Nursing Interventions: Comprehensive Predictor Retake 2019-2024, Exams of Nursing

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Symptoms and Conditions

Requiring Nursing Interventions

Comprehensive Predictor Retake 2019 - 2024

Exam with Correct Answers (Graded A+)

1. Allergic Reaction to Medication

A nurse is assessing a client who has received an antibiotic. The nurse should identify hypotension as an indication of a possible allergic reaction to the medication.

2. Responding to a Client Refusing Antipsychotic

Medication

A nurse on a mental health unit is caring for a client who has schizophrenia and is experiencing auditory hallucinations telling them to hurt others. The client is refusing to take anti-psychotic medication. The nurse should respond, "This medication will help you respond to the voices you are hearing."

3. Increased Risk for Complications with Electroconvulsive

Therapy

A nurse is providing care for a patient who has depression and is to have electroconvulsive therapy. The nurse should identify cardiac dysrhythmias as a condition that increases the client's risk for complications.

4. Reporting Laboratory Findings for Rheumatoid Arthritis

A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. The nurse should report to the provider an erythrocyte sedimentation rate of 75 mm/hr.

5. Effective Suctioning of the Airway

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. The nurse should identify decreased peak inspiratory pressure as an indication that suctioning has been effective.

6. Caring for a Client in Seclusion

A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. The nurse should speak assertively to the client.

7. Priority Action for a Client Post-Adrenalectomy

A nurse is caring for a client who is immediately postoperative following an adrenalectomy to treat Cushing's disease. The nurse's priority action is to monitor the client's fluid and electrolyte status.

8. Responding to a Client Refusing a Surgical Procedure

A nurse is caring for a client who is scheduled for a surgical procedure and states, "I don't want to have this surgery anymore." The nurse should respond, "You have the right to refuse the procedure."

9. Improvement in Borderline Personality Disorder

A nurse is evaluating a client who has borderline personality disorder. The behavior that indicates an improvement in the client's condition is decreased clinging behavior.

10. Healthy Snack Options for School-Age Children

A nurse is teaching a group of school-age children about healthy snack options. The snack the nurse should include is air-popped popcorn.

11. Pain Medication Concurrent with Enoxaparin

A nurse is providing teaching to a client who has a new prescription for enoxaparin. The medication for pain relief that can be taken concurrently with enoxaparin is acetaminophen.

12. Medication for Fibromyalgia Pain

A nurse is caring for a client who has fibromyalgia and requests pain medication. The medication the nurse should plan to administer is pregabalin.

13. Digoxin Toxicity Risk

A nurse is caring for a client who has congestive heart failure and is receiving furosemide and digoxin. The laboratory value that indicates the client is at risk for developing digoxin toxicity is potassium 3.1 mEq/L.

14. Contraindication for Alteplase

A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase. The client's history that should be identified as a contraindication for receiving alteplase is hip arthroplasty 1 week ago.

22. Adverse Effect of Betamethasone

A nurse is preparing to administer betamethasone to a client who is 25 weeks of gestation and has preterm labor. The adverse effect the nurse should identify is hyperglycemia.

23. Actions for Obtaining a Blood Sample from a Central

Venous Catheter

A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. The actions the nurse should take are: - Access the catheter using a large bore needle. - Aspirate for blood return to access catheter patency. - Flush the catheter with 0.9% sodium chloride.

24. Preparing a Preschooler for a Dressing Change

A nurse is preparing to perform a dressing change on a preschooler. The action the nurse should take to prepare the child for the procedure is explain in simple terms how the procedure will affect the child.

25. Wound Care Technique

A nurse is performing wound care for a client who has an abdominal incision. The technique the nurse should implement is irrigate the wound with a low-pressure flow of solution.

26. Prioritizing Care for Multiple Antepartum Clients

A nurse on an antepartum unit is prioritizing care for multiple clients. The client the nurse should see first is a client who has preeclampsia and reports a persistent headache.

27. Information to Report to the Occupational Therapist

A nurse is caring for a client who is recovering from an amputation of her right arm above the elbow. The information the nurse should report to the occupational therapist is the client lives in a two-story home.

28. Responding to a Client with Major Depressive Disorder

A nurse is caring for a client who has major depressive disorder. The response the nurse should make is "Can you give me an example of how others are making you feel this way?"

29. First Action for a Client with Severe Head Trauma and

Nasal Bleeding

A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. The first action the nurse should take is establish a patent airway.

