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Ncsbn- post test a-l

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A nurse is caring for a 69 year-old client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis? a. Irrigate with 5 mL of 0. 9% normal salineb. Palpate for a thrill over the fistulac. Observe for edema proximal to the sited. Feel for a bruit over the fistula. Palpate for a thrill over the fistulaThe RN is working in a clinic where a client presents with a painful, blistering rash on the hip. The health care provider diagnoses shingles (herpes zoster). What is the priority nursing diagnosis? a. Knowledge deficit related to disease processb. Pain related to nerve root inflammation and skin lesionsc. Risk for infection related to skin lesionsd. Risk for impaired skin integrity related to skin lesionsb. Pain related to nerve root inflammation and skin lesionsA 2 year-old child is brought to the emergency department at 2: 00 pm. The mother states: “ My child has not had a wet diaper all day.” The child is pale, with a heart rate of 132 beats per minute. What other assessment data would the nurse obtain next to help determine an admitting diagnosis? a. History of fluid intakeb. Dietary patterns in the past 48 hoursc. Description of play activityd. Status of the eyes and the tongued. Status of the eyes and the tongueA nurse from the mental health unit is reassigned to the pediatrics unit and will be caring for a child with asthma. Which of these findings would the charge nurse emphasize as the first thing to indicate a worsening condition in the child? a. Increased need to use bronchodilatorsb. A downward trend in peak flow rates as measured by a peak flow meterc. Coughing, especially if the cough is frequent and occurs in spasmsd. An audible whistling or wheezing when the child exhalesb. A downward trend in peak flow rates as measured by a peak flow meterA nurse is assessing a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client’s total protein level is reported as 4. 5 g/dL. Which approach to therapy should the nurse anticipate? a. Total parenteral nutrition (TPN) via central lineb. Blood for coagulation studies dailyc. Additional potassium via IV administrationd. Serum lipase levels every 12 hoursa. Total parenteral nutrition (TPN) via central lineThe nurse is working in a community health clinic answering telephone calls. Which client would the nurse recommend to be seen immediately by a health care provider? a. “ I started my period and now my urine has turned bright red.” b. “ I was started on some medicine yesterday for a urine infection and now my lower belly hurts when I go to the bathroom.” c. “ I went to the bathroom and my urine looked very red but it didn’t hurt when I went.” d. “ I am an diabetic and today I have been going to the bathroom every hour.” c. “ I went to the bathroom and my urine looked very red but it didn’t hurt when I went.” The nurse works in an ambulatory care clinic where there are four children with gastrointestinal findings waiting to be seen by the health care provider. Which child is at greatest risk for developing metabolic acidosis? a. The child who has been vomiting for more than 48 hoursb. The child with nausea and anorexiac. The child with severe diarrhea for 24 hoursd. The child with alternating constipation and diarrheac. The child with severe diarrhea for 24 hourA client comes into the community health center upset and crying, stating: “ I will die of cancer now that I have this disease.” The client hands the nurse a piece of paper with the word “ pheochromocytoma” written on it. What would be the best initial response by the nurse? a. “ You probably have had episodes of sweating, heart pounding and headaches. Is that correct?” b. “ Pheochromocytomas are usually noncancerous, but they do need to be treated to avoid complications.” c. “ This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline.” d. “ Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor.” b. “ Pheochromocytomas are usually noncancerous, but they do need to be treated to avoid complications.” The nurse is providing care to a client who has just received an epidural for anesthesia during labor. The nurse recognizes which of the following as the most important nursing intervention following this procedure? a. Monitor maternal blood pressure for possible hypotensionb. Reduce the intravenous fluid infusion to a keep open ratec. Monitor the fetus for possible tachycardiad. Monitor maternal pulse for possible bradycardiaa. Monitor maternal blood pressure for possible hypotensionA nurse is assessing a newborn infant and observes low-set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. What priority focus in the maternal history should the nurse ask about? a. Alcohol use during pregnancyb. Maternal and paternal agesc. Family genetic disordersd. Use of vitamins and supplements during pregnancya. Alcohol use during pregnancyA 3 year-old child is brought to the health clinic. The grandmother reports that the child is always “ scratching his bottom” and is “ extremely irritable.” Based on this information, which health issue would the nurse assess for initially? RingwormScabiesAllergiesPinwormPinwormThe nurse is caring for a client with urinary incontinence. The client asks the nurse about the use of biofeedback to treat this condition. What is the most appropriate response by the nurse? a. “ Biofeedback has not been shown to be very helpful for urinary incontinence problems.” b. “ Surgery is generally needed in order to produce any real improvement.” c. “ Medications are the approved method of treating this type of problem.” d. “ This type of treatment has been used successfully to manage urinary incontinence.” d. “ This type of treatment has been used successfully to manage urinary incontinence.” The nurse is caring for a client in the coronary care unit who has developed acute renal failure as a consequence of cardiogenic shock. Which of the following findings are consistent with the