Fundamentals Questions AND Rationale PDF

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FUNDAMENTALS FUNDAMENTALS - FUNDAMENTALS List the pertinent information that should be included in a transfer report Please describe the five rights of delegation What are the three provider responsiblities for obtaining informed consent List 3 actions to take during the analysis or data collection step A nurse is caring for an older adult client with dementia. What preventative measures should the nurse institute to reduce the risk of falls? A nurse is providing discharge education to a client regarding home wound care. What manifestations of wound infection should the nurse include in this education? A client has been diagnosed with Varicella. What type of tier transmission precaution is required? What protective equipment will be required for prevention of transmission? Describe the motor, cognitive and psychosocial development during infancy. List five (5) expected assessment findings for the older adult due to the physical changes during aging. - 1. Decreased skin turgor, subcutaneous fate and connective tissues 2. Thickening of fingernails and toenails 3. Increase Blood Pressure 4. Decrease intestinal motility, which leads to increased risk of constipation 5. Decrease sensitivity of tissue cells to insulin A client asks the nurse to explain the different types of advance directives. What information should be provided regarding living wills, durable power of attorney and DNR orders? A nurse is documenting on the electronic medical record (EMR). How should the nurse ensure client confidentiality during documentation? Which of the four (4) clients should the nurse assess first? 1) Diabetic client who is 3 days post-operative for an above the knee amputation (AKA). 2) Febrile client with last recorded temperature of 100.5 F. 3) Client requiring discharge teaching on a low sodium diet.

4) Client with adventitious breath sounds complaining sudden dyspnea. A nurse is preparing for a procedure with a client who has a latex allergy. What action should the nurse take regarding this allergy? Identify two (2) teaching points for a client with Vancomycin-resistant Staphylococcus aureus. A nurse is caring for several clients receiving intravenous therapy. What are actions the nurse should use to prevent IV infections? Explain the steps involved in providing an intermittent enteral feeding. A nurse is caring for a client that exhibits signs and symptoms of aspiration during their enteral feeding. What is a priority intervention the nurse should carry out? The nurse is discharging a client home with instructions on proper crutch use. Identify three (3) priority teaching points to include in the discharge instructions. - When going up the stairs use Good leg first followed by crutches and the bad leg. Going down the stairs Step down with your crutches and your injured leg together then bring your stronger leg down When walking on crutches move the crutches first, your injured leg next, and then your stronger leg. Identify three (3) priority teaching points to include when educating a client to use a cane. - Cane used on strong side Advance cane then walk towards cane Elbow should be slightly flexed Describe tertiary prevention measures and provide one (1) example. - Begins after injury Prevention of pressure ulcers after spinal injury Promoting independence after traumatic brain injury Referrals to support groups Rehabilitation center PHARMACOLOGY - PHARMACOLOGY A nurse is preparing to administer ipratropium by metered dose inhaler. What adverse effects should the nurse instruct the client to monitor for? - Ipratropium is an Inhaled anticholinergic for the treatment of COPD/allergen/exercise induced bronchospasms which means it will cause the same effects as anticholinergics but in a local area. This

include dry mouth and hoarseness which is usually by having sips of water or sucking on dry candy. A nurse is instructing a client who has a new prescription for nitroglycerin transdermal patch about administration. What instructions should the nurse include? - Nitroglycerin is a drug that causes coronary vasodilation, in patch from the nurse needs to be sure that the client knows how/when/where to apply the patch. Her instructions should include; Do not cut the patch, be sure to rotate sites of application, wash site with soap and water and dry thoroughly before applying the patch, apply patch in hairless area of skin, do not place over cuts/scratches, remove patch at night and be medication free 10-12 hr/day. A client has a new prescription for salmeterol. The nurse is teaching the client about adverse effects of the medication. What instructions should the nurse include in this education? A client has a new prescription for an albuterol inhaler and a beclomethasone inhaler. What instructions should the nurse include concerning use of these inhalers? A nurse is administering gemfibrozil to a client with elevated cholesterol. Identify two (2) adverse effects related to this medication. - Gemfibrozil elevated HDL levels, the medication may cause hepatotoxicity as well as gallstones. Other side effects include myopathy as well as GI distress. A nurse has provided education to a client who has a new prescription for brimonidine ophthalmic drops. What statements by the client would indicate they understand the instructions? - The client will state that they may feel discomfort, pruritus after administration. Nurse should advise the client not to rub eyes. A nurse is administering a unit of packed red blood cells (PRBCs) to a client. What symptoms would indicate circulatory overload? Name three (3) clinical manifestations of circulatory overload. What are three (3) interventions the nurse can take action on if overload occurs? A nurse is caring for a client who has a prescription for digoxin. What are manifestations for digoxin toxicity that the nurse should monitor for before administering this medication? A nurse is providing instructions to a client who has a prescription for methotrexate. What should the nurse include in the client education? A nurse is preparing to administer a topoisonmerase inhibitor to a client with ovarian cancer. What are adverse effects the nurse should monitor when administering this medication? -