30. Findings in Sinus Arrhythmia

A nurse is reviewing the rhythm strip of a client who is experiencing sinus arrhythmia. The finding the nurse should expect is P to QRS ratio 1:.

31. Documentation of Confabulation

A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as confabulation.

32. Recommendations for a Client Post-Knee Surgery

A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. The recommendation the nurse should make is place a handrail in the entryway of the house.

33. Action to Prevent Dislocation of a Hip Prosthesis

A nurse is caring for a client who is postoperative following total hip arthroplasty. The action the nurse should take to prevent dislocation of the prosthesis is keep an abduction pillow between the client's legs.

34. Information about the Varicella Zoster Virus

A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster virus. The information the nurse should include is children who have varicella are contagious until the vesicles are crusted.

35. Action for a Client Experiencing a Panic Attack

A nurse is caring for a client who is experiencing a panic attack. The action the nurse should take is sit with the client to provide a sense of security.

36. Ergonomic Principle Understood by a Newly Licensed

Nurse

A nurse is teaching a newly licensed nurse about ergonomic principles. The action by the newly licensed nurse that indicates an understanding of the teaching is uses a mechanical lift device to move a client from the bed to the chair.

37. Understanding of Condom Use Teaching

A nurse is teaching a client about condom use. The client statement that should be identified as an understanding of the teaching is "I can use water-based lubricant with the condom."

Crutch Safety Teaching

Correct Client Actions

B. The client places the crutches 30 cm (12 in) to the front and side of each foot while standing D. The client keeps her axillae free of pressure

Incorrect Client Actions

A. The client flexes her elbows 10 degrees when supporting weight by using the handgrips (should be 30 degrees) C. The client leans on both crutches to support body weight

Preparing the Body of a Deceased Client

Appropriate Actions

A. Place a pillow under the client's head D. Place the client's arms across their chest

Inappropriate Actions

B. Remove the client's dentures C. Remove the client's identification tags

Operating a Fire Extinguisher

Unlock the handle by pulling on the pin. Point the hose at the base of the fire. Squeeze the handles together. Sweep the extinguisher from side to side.

Legal Recommendations for Newly Licensed

Nurses

A. Ensure that the client has a living will on file prior to treatment. C. Obtain personal professional liability insurance coverage.

Recommendations to Avoid

B. Place copies of incident reports in the clients' medical records. D. Overestimate the clients' acuity to prevent short staffing.

Caring for a Client with Language Barriers

A. Review the facility policy about the use of an interpreter. B. Direct attention toward the interpreter when speaking to the client.

Actions to Avoid

C. Request a family member or friend to interpret information to the client. D. Request an interpreter of a different sex from the client.

Manifestations of Hypovolemic Shock

B. Change in level of consciousness

Findings that Do Not Indicate Hypovolemic Shock

A. Decreased respiratory rate C. Increased urine output D. Hyperactive deep-tendon reflexes

Caring for a Client with a Cast

A. Position the casted extremity on a pillow. D. Palpate the pulse distal to the cast.

Actions to Avoid

B. Place an ice pack over the cast. C. Teach the client to keep the cast clean and dry.

Evaluating a Client's Gait

C. The client's heels touch the ground before their toes.

Findings that Do Not Indicate a Standard Gait

A. The client looks at the floor when walking. B. The client's shoulders are rounded slightly forward. D. The client's dominant foot bears more weight.

Caring for a Client with Suicidal Ideation

D. Establish a no-suicide contract with the client.

Actions to Avoid

A. Place the client in a group therapy session. B. Avoid discussing suicidal thoughts with the client. C. Give the client a radio to listen to in his room.

Nutrition Therapy for a Client with Anorexia

due to Chemotherapy

A. "Snack frequently on fresh fruit." D. "Add grated cheese to vegetable dishes."

Prioritizing Triage of Fire Victims

A. Client who has a compound fracture of the femur B. Client who has hypertension and reports chest pain

Clients Not Prioritized as Emergent

C. Client who has severe abdominal pain D. Client who has a deep laceration on both thighs

Time Management Strategies for Nurses

A. Gather supplies prior to completing a dressing change. B. Complete partial assessments on all clients before planning the day.

Strategies to Avoid

C. Prioritize activities based on the nurse's needs. D. Use break time to perform documentation.

Assigning Clients to Rooms on a Mental

Health Unit

C. A client who has bipolar disorder and impaired social interactions.

Clients Not Assigned Near the Nurse's Station

A. A client who has a somatic symptom disorder and reports chronic pain. B. A client who has an anxiety disorder and is experiencing moderate anxiety. D. A client who has a depressive disorder and reports feeling hopeless.

