RN Question trainer Test 5 NGN
R: The nurse plans an 1100 dressing change on a preschool age client diagnosed with deep partial thickness burns of the left leg. Which action is most important for the nurse to take? correct answersADMINISTER MORPHINE SULFATE IV @ 1030
*** the nurse should administer the medication so that the peak effect of the medication is at the time of the dressing change
R: The nurse cares for a client diagnosed with venous thromboembolism (VTE) of the left leg. Which nursing goal is appropriate for the client? correct answersDECREASE INFLAMMATORY RESPONSE IN AFFECTED EXTREMITY TO PREVENT FURTHER EMBOLUS FORMATION
*** it is important to prevent the complication of pulmonary embolism in clients at high risk. Decreasing the inflammatory response will help prevent additional embolus formation and pulmonary embolism. - first priority is preventing pulmonary embolism (stop it from getting to the lungs)
R: the nurse cares for a post-op client. Four hours after surgery, the client voids 200 mL
of urine with a specific gravity of 1.019. The nurse takes which action? correct answersRECORDS THE TIME AND THE AMOUNT OF URINE
*** the nurse would record the output amount and specific gravity normal result of 1.019.
normal urine specfic gravity correct answers1.003 - 1.030.
R: A client is admistted with a diagnosis of trigeminal neuralgia (tic duoloureux) involving the maxillary branch of the affected nerve. it is most important for the nurse to include which instruction? correct answers"EAT SOFT, LUKEWARM FOODS"
*** intense facial pain experieced along the nerve tract is characteristic of this condition. Nursing care should be directed towards preventing stimuli to the area and decreasing pain. Soft foods reduce the need for chewing. hot or cold foods increase the pain, so lukewawrm (neutral temperatures) are recommended. - avoid chewing on the affected side
R: At approximately 2000 hours the nurse begins to document the nurse's notes for the 0700 to 1900 shift. The last written entry is noted for 0400 and there is no signature. Which response by the nurse is most appropriate? correct answersBEGIN DOCUMENTING ON THE NEXT LINE BELOW THE LAST ENTRY AND MAKE A NOTE FOR THE PREVIOUS NURSE TO MAKE A LATE ENTRY TO COMPLETE THE RECORD *** the previous nurse can make a "late entry" to add any additional information. The nurse would begin documenting on the next line below. - blank lines in a written document should never be left in the nurses notes
R: The nurse provides care for a client diagnosed with ischemic stroke immediately after
arrival in the ED. The client is under construction for thrombolytic therapy. Which is the most importatn question for the nurse to ask? correct answers" WHEN DID YOU FIRST
NOTICE YOUR SYMPTOMS"
***establishing timeline is priority. IV tisue plasminogen activator (t-PA), a thrombolytic agent, must be administered within 3 hrs (or 4.5 hrs for some patients) after symptom onset
R: The nurse cares for a client recieving atorvastatin. Which is the most important statement made by the client for the nurse to report to the HCP? correct answers"I TAKE COLCHICINE"
***The concurrent use of colchicine and atorvastatin increases the clients rf rhabdomyolysis
- grapefruit juices decreases the enzyme that breaks down atorvastatin ( avoid grapefruit juice)
- liver enzymes are checked regularly for a pt on atorvastatin
R: The nurse works with clients in a prenatal clinic. Which phone message does the nurse return first? correct answersA 26 YO CLIENT AT 36 WEEKS GESTATION REPORTS, " MY HEART IS BEATING FASTM AND I THINK I HAVE BEEN LEAKING URINE FOR THE PAST WEEK"
*** tachycardia and palpitations may indicate the presence if infection. this client requires further assessment immediately.
R: The nurse begins a therapeutic relationship with a client diagnosed with generalized anxiety disorder. It is most important for the nurse to obtain which information? correct answersIN WHAT SITUATIONS THE CLIENT BECOMES ANXIOUS
*** determining in what situation the client becomes anxious will provide necessary information in a baseline assessment of the client's anxiety
R: A client with a new precription for warfarin 5 mg PO daily is seen in the clinic. Which laboratory test resuslt is most important for the nurse to report to the HCP? correct answersSERUM CREATININE OF 1.8 MG/DL
*** a serum creatinine level of 1.8 is higher than normal. this value indicates renal dysfunction and client will need the warfarin dose adjusted in order to prevent toxicity.
