Question: A client has arterial blood gas values: pH 7.30, PaO2 89, PaCO2 50 and HCO3 26 mEq/L. Based on these values, the nurse should suspect...

Answer: Respiratory Acidosis

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Question: A client admitted with deep vein thrombosis (DVT) is prescribed bed rest. Which action should the nurse take?

Answer: When the client has an urge to void, assist her to a sitting position.

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Question: When preparing client for bronchoscopy the nurse instructs client to avoid what?

Answer: Eating

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Question: Which of the following in an example of primary preventive measure?

Answer: Avoiding overexposure to the sun.

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Question: When caring for a client with acute respiratory failure the nurse should expect to focus on resolving which of the following problems?

Answer: Hypercapnia, hypoventilation, and hypoxemia.

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Question: What is the mechanism of action of ahydrous theophylline in treating a nonreversible obstructive airway disease such as COPD?

Answer: It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive.

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Question: A client with schizophrenia is admitted to the facility, when collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia?

Answer: Apathy, blunted affect, and lack of motivation.

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Question: What is the most appropriate nursing diagnosis for a client with acute pancreatitis?

Answer: Deficient fluid volume

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Question: A client has arterial blood gas values: pH 7.30; P2O2 89; PaCO2 50; and HCO3 26 mEq/L. Based on these values the nurse should suspect which?

Answer: Respiratory Acidosis

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Question: A client admitted with deep vein thrombosis is prescribed bed rest. bed rest. Which action should the nurse take?

Answer: When the client has urge to void, assist her to a sitting position.

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Question: Client with schizophrenia is taking the atypical antipsychotic medication clozapine (Clozaril). What are the signs and symptoms which indicate an adverse reaction to this med?

Answer: 1. Sore throat
2. Fever

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Question: A client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action would be appropriate for this client?

Answer: Restricting the client's access to food except at specified meal and snack times.

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Question: A client with constipation is prescribed an irrigating enema. What are the steps?

Answer: 1. Assist into sims
2. Lubricate the end of the catheter
3. Keep solution container below 18" above bed level

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Question: The nurse is caring for a client who had a subtotal gastrectomy 24 hours ago. The nurse should?

Answer: Irrigate the NG tube with normal saline solution.

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Question: DO NOT delegate what you can E.A.T.

Answer: E - evaluate
A - assess
T - teach

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Question: No Pee, no K

Answer: Do not give potassium without adequate urine output

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Question: The nurse is caring for a 40 yr old client admitted with an acute myocardial infarction. Which behavior by the client indicates adult cognitive development?

Answer: Generates new levels of awareness.

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Question: Addisons = down, down, down, up, down

Answer: hyponatremia, hypotension, decreased blood volume, hyperkalemia, hypoglycemia

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Question: Cushings disease = up, up, up, down, up

Answer: hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia

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Question: EleVate Veins; dAngle Arteries for better perfusion.

Answer: A= appearance
P= pulse (>100, <100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)

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Question: For newborn babies APGAR

Answer: My - Measles
Chicken - Chicken Pox / Varicella
Hez - Herpes Zoster / Shingles
TB
or... MTV = Measles, TB, Varicella - chicken pox / herpes-zoster shingles
Private Room - neg pressure w 6-12 air exchanges/hr. N95 for TB

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Question: Transmission-Based Precautions: AIRBORNE

Answer: Think of SPIDERMAN
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diptheria
E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus Private Room or Cohort Mask

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Question: Transmission-Based Precautions: Droplet

Answer: MRS. WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile
E - eye infxn - conjuctivitis

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Question: CONTACT PRECAUTION

Answer: VCHIPS
V - varicella zoster
C - cutaneous diptheria
H - herpes simplex
I - impetigo
P - pediculosis
S - scabies

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Question: SKIN INFECTIONS: VCHIPS

Answer: Rectal Bleeding

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Question: Which of the following is a sign of colon cancer?

Answer: maintaining fluid balance

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Question: When planning care for a client with a small bowel obstruction the nurse should consider the primary goal to be...

Answer: 1. Explain the procedure
2. Make sure informed consent is obtained.
3. Instruct client to void.

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Question: Which nursing interventions should be performed before an abdominal paracentesis?

Answer: Administering IV fluids

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Question: The nurse caring for a client with a small-bowel obstruction would plan to implement which intervention?

Answer: Metabolism and excretion

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Question: Alterations in hepatic blood flow resulting from a drug interaction also can affect?

Answer: Atrophy of the gastric mucosa

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Question: For a client at the age of 82, which age-related change increases the risk of anemia?

Answer: Abduction

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Question: As the client moves the arm away from the midline, the nurse evaluates the ability to perform?

Answer: Store the drug in a tight light-resistant container

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Question: Which statement regarding usage of glutethimide is correct?

Answer: Joint stiffness that decreases with activity

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Question: Which of these findings best correlates with a diagnosis of osteoarthritis?

Answer: Acetylcholine

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Question: Which of the following would the nurse identify as a neurotransmitter?

Answer: 1. Right leg is shorter
2. Right leg is adducted
3. Right leg is externally rotated

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Question: A client with a suspected fracture of the right hip is in ER. Which data collection would the nurse expect to see in the clients right leg?

Answer: A safe environment

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Question: The nurse is caring for a client with delirium. Which of the following is most important for the nurse to provide the client?

Answer: ECT will induce a seizure.

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Question: Electroconvulsive therapy (ECT). When teaching the client and family about this treatment, the nurse should include which point?

Answer: Polyuria

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Question: A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which early adverse effect of lithium?

Answer: Expression of fear of colorectal cancer following 3 days of constipation.

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Question: The nurse is caring for a client with hypochondriasis. Which behavior would the nurse be most likely to encounter?

Answer: Breath sounds clear on auscultation.

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Question: Which of the following outcome criteria would be most appropriate for the client with ineffective airway clearance?

Answer: Bronchospasm

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Question: Antiplatelet drugs most commonly produce which hypersensitivity reaction?

Answer: Apply acyclovir ointment every three hours, 6 times per day for 7 days

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Question: A client with primary herpes genitalis. What are the instructions?

Answer: Take on an empty stomach and maintain treatment.

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Question: What are the instructions for a 19 year old with acne vulgaris taking tretinoin (Retin-A), benzoyl peroxide and tetracycline (Achromycin)?

Answer: ...start after a known voiding that empties the bladder.

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Question: When initiating a 24 hour urine specimen, the collection time should...

Answer: 1. Smoking may lower drug level
2. Avoid prolonged sun exposure
3. Increase fluid & fiber to prevent constipation.

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Question: The nurse is teaching a client about the intidepressant amitriptyline (Elavil). Which points should the nurse be including in the teaching?

Answer: ...self-awareness and understanding.

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Question: The basis for building a strong therapeutic nurse-client relationship begins with the nurses...

Answer: Pathologic bone fractures

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Question: Clients with multiple myeloma are at risk for?

Answer: GI upset and a metallic taste

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Question: Early s/s of Vitamin D toxicity include?

Answer: ...tell the client to rest in a room set at a comfortable temperature.

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