Identifying Effective Coping in a Client with a

Partner with Alcohol Use Disorder

B. The client attends regular counseling sessions.

Coping Strategies that Are Not Effective

A. The client utilizes strategies to enhance codependent behaviors. C. The client exhibits sympathy to the partner. D. The client ignores the partner when they are using alcohol.

Priority Action for a Client Experiencing

Thyroid Storm

D. Monitor the client's cardiac rhythm.

Actions with Lower Priority

A. Obtain the client's blood glucose. B. Administer 0.9% sodium chloride IV. C. Provide a cooling blanket.

Postoperative Instructions to Promote

Circulation

B. "Use an incentive spirometer every 4 hours." D. "Place a pillow under your knees while in bed."

Instruction to Avoid

A. "Remain on bed rest for 24 hours following the procedure."

Pouring Sterile Solution for Wound Irrigation

B. Hold the irrigation solution bottle with the label facing away from the palm of the hand. D. Remove the cap and place it sterile-side up on a clean surface.

Actions to Avoid

A. Hold the bottle in the center of the sterile field when pouring the solution. C. Place the sterile gauze over areas of spilled solution within the sterile field.

Responding to Suspected Child Abuse

D. Document clinical findings.

Actions to Avoid

A. Contact child protective services. B. Refer the parents to a self-help group. C. Instruct the parents about methods of discipline.

Teaching for Percutaneous Central Venous

Access Device Placement

A. "The provider will wear a mask while performing the procedure." B. "You should not eat or drink for 4 hours prior to the procedure."

Statements to Avoid

C. "Your head will be elevated as high as possible while the catheter is inserted." D. "The provider will give you pain medication before inserting the catheter."

Prescriptions for Acute Exacerbation of

Multiple Sclerosis

A. Interferon beta-1a

Prescriptions that Do Not Treat Acute Exacerbation of

Multiple Sclerosis

B. Enoxaparin C. Atorvastatin D. Amoxicillin

Referral for a Client with Early-Stage

Alzheimer's Disease

A. Respite care

Referrals to Avoid

B. Restorative care C. Hospice D. Rehabilitation facility

Manifestations of Moderate Dehydration in a

School-Age Child

A. Orthostatic hypotension D. Bradycardia

Findings that Do Not Indicate Moderate Dehydration

B. Decreased respirations C. Polyuria

Responding to a Client's Ambivalence about

Pregnancy

B. "Have you discussed these feelings with your partner?" D. "Describe your feelings to me about being pregnant."

Responses to Avoid

A. "When did you start having these feelings?" C. "You should discuss your feelings about being pregnant with your provider."

Promoting Client Advocacy Among Nursing

Staff

C. Encourage staff to implement the principle of client-centered care when a client is having difficulty making a choice.

Actions to Avoid

A. Instruct unit staff to share personal experiences to help clients make decisions. B. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice.

Reporting Safety Concerns in the Client Care

Environment

Developing a System for Staff Members

Establish a formal process for staff members to report any safety concerns they identify in the client care environment. Ensure that this reporting system is well-communicated and accessible to all staff members. Encourage a culture of open communication and accountability, where staff feel empowered to voice their concerns without fear of repercussions.

Informing Staff about Informed Consent

Instruct staff members to thoroughly explain all procedures to clients before obtaining their informed consent. Emphasize the importance of clear communication and ensuring that clients understand the nature, risks, and benefits of any proposed interventions. Provide training or resources to help staff members develop effective patient education strategies.

Managing Nosebleeds in School-Age Children

Nurse's Instructions for the Parent

"Use your thumb and forefinger to apply firm, steady pressure to the soft part of the nose, just below the bone, for 5-10 minutes. This will help stop the bleeding." "Have your child sit upright and lean slightly forward. This will prevent the blood from going down the back of the throat." "Do not let your child blow their nose, as this can dislodge the clot and restart the bleeding." "If the bleeding does not stop after 10-15 minutes of continuous pressure, seek medical attention immediately."

Addressing Impaired Swallowing During

Feeding

Nurse's Next Action

After observing the client coughing after each bite, the nurse should ask a speech therapist to evaluate the client's ability to swallow. This specialized assessment will help determine the underlying cause of the swallowing impairment and guide the development of an appropriate care plan.

Prioritizing Care in an Acute Mental Health

Facility

Client the Nurse Should See First

The client who is taking clozapine to treat schizophrenia and reports a sore throat should be the nurse's top priority. Clozapine can cause potentially life- threatening side effects, and a sore throat may be a sign of agranulocytosis, a serious adverse reaction that requires immediate medical attention.

