Worksheets1st quiz
Total questions: 25
Worksheet time: 40mins
The nurse prepares to insert an indwelling Foley catheter in an elderly female client. Arrange the following steps in the order the nurse should perform them.
All options must be used.
1) Open the sterile pack between the client’s legs.
2) Wipe the urinary meatus with a cotton ball saturated with
cleansing solution.
3) Inflate the balloon of the catheter to check for
leaks.
4) Place the client supine with knees flexed.
5) Lubricate the tip of the catheter
6) Put on the sterile gloves
(a)
The nurse is emptying an evacuator of a Jackson-Pratt drain. The nurse has drained the fluid into a calibrated container and has placed the container on a level flat surface. The nurse measures 20 mL of bloody fluid. Arrange the following actions the nurse should take in sequential order. All options must be used
1. Dispose of the bloody drainage.
2. Compress the evacuator
completely.
3. Replace the plug in the
evacuator.
4. Cleanse the plug with an
alcohol wipe.
5. Document the amount, odor, and
consistency of the drainage.
(a)
A client at 35 weeks gestation is admitted to the labor and delivery unit for severe pre-eclampsia. She is started on IV magnesium sulfate for seizure prophylaxis. Which of the following signs indicate that the client has developed magnesium sulfate toxicity? Select all the apply.
0/4 patellar reflex
Blood pressure of 156/84 mmHg
Client voiding 600mL in 8hours
Respirations of 10/min
Serum magnesium level of 8.0 mEq/L (4mmol/L)
The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD). The nurse advise the parent that the child might experience which side effects?
Decreased blood pressure and growth delays
Heart palpitations and weight gain
Loss of appetite and restlessness
Trouble sleeping and a dry cough
The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
Offering high-calorie snacks.
Watching for signs of infection.
Observing for signs of over sedation.
Using a sunscreen with an SPF of 30.
Which of the following pediatric clients is at greatest risk for latex allergy?
The child with a myelomeningocele.
The child with epispadias.
The child with coxa plana.
The child with rheumatic fever.
The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply.
History of angioedema with lisinopril
History of epilepsy
Known allergy to avocados and bananas
Known allergy to shellfish
Lip swelling when blowing up balloons
A parent calls the nurse telehealth triage line with concerns about an allergic reaction to something a child ate. Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction? Select all that apply.
Dyspnea
Fever
Lightheadedness
Skin rash (hives
Wheezing
An UAP is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which action require intervention by the registered nurse? Select all that apply.
The UAP adds milk to mashed potatoes to make them thinner.
The UAP encourages the client to occasionally turn the head to the left.
The UAP helps the client sit in an upright position
The UAP places food on the strong side of the client's mouth
The UAP puts a straw in a fruit smoothie to prevent spilling
The nurse prepares to administer IV vancomycin to an 80-year old client with a methicillin-resistant Staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply.
Blood urea nitrogen is 60 mg/dL
Creatinine is 2.1 mg/dL
Glucose is 140 mg/dL
Hemoglobin is 15g/dL
Magnesium is 1.5 mEq/L
The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply.
Assess client for lethargy and decreased deep tendon reflexes
Assess skin for flushing and red rash on face and torso
Infuse medication over at least 60 minutes
Monitor blood pressure during infusion
Observe IV site every 30minutes for pain, redness, and swelling
The nurse recognizes which of the following as the priority nursing diagnosis for the client in thyroid crisis?
Risk for ineffective breathing pattern
Risk for imbalanced body temperature
Risk for decreased cerebral tissue perfusion
Activity intolerance
The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis. Which of the following actions can be delegated to UAP? Select all that apply.
Administer artificial tears if the client reports eyes dryness
Assist the client to bathe and change the bed linens to maintain client comfort
Lower the room temperature and provide cool cloths on request
Reinforce to the client that fever is expected with thyrotoxicosis
Return a call to the client's family telling them the client's condition is unchanged
An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse?
Nurse has client lie supine for 5-10minutes prior to starting procedure
Nurse interprets a decrease in systolic BP by 10mmHg as normal finding
Nurse starts by measuring BP and heart rate (HR) with the client standing
Nurse takes BP and HR after standing at 1-and 3-minute intervals
The client with Alzheimer’s disease has been prescribed donepezil (Aricept). Which information should the nurse include in the teaching plan for a client on Aricept?
“Take the medication with meals.”
“The medicine can cause dizziness, so rise slowly.”
“If a dose is skipped, take two the next time.”
“The pill can cause an increase in heart rate.”
A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action?
Assess the client's orthostatic blood pressure
Assist the client to a sitting position
Hold and walk with client
Keep the client on bed rest
A client is receiving a blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50mmHg. The client reports "feeling a little cold." Based on this assessment, in what order should the nurse complete the following actions? All options must be used.
1) Administer prescribed vasopressor
2) Using new tubing, infuse normal saline into vein
3) Document the occurrence
4) Stop the blood transfusion
5) Collect urine specimen
(a)
The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action?
Advance tip of needle through epidermis until the bevel is no longer visible under the skin
Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle; don clean gloves
Injects medication slowly while raising a small wheal (bleb) on the skin
Inserts needle at a 10-degree angle most parallel to skin with the bevel up
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted.
The nurse’s assessment of this data is:
The infant is at low risk for congenital anomalies.
The infant is at high risk for intrauterine growth retardation.
The infant is at high risk for respiratory distress syndrome.
The infant is at high risk for birth trauma.
The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement by the client indicates an appropriate understanding about weight gain?
"I should gain 10-15lb (4.5-6.8kg) during the first trimester."
"I should gain a total of about 30lb (13.6kg) during my pregnancy."
"I should gain no more than 0.5lb (0.2kg) per week during the third trimester."
"If I gain<20lb (9.1kg) during pregnancy, it will be easier to lose weight postpartum."
The nurse is planning care for a newborn client at term gestation who is large for gestational age. Which of the following are appropriate interventions to include in the plan of care? Select all that apply.
Assess newborn for birth-related injuries
Discuss the need for feeding supplementation if symptoms of hypoglycemia occur
Encourage the mother to breastfeed the newborn every 2-3hours
Notify the health care provider if capillary blood glucose is <45mg/dL (2.5 mmol/L)
Perform capillary blood glucose checks prior to feedings
The nurse is caring for a client diagnosed with endometrial cancer who is receiving brachytherapy. Which interventions should the nurse implement while caring for this client? Select all that apply.
Cluster care to limit each staff member's time in the room to 30 minutes a shift
Instruct the client to be up and around in the room but not to leave the room
Keep the door to the room closed as radiation is emitting constantly from the client.
Teach family members and visitors to stay at least 6feet away from the client
Use a lead apron and wear a radiation film-badge when providing direct client care
A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse?
Give the client a book to read
Provide earphones and a DVD player and have the client sing along with the music
Tell the client that the voices will go away when the medication starts to work
Tell the client to ignore the voices
The doctor accidently cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with:
Negligence
Tort
Assault
Malpractice
A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
Fetal heart tones 160 beats per minute
A moderate amount of clear fluid
A small amount of greenish fluid
A small segment of the umbilical cord
