R= a disaster alarm has been declared at the hospital and many clients are expected. The
nurse provides care for clients on the maternal-child unit. Which client on this unit is
considered for discharge within the next hour? SATA - ANSWER - a multipara client
who delivered over an intact perineium 12 hours ago (stable rn and can have a home visit
follow up)
- a 3 day old breast feeding client with a total serum bilirubin of 12 (photo therapy is
considered for a client with a total serum bilirubin between 13-15 @ 72 hours of age. the
bilirubin levels peak between 3-5 days of age. pt can have bilirubin levels drawn at 5 days of
age in the outpatient lab)
-a 2 year old client delivered by a mother recieving intrapartum antibiotic therapy for GBS.
(stable)
*** patient recieving antibiotics after 24 hours need to stay because we dont know if it was
effective
- epigastric pain indicates a pending eclampsia and os unstable.
R: The nurse recieves change- of-shift report. Which client does the nurse see first? -
ANSWER A CLIENT 10 HOURS POSTOP AFTER A RIGHT MASTECTOMY AND REPORTING
WET SHEETS UNDER THE BACK
*** feelings of wet sheets may indicate HEMORRHAGE from the operative site and need to
be investigated immediately. the client is unstable and need to be investigated for potential
bleeding.
1
, - I chose " a client diag with COPD with a PAO2 of 70" but this level of oxygenation is
considered "normal to good" for COPD patients.
R: Akathisia is evidenced by... - ANSWER - extrapyramidal symptoms seen in facial
grimaces, nervous- looking hand gestures, and restless legs both during night and day.
- akathisia can happen in the first couple of week after taking antipschotic med
R: the nurse provides care for a client receiving chlordiazepoxide. It is most important for the
nurse to reinforce which expected finding to the client? - ANSWER DROWSINESS AND
CONFUSION
*** chloridaizepoxide is an anti-anxiety and sedative/hypnotic mediation used to treat
anxiety and alcohol withdrawal. This medication causes drowsiness and sedation. It is
important for this client to use caution when driving or operating equipment.
R: the nurse prepares to administer subcutaneous insulin to a client. The nurse scans the
insulin barcode and the prompt seen on the computer screen is for another nurse to verify
the insulin dosage. Which action does the nurse perform first? - ANSWER PREPARE
THE CORRECT DOSE OF INSULIN IN THE SYRINGE
*** the first action of the nurse is to prepare the medication as prescribed. So the second
verification can be a check of all parts of the prescription. High- alert medications have
safeguards in place in regard to limiting access and providing alerts to promo safety.
R: the nurse prepares to insert a peripheral IV catheter in a client iagnosed with T1DM who
reports extreme thirst, frequent urination, and fruity smelling breath. Which nursing action
demonstrates appropriate peripheral line placement? SATA - ANSWER - insert IV
catheter in one of the dorsal metacarpal veins ( dorsal metacarpal vein allows rapid fluid
resusitation because these veins are large and easy to find)
2
nurse provides care for clients on the maternal-child unit. Which client on this unit is
considered for discharge within the next hour? SATA - ANSWER - a multipara client
who delivered over an intact perineium 12 hours ago (stable rn and can have a home visit
follow up)
- a 3 day old breast feeding client with a total serum bilirubin of 12 (photo therapy is
considered for a client with a total serum bilirubin between 13-15 @ 72 hours of age. the
bilirubin levels peak between 3-5 days of age. pt can have bilirubin levels drawn at 5 days of
age in the outpatient lab)
-a 2 year old client delivered by a mother recieving intrapartum antibiotic therapy for GBS.
(stable)
*** patient recieving antibiotics after 24 hours need to stay because we dont know if it was
effective
- epigastric pain indicates a pending eclampsia and os unstable.
R: The nurse recieves change- of-shift report. Which client does the nurse see first? -
ANSWER A CLIENT 10 HOURS POSTOP AFTER A RIGHT MASTECTOMY AND REPORTING
WET SHEETS UNDER THE BACK
*** feelings of wet sheets may indicate HEMORRHAGE from the operative site and need to
be investigated immediately. the client is unstable and need to be investigated for potential
bleeding.
1
, - I chose " a client diag with COPD with a PAO2 of 70" but this level of oxygenation is
considered "normal to good" for COPD patients.
R: Akathisia is evidenced by... - ANSWER - extrapyramidal symptoms seen in facial
grimaces, nervous- looking hand gestures, and restless legs both during night and day.
- akathisia can happen in the first couple of week after taking antipschotic med
R: the nurse provides care for a client receiving chlordiazepoxide. It is most important for the
nurse to reinforce which expected finding to the client? - ANSWER DROWSINESS AND
CONFUSION
*** chloridaizepoxide is an anti-anxiety and sedative/hypnotic mediation used to treat
anxiety and alcohol withdrawal. This medication causes drowsiness and sedation. It is
important for this client to use caution when driving or operating equipment.
R: the nurse prepares to administer subcutaneous insulin to a client. The nurse scans the
insulin barcode and the prompt seen on the computer screen is for another nurse to verify
the insulin dosage. Which action does the nurse perform first? - ANSWER PREPARE
THE CORRECT DOSE OF INSULIN IN THE SYRINGE
*** the first action of the nurse is to prepare the medication as prescribed. So the second
verification can be a check of all parts of the prescription. High- alert medications have
safeguards in place in regard to limiting access and providing alerts to promo safety.
R: the nurse prepares to insert a peripheral IV catheter in a client iagnosed with T1DM who
reports extreme thirst, frequent urination, and fruity smelling breath. Which nursing action
demonstrates appropriate peripheral line placement? SATA - ANSWER - insert IV
catheter in one of the dorsal metacarpal veins ( dorsal metacarpal vein allows rapid fluid
resusitation because these veins are large and easy to find)
2