A nurse is preparing to educate a client with diabetes who has a new prescription for metformin. What should the nurse included in the client instructions? A client has been prescribed timolol eye drops. What are three (3) possible adverse effects of this medication and nursing interventions/client education related to these effects? A nurse is caring for a client who has a new prescription for alosetron. What are the expected therapeutic effects of this medication? An oncology client is prescribed filgrastim. What are the indications for this therapy? A client with hypertension is prescribed verapamil. What are the three (3) expected outcomes of this medication therapy? A client has been prescribed oxybutynin for treatment of overactive bladder and has been experiencing anticholinergic side effects. List two (2) actions the client will take to prevent adverse effects of the medication therapy. - Advice clients to increase dietary fiber, drink 2-3 L/day of fluids, and avoid driving or other hazardous activities if vision is impaired. Also warn client that they may experience tachycardia. If client is experiencing photophobia advise client to ware sunglasses when out and/or rest in dark/lightly dim environment. A nurse is preparing to administer acetylcysteine. What are indications for therapy? A client is receiving packed red blood cells and begins to exhibit signs of anaphylaxis. Name two (2) manifestations the nurse may note. What is the priority intervention? A client has been prescribed pregabalin for simple partial seizures. What is a contraindication for this medication? Benzodiazepines are the first-line treatment for alcohol withdrawal due to their ability to decrease the intensity of withdrawal symptoms. List two (2) nursing considerations for clients on benzodiazepines. A nurse is caring for a client prescribed acetaminophen as needed for pain relief. The nurse knows acetaminophen should not exceed ____ grams per day. The nurse will monitor for early signs of toxicity. Name three (3) manifestations of toxicity. What parameter of the cardiovascular system should the nurse monitor when a client is receiving Albuterol? A client is prescribed rosuvastatin (Crestor). Identify three (3) adverse effects and lab values the nurse should monitor. -

A nurse is caring for a client prescribed the chemotherapy agent topotecan (Hycamtin). What are adverse effects of this medication and nursing interventions/client education for this medication? A nurse is preparing a client for discharge. What information should the nurse include regarding the client's new medication acetazolamide? What are examples of beta adrenergic blockers? What are contraindications/precautions for these medications? A nurse is receiving a new client that is prescribed IV amiodarone. Identify two (2) adverse effects the nurse should monitor for with amiodarone? MED SURGE - MED SURGE A nurse is caring for a client following an infratentorial craniotomy. How should the nurse position this client in the immediate post-operative period? - Infratentorial craniotomy clients lie flat and side-lying. Turn the client side to side every 2hr. for 24 to 48 hrs. (Supratentorial need HOB to 30 degrees while turning the client side to side.) A nurse is caring for a client who has been admitted with renal calculi. List three (3) interventions the nurse will take in the management of renal calculi. Define the following types of urinary incontinence: Stress, urge, overflow, reflex, functional, total. A nurse is caring for a client experiencing metabolic acidosis. What are three (3) causes of metabolic acidosis? What are the expected assessment findings for a herniated lumbar disk? A nurse is caring for a client following a bone marrow biopsy. What information should the nurse include in the discharge education? - Client needs to report excessive bleeding and evidence of infection, client needs to inspect the sire of the biopsy daily, keep a clean dressing, dry, and intact. If sutures are in place, remind the client to return in 7 to 10 days to have them removed. A nurse is providing client education regarding modes of hepatitis transmission. What are the routes of transmission and risk factors for Hepatitis A, B, C, D and E? A nurse is providing education regarding risk factors for gout. What information should be provided? - Risk factor for gout include; Obesity, cardiovascular disease, trauma, alcohol ingestion, starvation dieting, diuretic use, some chemotherapy agents, chronic kidney failure.