R: The nurse plans an 1100 dressing change on a preschool age client diagnosed with deep partial thickness burns of the left leg. Which action is most important for the nurse to take? correct answersADMINISTER MORPHINE SULFATE IV @ 1030
*** the nurse should administer the medication so that the peak effect of the medication is at the time of the dressing change
R: The nurse cares for a client diagnosed with venous thromboembolism (VTE) of the left leg. Which nursing goal is appropriate for the client? correct answersDECREASE INFLAMMATORY RESPONSE IN AFFECTED EXTREMITY TO PREVENT FURTHER EMBOLUS FORMATION
*** it is important to prevent the complication of pulmonary embolism in clients at high risk. Decreasing the inflammatory response will help prevent additional embolus formation and pulmonary embolism. - first priority is preventing pulmonary embolism (stop it from getting to the lungs)
R: the nurse cares for a post-op client. Four hours after surgery, the client voids 200 mL
of urine with a specific gravity of 1.019. The nurse takes which action? correct answersRECORDS THE TIME AND THE AMOUNT OF URINE
*** the nurse would record the output amount and specific gravity normal result of 1.019.
normal urine specfic gravity correct answers1.003 - 1.030.
R: A client is admistted with a diagnosis of trigeminal neuralgia (tic duoloureux) involving the maxillary branch of the affected nerve. it is most important for the nurse to include which instruction? correct answers"EAT SOFT, LUKEWARM FOODS"
*** intense facial pain experieced along the nerve tract is characteristic of this condition. Nursing care should be directed towards preventing stimuli to the area and decreasing pain. Soft foods reduce the need for chewing. hot or cold foods increase the pain, so lukewawrm (neutral temperatures) are recommended. - avoid chewing on the affected side
R: At approximately 2000 hours the nurse begins to document the nurse's notes for the 0700 to 1900 shift. The last written entry is noted for 0400 and there is no signature. Which response by the nurse is most appropriate? correct answersBEGIN DOCUMENTING ON THE NEXT LINE BELOW THE LAST ENTRY AND MAKE A NOTE FOR THE PREVIOUS NURSE TO MAKE A LATE ENTRY TO COMPLETE THE RECORD *** the previous nurse can make a "late entry" to add any additional information. The nurse would begin documenting on the next line below. - blank lines in a written document should never be left in the nurses notes
R: The nurse provides care for a client diagnosed with ischemic stroke immediately after
arrival in the ED. The client is under construction for thrombolytic therapy. Which is the most importatn question for the nurse to ask? correct answers" WHEN DID YOU FIRST
NOTICE YOUR SYMPTOMS"
***establishing timeline is priority. IV tisue plasminogen activator (t-PA), a thrombolytic agent, must be administered within 3 hrs (or 4.5 hrs for some patients) after symptom onset
R: The nurse cares for a client recieving atorvastatin. Which is the most important statement made by the client for the nurse to report to the HCP? correct answers"I TAKE COLCHICINE"
***The concurrent use of colchicine and atorvastatin increases the clients rf rhabdomyolysis
- grapefruit juices decreases the enzyme that breaks down atorvastatin ( avoid grapefruit juice)
- liver enzymes are checked regularly for a pt on atorvastatin
R: The nurse works with clients in a prenatal clinic. Which phone message does the nurse return first? correct answersA 26 YO CLIENT AT 36 WEEKS GESTATION REPORTS, " MY HEART IS BEATING FASTM AND I THINK I HAVE BEEN LEAKING URINE FOR THE PAST WEEK"
*** tachycardia and palpitations may indicate the presence if infection. this client requires further assessment immediately.
R: The nurse begins a therapeutic relationship with a client diagnosed with generalized anxiety disorder. It is most important for the nurse to obtain which information? correct answersIN WHAT SITUATIONS THE CLIENT BECOMES ANXIOUS
*** determining in what situation the client becomes anxious will provide necessary information in a baseline assessment of the client's anxiety
R: A client with a new precription for warfarin 5 mg PO daily is seen in the clinic. Which laboratory test resuslt is most important for the nurse to report to the HCP? correct answersSERUM CREATININE OF 1.8 MG/DL
*** a serum creatinine level of 1.8 is higher than normal. this value indicates renal dysfunction and client will need the warfarin dose adjusted in order to prevent toxicity.