Delegating Client Tasks to Assistive Personnel

(AP)

Statements the Nurse Should Include in the Teaching

"The RN evaluates client needs to determine tasks to delegate." "The RN is legally responsible for the actions of the AP."

These statements emphasize the nurse's role in assessing client needs, selecting appropriate tasks to delegate, and maintaining accountability for the AP's performance.

Assessing a Client with Cocaine Use

Findings the Nurse Should Expect

The nurse should expect the client to exhibit elevated temperature, as cocaine use can lead to hyperthermia. Other expected findings include slurred speech and memory loss, which are common symptoms of cocaine intoxication.

Addressing Persistent Pain After Ibuprofen

Administration

Nurse's Action

The nurse should report the client's finding of persistent pain to the provider. This will allow the provider to evaluate the client's response to the ibuprofen and consider alternative pain management strategies, such as prescribing an opioid medication or adjusting the dosage.

Interventions for an Older Adult Client with

Dementia

Appropriate Interventions

Allow the client to choose among a variety of activities each day. Give the client one simple direction at a time. Reinforce orientation to time, place, and person. Establish eye contact when communicating with the client.

These interventions aim to provide structure, simplify tasks, and maintain the client's sense of orientation and connection, which are important considerations when caring for individuals with dementia.

Nutritional Teaching for a Client with Severe

Nausea

Client Response Indicating Understanding

The client's statement, "I should sip on clear carbonated beverages that have gone flat," indicates an understanding of the teaching. Consuming flat, clear carbonated drinks can help settle the stomach and alleviate nausea in some individuals.

Teaching About Disulfiram for Alcohol Use

Disorder

Appropriate Statement

The nurse should state, "Wait at least 12 hr after your last drink to take this medication." This emphasizes the importance of avoiding alcohol consumption while taking disulfiram, as the combination can lead to severe, unpleasant reactions.

Assessing Client Understanding After Total

Hip Arthroplasty

Statement Indicating Understanding

The statement, "I won't cross my legs when sitting in a chair," indicates the client's understanding of the discharge teaching. Avoiding leg crossing is an important precaution to prevent dislocation of the hip prosthesis.

Teaching About Oral Chlorpromazine

Administration

Information to Include

The nurse should inform the client to "Move slowly when standing from a sitting position." This is important because chlorpromazine can cause orthostatic hypotension, which increases the risk of falls and injuries when transitioning between positions.

Managing Magnesium Sulfate Infusion in

Preeclampsia

First Action the Nurse Should Take

The nurse should first discontinue the magnesium sulfate infusion in response to the client's report of difficulty breathing. This is a potentially serious adverse effect that requires immediate intervention to ensure the client's safety.

Reporting Laboratory Findings for a Client on

Cyclosporine

Finding to Report to the Provider

The nurse should report the serum creatinine of 1.6 mg/dL to the provider. This finding may indicate impaired kidney function, which is a common adverse effect of cyclosporine and requires close monitoring and potential adjustments to the medication regimen.

Implementing Fall Precautions

Appropriate Action

The nurse should establish an elimination schedule for the client. This proactive approach helps to prevent falls by ensuring the client's toileting

needs are met in a timely manner, reducing the risk of the client attempting to ambulate unassisted.

Responding to a Client's Plan to Leave

Against Medical Advice

Action the Charge Nurse Should Intervene On

The charge nurse should intervene if the nurse asks security to detain the client until the provider is notified. Detaining a client against their will without a valid legal reason would be an inappropriate and potentially unethical action.

Nursing Interventions for a Client with SIADH

Appropriate Intervention

The nurse should include the intervention, "Encourage oral hydration of 1,800mL daily." This helps to dilute the client's serum sodium concentration, which is typically elevated in SIADH, and promotes fluid balance.

Actions When Using an IV Pump

Appropriate Action

The nurse should check the cords of the IV pump for fraying. Ensuring the integrity of the electrical components is crucial for the safe operation of the IV pump and the client's safety.

Teaching About Critical Pathways

Information to Include

The nurse should inform staff that "Critical pathways should reduce health care costs." This is a key purpose of implementing critical pathways, as they aim to standardize and streamline the delivery of care, ultimately leading to cost savings.

Teaching About Myringotomy Postoperative

Care

Statement to Include

The nurse should include the statement, "You should blow your nose with your mouth closed." This helps to prevent the introduction of air or pressure