A nurse is caring for a client scheduled for a liver biopsy. What nursing actions should be taken before, during and after this procedure? - Pre: explain the procedure, witness informed consent, and ensure fasting since midnight, give meds as prescribed. Intra: Assist client into the supine position with upper right quadrant exposed, assist the client with relaxation techniques, instruct the client to exhale and hold for at least 10 seconds while the needle is inserted, resume breathing once the needle is withdrawn, apply pressure to puncture site. Post: Assist the client to a right side-lying position and maintain for several hours, monitor vitals, assess for abdominal pain, bleeding, manifestation of pneumothorax. A nurse is caring for a client with colorectal cancer who is scheduled for a colectomy. What preoperative and post-operative education should be provided to this client? A nurse is caring for a client with Cushing's disease. Would the nurse expect this client's plasma cortisol levels to be increased or decreased? A nurse is caring for a client following a colposcopy with cervical biopsy. What postprocedure information should be provided? What is a potassium hydroxide (KOH) test and what specific nursing actions should be taken when obtaining fungal skin specimens? - The test confirms fungal lesions Scales scraped off a lesion is mixed with KOH. Teach the client what to expect in regards of the test and the procedure Establish sterile field Place sample in container with appropriate solution, label, and send to the laboratory Client may remove dressings after 8hers, may use tap water or NS to clean the biopsy site. If prescribed client may apply an antibacterial topical medication to prevent infection. If sutures are used client should returned within 7-10 for removal A nurse is caring for a client with multiple risk factors for peripheral vascular disease. List four (4) risk factors associated with peripheral vascular disease. What type of respiratory failure is caused by Guillain-Barre' syndrome? - With GuillainBarre' syndrome as well as Multiple Sclerosis, spinal cord injuries and CVA that impair the client's rate and depth or respirations the client will have ventilatory failure. Other

causes of Ventilatory failure include COPD, pulmonary embolism, pneumothorax, flail chest, ARDS, Asthma, Pulmonary edema, fibrosis of lung tissue, increase ICP. MATERNITY - MATERNITY A nurse is providing community education regarding risk factors for ovarian cancer. Identify five (5) risk factors associated with the development of ovarian cancer. - Age greater than 40 BRCA1 &2 gene mutation Diabetes Mellitus Use of infertility medication History of dysmenorrhea Early menarche or late menopause Hormone replacement therapy A nurse is instructing a newly diagnosed client with fibrocystic breast tissue disorder about diet. What should the nurse instruct the client to avoid in their diet? (Review the Med Surg RM) a. Alcohol b. Caffeine C. Milk d. Orange juice What should the nurse teach the client about depot medroxyprogesterone acetate as a method of contraception? What would the nurse teach to the postpartum mother before administering the Rho(D) Immune Globulin? - Given within 72hrs after birth (+baby from a -mother) After administration of the rubella vaccine and the RhO(D) immunoglobulin, a titer must be pulled 3 months after to make sure the mother's baby has built up the appropriate immunity. What are five (5) adverse effects noted with epidural analgesia administration during labor? - Decreased gastric motility, Nausea and Vomiting Inhibition of bowel and bladder elimination Hypotension Respiratory depression Allergic reaction Elevated temperature The client enters the obstetrical clinic for birth control information on using a diaphragm. What five (5) instructions would be provided by the nurse to explain use of the diaphragm? - Fitted by a provider Replace every 2 years Can be inserted 6hr before and remove 6hr after sex but no longer than 24hrs