diagnosis? (Select all that apply.)OliguriaJugular vein distentionCrackles on auscultation in bilateral basesWeight lossPitting sacral edemaOliguriaJugular vein distentionCrackles on auscultation in bilateral basesPitting sacral edemaFindings related to fluid retention and heart failure are expected, because the kidneys are unable to function properly due to a decrease in glomerular filtration rate and tubular necrosis. In the bed-bound client, pitting sacral edema would be seen, since fluid follows gravity. Weight gain, jugular vein distention, oliguria and crackles in the lungs would also be expected with fluid overload in this client. Treatment consists of diuresis, with a possible small fluid challenge, if the client can tolerate it, to correct pre-renal azotemia. If these options are not effective or inappropriate for the client, dialysis or ultrafiltration may be used to remove excess fluid. In many cases, this type of treatment is temporary, and can be stopped as the kidney function improves with improved urine output and decreasing creatinine levels. The client has undergone a dilation and curettage (D & C) following a spontaneous abortion at 8 weeks. To promote an optimal recovery, what information should the nurse include in the discharge teaching? (Select all that apply.)a. Expect heavy bleeding for at least a weekb. Use sanitary pads until vaginal bleeding has stoppedc. Strenuous sport activities should be postponed until bleeding stopsd. Resume vaginal intercourse 6 weeks after the proceduree. Referral for grief counselingb. Use sanitary pads until vaginal bleeding has stoppedc. Strenuous sport activities should be postponed until bleeding stops. Referral for grief counselingA family arrives at the emergency department. A parent believes the child ingested an undetermined number of acetaminophen tablets approximately 1 hour ago. The serum acetaminophen level confirms acute poisoning. Which of these orders should be implemented first? Oral activated charcoal therapyN-acetylcysteine (NAC) (Mucomyst)Ondansetron (Zofran) 0. 1 mg/kg for nauseaConsultation with a medical toxicologistN-acetylcysteine (NAC) (Mucomyst)A nurse is discussing Kawasaki disease with a group of student nurses. What statement made by a student about Kawasaki disease is incorrect and needs to be clarified? a. “ It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes.” b. “ In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.” c. “ Kawasaki disease occurs most often in boys, who are younger than 5 years-old and of Hispanic descent.” d. “ Initial findings include a sudden high fever, often up to 104 F (40 C), which lasts one to two weeks.” c. “ Kawasaki disease occurs most often in boys, who are younger than 5 years-old and of Hispanic descent.” The client is newly diagnosed with gastroesophageal reflux disease (GERD). Which statement(s) made by the client indicates a need for further education about this disease? (Select all that apply.)“ When I have a headache I’ll be sure to take aspirin instead of acetaminophen.”“ I will drink less coffee and cola.”“ I’ll wait a while after eating before I go exercise at the gym.”“ I will take my omeprazole (Prilosec) as needed when I have heartburn.”“ I am going to enroll in a smoking cessation class.”“ A bedtime snack may help me sleep better.”“ When I have a headache I’ll be sure to take aspirin instead of acetaminophen.”“ I will take my omeprazole (Prilosec) as needed when I have heartburn.”“ A bedtime snack may help me sleep better.” GERD occurs as a result of gastric secretions from the stomach moving up the esophagus, usually because the lower esophageal sphincter is too relaxed. The client should eat meals several hours before lying down and give up those late night snacks which may trigger bedtime symptoms. Food and beverages that may trigger symptoms, such as caffeine and carbonated beverages, should be avoided. Proton pump inhibitors such as omeprazole (Prilosec) may take one to four days for their full effect, so they should be taken routinely, and a fast-acting antacid should be used for acute relief of heartburn symptoms. Aspirin and NSAIDs can aggravate GERD, so they should be avoided, and alternatives such as acetaminophen should be used instead. Avoiding tobacco and losing weight may also help improve heartburn. A nurse is caring for a client who was successfully resuscitated from a pulseless arrhythmia. Which assessment is critical for the nurse to include in the plan of care? Hourly urine outputTemperature every two hoursWhite blood count trendsBlood glucose every four hoursHourly urine outputA client states, “ I feel funny.” The nurse uses electronic equipment to obtain vital signs and notes these findings: blood pressure 100/56 mm Hg, pulse 38, respirations 26. The client’s previous reading: blood pressure 130/88 mm Hg, pulse 82, respirations 21. List the correct order of actions the nurse should now take (with 1 being the top priority). a. Assess for chest pain, dyspnea, low oxygen saturation, restlessness or other signs of respiratory or cardiac impairmentb. Simultaneously check an apical and radial pulse manuallyc. Notify the health care providerd. Anticipate the need for ECG, oxygen administration, and emergency pacingThe sudden drop in both blood pressure and pulse indicate an acute cardiovascular event requiring rapid assessment and intervention to prevent cardiac arrest. At this point, the patient is not in crisis but needs a quick targeted assessment. Verify the bradycardia manually; perfusion may not occur with some arrhythmias, such as premature ventricular contractions, so checking the apical rate while palpating a distal pulse provides a quick assessment. Assessment for cardiovascular and respiratory instability is next. With all the assessment data in hand, it’s time to contact the health care provider, anticipating the need for ECG, oxygen as well as interventions to improve cardiac output such as atropine IV and cardiac pacing

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