurse determines that the medication is effective when the client reports relief of - ansnausea A client who is postoperative reports incisional pain. The surgeon has prescribed subcutaneous morphine. Before administering this medication, the nurse should complete which priority assessment? - ansRespiratory rate
A nurse is caring for a client who has difficulty swallowing medications and is prescribed aspirin (Ecotrin) PO once daily. The client asks if the medication can be crushed to make it easier to swallow. The nurse's response should be, "Crushing the pill - ansmight cause you to have a stomachache or indigestion." A nurse is caring for a client who has poison ivy and dermatitis and is started on diphenhydramine (Benadryl). Which of the following nursing recommendations is appropriate for decreasing the dry mouth associated with the use of diphenhydramine? - ans"Chew on sugarless gum or suck on hard, sour candies." A nurse is caring for a client who has several environmental allergies and was admitted in status asthmaticus. The provider prescribes cromolyn sodium (Intal) via metered dose inhaler (MDI) to be added to the client's home management along with an albuterol (Proventil) MDI. When performing discharge teaching, the nurse should identify the need for additional teaching when the client states, - ans"I will be sure to take the Intal four times a day before using the Proventil." A nurse is caring for a client who is taking levothyroxine (Synthroid). Which of the following manifestations should suggest to the nurse that the client may have taken an overdose of levothyroxine? - ansInsomnia A nurse is caring for a client who is taking naproxen (Naprosyn) following an exacerbation of rheumatoid arthritis. Which of the following comments by the client requires further discussion by the nurse? - ans"I've been buying Tagamet to help with the indigestion I've had." A nurse is caring for a client who received morphine sulfate 30 min ago. Which of the following best determines therapeutic client response to this medication? - ans0 rating on pain scale A nurse is caring for a client who reports daily use of acetaminophen (Tylenol) to manage mild knee pain. Which of the following statements by the client should be of most concern to the nurse? - ans"I take three or four Vicodin ES tablets a day for severe knee and joint pain." A nurse is caring for a client who reports occasionally self-medicating with an over-the- counter calcium carbonate antacid. To avoid the adverse effects of calcium carbonate, the nurse should recommend that the client take this medication with - answater. A nurse is caring for a client who reports taking bisacodyl (Ducolax) to promote a daily bowel movement. Which of the following should be the nurse's priority response? - ans"How long have you been taking the Ducolax?" A nurse is caring for a client who requests pain medication. The nurse should understand that acute pain can cause which of the following? - ansIncreased heart rate
A nurse is caring for a client. The client states, "I don't want to take my medication.Which of the following actions should the nurse take? - ansDocument that the client refuses the medication. A nurse is caring for an older adult client who is hospitalized. Which of the following medications is likely to put the client at risk for orthostatic hypotension? (Select all that apply.) - ans- Furosemide (Lasix)
- Telmisartan (Micardis)
- Phenelzine sulfate (Nardil) A nurse is developing home instructions for a client who is prescribed phenytoin (Dilantin) via the tube. Which of the following should the nurse include in the instructions? - ansAlcohol increases the chance of phenytoin toxicity. A nurse is giving discharge instructions to a client who has asthma and is about to start taking theophylline (Theo-24). The nurse should tell the client that this medication might cause which of the following adverse effects? - ansTachycardia A nurse is instructing a hospitalized client who has asthma about how to use an albuterol (Proventil) inhaler. The nurse should recognize that the client understands how to use the inhaler when the client demonstrates by - ansholding a breath for 10 seconds after inhaling the medication. A nurse is monitoring a client's IV site. Which of the following findings are associated with phlebitis and should be reported to the RN? (Select all that apply.) - ans- Erythema
- Throbbing
- Warmth at insertion site
- Streak formation A nurse is preparing a medication and is converting 0.8 grams to milligrams. The nurse should do which of the following? - ansMove the decimal point 3 places to the right. A nurse is preparing an injection using a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule? - ansTap the top of the ampule, place a gauze pad or unwrapped alcohol swab around the ampule neck, and break off the top with a forward motion away from the hands. A nurse is preparing to administer a bisacodyl (Dulcolax) 10 mg suppository. Which of the following are correct administration guidelines for the nurse to implement? (Select all that apply.) - ans- Lubricate index finger
- Insert suppository just beyond internal sphincter
