You are caring for a client with frostbite on the feet. Place the following interventions in the correct order.
Remove the victim from the cold environment.
Administer pain medication
Monitor for signs of compartment syndrome
Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C)
Apply a loose, sterile, bulky dressing
A client underwent a continent ileostomy. Within which time frame should the client expect to empty the reservoir?
Which phase of a migraine headache usually lasts less than an hour?
Premonitory
Postdrome
Headache
Aura
You are caring for a client with frostbite on the feet. Place the following interventions in the correct order.
Monitor for signs of compartment syndrome
Administer pain medication
Remove the victim from the cold environment.
Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C)
Apply a loose, sterile, bulky dressing
The nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, what actions would the nurse take? Arrange the actions in the order that they would be performed. All options must be used.
Administer oxygen
Position the client in a left Trendelenburg's Position
Take client's vital signs
Contact the primary care provider
Clamp IV catheter
The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?
Complaints of extreme fatigue and hair loss
Exophthalmos and complaints of nervousness
Complaints of profuse sweating and flushed skin
Tetany and complaints of stiffness of the hands
For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?
The registered nurse (RN) is educating a new nurse on mitral stenosis. Which statement by the new nurse indicates that the teaching has been effective?
"Left ventricle to aorta narrowing will impede flow of blood."
"Left atrium to left ventricle narrowing will impede flow of blood."
"Right atrium to right ventricle narrowing will impede flow of blood."
"Right ventricle to pulmonary artery narrowing will impede flow of blood."
A client with a short arm cast is suspected to have compartment syndrome. Which actions should the nurse include in the plan of care? Select all that apply
Assess Neurovascular Status Every 8 Hours
Provide Support To the Injured Extremity
Apply ice to the Extremity
Elevate the arm above heart level
Prepare to remove the cast
A QRS complex should measure no more than?
0.04 seconds
0.08 seconds
0.12 seconds
0.20 seconds
Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply.
Verbal communication is almost nonexistent.
Gross motor skills are impacted by involuntary body movements.
The client needs frequent redirection because of short attention span.
Interpersonal relationships are negatively impacted because of delusional thoughts.
Conversations are difficult to follow because of demonstration of loose associations of thought.
What term is used to describe the speech pattern being used when the client imitates or repeats what the nurse is saying?
Clang associations
Word salad
Neologisms
Echolalia
The nurse working with a client with Antisocial Personality Disorder would expect which behaviors? (3)
Compliance with expectations and rules
The exploitation of other clients
Seeking special privileges
Superficial friendliness towards others
Utilization of rituals to allay anxiety
Withdrawal from social activities
Clients with schizotypal personality disorder are most likely to benefit from which nursing intervention?
Improving Community Functioning
Teaching Social Skills
Cognitive Restructuring Techniques
Providing Emotional Support
What is the PRIORITY treatment of cardiogenic shock
Oxygen & Pharmacological Therapy
Fluid Therapy
Oxygenation
Circulation
Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?
2 hours
1 hour
30 minutes
90 minutes
A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs:
Venturi Mask 6 L Oxygen
100% oxygen via non-rebreather mask
Continuous BiPaP
Oxygen cannula 5-6 liters
[[1]] AV block occurs when all but one of the atrial impulses are conducted through the AV node into the ventricles
[[2]] AV block occurs when no atrial impulses are conducted through the AV node into the ventricles
[[3]] AV block occurs when all atrial impulses are conducted through the AV node into the ventricles at a slower-than-normal rate
[[4]] AV block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles
Second Degree, Type I
Third Degree
First Degree
Second Degree, Type II
The nurse is preparing to educate the client on how to perform incentive spirometry. Which concepts should the nurse include?
Incentive spirometry provides visual reinforcement of deep breathing
The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue
Decrease oxygen saturation is expected during the first few minutes of incentive spirometry
Proper, frequent use of incentive spirometry can improve pulmonary circulation
Systolic murmur, with a blowing sound heard best at the apex and may radiate to the left axilla. Pulse may be regular or irregular due to extrasystole beats or atrial fibrillation
Mitral Stenosis Assessment Findings
Mitral Regurgitation Assessment Findings
Mitral Valve Prolapse Assessment Findings
Aortic Regurgitation Assessment Findings
The anti-diuretic hormone is __________ in Diabetes Insipidus and _________ in SIADH.
high, low
absent, absent
low, high
low, low
Which likely takes place in the fourth stage of Kubler-Ross's stages of grieving?
Anger
Bargaining
Depression
Denial
[[1]] is the purple vaginal mucosa
[[2]] is the softening of the lower uterine segment
[[3]] is the softening of the cervix
CHADWICK SIGN
HEGAR SIGN
GOODELL SIGN
Reorder the following: The nurse is reviewing the clients with the UAP when prioritizing afternoon nursing care. Place the following clients in their priority order for the nurse's administration of client care at 1300 hours.
Client 2: 1300 - Dressing change to left heel wound
Client 4: 1300 - Soonest time for requested post-operative pain medication
Client 3: 1300 - Intravenous Piggyback (100 cc) every 6 hours
Client 1: 1300 - After lunch toileting
Which of the following are true regarding Gentamicin (Aminoglycoside)? Select all that apply.
Can cause irreversible ototoxicity
Can cause reversible nephrotoxicity
Administer IM or IV
Can cause irreversible nephrotoxicity
Often used to treat infections in those with Cystic Fibrosis
Which medication below is known as a Class III antiarrhythmic, used in severe arrhythmias such as V. Fib and V. Tach?
Diltiazem
Propranolol
Amiodarone
Amiodarone
Reorder the following steps of a myocardial infarction management
ANTIPLATELETS / ANTICOAGULANTS to prevent additional thrombi
NITRATES to relieve coronary artery spasms
BETA-BLOCKERS to reduce myocardial oxygen demand and MI mortality
THROMBOLYTICS to restore perfusion to the myocardium by dissolving clots
The nurse is precepting a new nurse in the care of a client returning to the surgical floor after a mastectomy with flap reconstruction. The client has two Hemovac drains in place. Which statements indicate the new nurse understands the management of surgical drains? Select all that apply.
If there is minimal drainage in the reservoir, I should open the drain plug to improve flow
I can tap the drain's spout on the measuring container to clear clots
I should compress the drain to remove all air before closing the plug
I should ensure the drain reservoir is below the level of the wound
I should document each drain's output separately in the record.
A client has chronic impaired peripheral arterial circulation. For which response should the nurse assess the client? Select all that apply.
Sores on the legs that do not heal
Diminished pulse in feet or legs
Brittle, slow-growing toenails
Lack of hair below the knees
Continuous leg discomfort
Cool, lower extremities
The nurse is monitoring for adverse effects in a client who is taking digoxin. Which findings are characteristic of digoxin toxicity? Select all that apply.
Tremors
Diarrhea
Irritability
Blurred Vision
Nausea & Vomiting