Empty bladder prior insertion Wash with mild soap and warm water What medications are administered to treat Streptococcus B-Hemolytic infection during labor? A nurse is caring for a client in the third stage of labor. What nursing interventions should be taken during this stage? What are six (6) emotional responses the nurse would assess for if a mother is experiencing postpartum depression? What are the indications for prescribing hormone replacement therapy (HRT) for a menopausal client? A nurse is preparing to administer a rubella vaccination. What are contraindications to this immunization? What assessment should the nurse perform before administering pain medication to a laboring client who reports the need to have a bowel movement? A nurse is caring for a client scheduled for a chorionic villus sampling (CVS) procedure. What client education should the nurse provide prior to the procedure? Identify potential complications associated with CVS. A nurse is caring for a client undergoing infertility testing. The client asks why a hysterosalpingography has been ordered. What is the nurse's best response? What are the causes of early decelerations of the fetal heart rate? What are the nursing interventions to take if these occur? Immediately after rupture of amniotic membranes, a client states that she can feel something in her vagina and the nurse is able to visualize the umbilical cord protruding from the introitus. Discuss emergency nursing care measures the nurse should take. The nurse is teaching the client about danger signs in the third trimester. What would the nurse include in the danger signs to be reported to the physician immediately? A 6-week gestation client enters the emergency department with complaints for unilateral stabbing pain and tenderness on the lower right abdominal quadrant and red vaginal bleeding. The physician diagnoses the client with an ectopic pregnancy. The physician orders methotrexate. What teaching should the nurse perform related to the administration of methotrexate? A nurse is completing an Apgar score on a newborn. What is assessed when obtaining an Apgar score? -

PEDIATRICS What is a Patent Ductus Arteriosus? Identify two (2) clinical manifestations of patent ductus arteriosus (PDA) - Patent ductus arteriosus is a connection between the aorta and the pulmonary arteries, It is a normal finding after birth but should close within days. Prostaglandins keep the PDA open if necessary. NSAIDs, can be used to close the PDA if necessary. (Could you confirm this) Small PDA has no symptoms while larger PDAs can cause anorexia, failure to thrive, or breathlessness. The nurse is teaching the parents of an infant with tonsillitis caused by group A ßhemolytic streptococci about the importance of compliance with antibiotic therapy. What teaching regarding this infection is important to share with the parents? - Tonsillitis caused by bacteria is treated by antibiotics, thus the nurse should educate about possible adverse effects of this medications such as diarrhea, opportunistic infections, rash, and allergic reactions. The nurse should also remind the client to take the full dose of prescribed antibiotics and not stop the medication when sing and symptoms disappear. A child was sent home from school with head lice. The child's mother has called the help line nurse for guidance. What are three (3) measures the nurse will inform the mother about to address the infestation of pediculosis capitis? A nurse is assessing for strabismus in a pediatric client. Identify three (3) clinical findings noted with strabismus. - Eyes appear crossed or an eye that "wonders" Uncoordinated eye movement Asymmetric corneal light reflex What are three (3) points the nurse should educate the parents of an epileptic client on regarding seizure medications? - CNS effects; irritability, hyperactivity The medications help control seizures but not cure the disorder The medication should be taken as prescribed; same time each day, and not skip a dose for risk of rebound seizures Identify three (3) points to discuss with new mothers who are breastfeeding their newborn. A nurse is preparing to administer the MMR immunization to a client. What are two (2) contraindications for this vaccine? What does FLACC stand for? How old does a child need to be to use the FLACC Scale for pain?

What is the form of evaluation when using the FLACC Scale? - Face, Legs, Activity, Cry, Consolability How old does a child need to be to use the FLACC Scale for pain? 2 months to 7 years What is the form of evaluation when using the FLACC Scale? Score of 0-2 given to each of the 5 categories 2 being the worst and 0 being painless A pediatric client was diagnosed with Reye Syndrome. Which of the following statements by the parent indicate understanding of this diagnosis? - Reye Syndrome typically follows a viral illness." (Did not know this) "There is no association between using aspirin for fevers and development of Reye Syndrome." "My son's liver function may return to full function." "His symptoms of irritability, confusion, and lethargy are expected with this diagnosis." "There is no known treatment for Reye Syndrome and its symptoms." (I know there is no treatment for Reye Syndrome but there is supportive care so I'm not sure if the supportive care would be considered treatment for the symptoms...) A nurse is caring for a child admitted with an acute exacerbation of asthma. Discuss the nursing care needs of this child. What information regarding strategies to decrease the spread of infection should...