and Answers Graded A+
A nurse is caring for a client who has been off not priority i guess..
the unit for physical therapy for the past hour
notes that the infusion pump for the clients TPN
is turned off. The client tells the nurse that the A nurse is reinforcing teaching to a client who is
battery went dead while she was in physical newly diagnosed with hypertension and has been
therapy. The nurse should monitor the client for prescribed captopril (Capoten). The nurse should
which of the following manifestations? - reinforce that which of the following medications
ANSWER -Shakiness and diaphoresis has the potential to reduce the antihypertensive
These are manifestations of hypoglycemia, which effect of captopril? - ANSWER -Aspirin
can occur if there is a sudden interruption in the (Bayer)
delivery of TPN, resulting in the client receiving
below the prescribed amount. Aspirin and other NSAIDS can reduce the
antihypertensive effects of captopril, which is an
ACE inhibitor. The nurse should reinforce to the
A nurse is reinforcing teaching to parents of a client that aspirin has the potential to reduce the
child who is admitted with rheumatic fever. Which antihypertensive effect of captopril and should be
of the following statements by the parent avoided.
indicates a need for further teaching? -
ANSWER -"This illness will not recur
because my child has now had it" A nurse is caring for a client who is prescribed
lithium (Eskalith). Which of the following clinical
It is possible for rheumatic fever to recur, so findings should be immediately reported to the
prophylactic treatment with monthly IM injections provider? - ANSWER -Slurred speech
of benzathine penicillin G, or daily oral doses of
penicillin or sulfadiazine, will be needed. lurred speech is an early clinical finding
associated with lithium toxicity and can
precipitate the onset of seizures or coma. Using
A nurse is assisting with the care of a client who the safety and risk reduction priority setting
is in labor. Following spontaneous rupture of framework, this finding jeopardizes the immediate
membranes, the nurse visualizes the umbilical physiological safety of the client and should be
cord protruding from the vagina and the fetal reported to the provider immediately.
heart rate is 50/min. After calling for assistance
and notifying the provider, which of the following
is the priority action by the nurse? - A nurse is reviewing the electronic fetal heart rate
ANSWER -Place the client in a knee-chest tracing of a client who is in labor. Which of the
position following images exhibits variable decelerations?
- ANSWER -*Variable decelerations are
Placing the client in a knee-chest position will aid caused from cord compression.
in keeping the pressure of the presenting part of
the fetus off the cord. Using the ABC priority Late decelerations are caused from
setting framework, the greatest risk is the uteroplacental insufficiency.
cessation of circulation to the fetus; therefore,
this is the priority action the nurse should take. Prolonged decelerations are a decrease in the
BUT wrapping the umbilical cord in the 0.9% fetal heart rate of 15/min below baseline.
sodium chloride solution is also CORRECT but Prolonged decelerations last more than 2 min but
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, Nurse Logic Testing and Remediation Advanced Test Questions
and Answers Graded A+
less than 10 min. This can result from maternal infections are caused from health care delivery in
hypotension, umbilical cord prolapsed, placental a health care facility. These result from
rupture, placental hemorrhage, and tetanic prescribed antibiotic administration, presence of
contraction. multi-medication resistant organisms, breeches in
infection control practices, and invasive
Early decelerations are caused from head procedures. The urinary tract is a common site
compression. for health care associated infections. ***(UTIs
and CAUTIs from caths)
A nurse is reinforcing teaching about methods to Surgical wound is correct. ***(any open wound
decrease nausea to a client who is receiving can contract bacteria if not properly
chemotherapy. Which of the following statements cleaned/maintained)
by the client indicates a need for further
teaching? - ANSWER -"I should eat low Musculoskeletal system is INCORRECT. While
carbohydrate foods" is correct. Clients who are injuries can occur in the health care setting that
experiencing nausea should eat foods high in affect the musculoskeletal system, this is not a
carbohydrates, such as crackers, yogurt, toast, common site for health care associated
bananas, and sherbet. This is not an appropriate infections.
statement by the client and indicates a need for
further teaching Respiratory tract is correct. ***( droplet and
airborne precautions are a must, TB, pertussis,
rubella etc..)
A nurse is reinforcing teaching regarding foods
containing complete protein to a client. Which of Blood stream is correct. ***(any open wound
the following should be included in the teaching? again, any time an IV is placed or injected etc.
- ANSWER -Soybeans hard line to the blood stream and cause for
sepsis)
Food sources of complete proteins contain
sufficient quantities of all nine essential amino
acids to support body growth and maintenance. A nurse is caring for an infant who has been
Soybeans are a source of complete protein and prescribed a one-time dose of ceftriaxone
should be included in the teaching. (Rocephin) 50 mg/kg IM. The infant weighs 17.6
lb. Available is 500 mg/mL. How many mL should
the nurse administer? - ANSWER -0.8mL
A nurse in a long-term care facility is assisting
with an educational program regarding common STEP 1: Determine the infant's weight in kg: 2.2
sites of health care associated infections for a lb / x kg = weight in lb / 1 kg; 2.2 lb / x kg = 17.6
group of newly hired assistive personnel. Which lb / 1 kg. Cross multiply and x = 8 kg
of the following sites should be included in the
teaching? (Select all that apply.) - STEP 2: Find total of one-time dose: Amount
ANSWER -Urinary Tract, Surgical Wounds, prescribed x kg weight (mg x kg) = total daily
Respiratory Tract, an Blood Stream are all dose; 50 mg x 8 kg = 400 mg
correct
STEP 3: What is the dose needed? Dose needed
Urinary tract is correct. Health care associated = Desired; Desired = 400 mg
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