appropriate action for romberg test

have pt stand with feet together & eyes closed

appropriate intervention for insomnia

eat a light carb snack before bedtime

nurse action when pt states they dont see the point of living

ask pt if they plan to harm themselves

statement shows pt understands teaching for hydrochlorothiazide

leave light on in bathroom at night

action if pt is having trouble voiding post surgury

allow pt to hear running water while attempting to void

appropriate care for pt with TPN and fat embolism orders?

admin TPN and fat embolism separate

action to take with pt order for wrist restraints

allow room for 2 fingers between pt skin and restraints

proper steps when assessing for extraocular eye movements?

instruct pt to follow finger for 6 cardinal gazes

pt statement to demonstrate understanding on home safety

have fire escape plan with family, i need to check meds for exp dates, apply tape over frayed electrical cords

pt teaching home safety instructions

use electrical tape to secure cords to baseboards on floor

action for using fracture bedpan with immobile pt

keep bed flat while pt is on bedpan

which is an ethical delima

family of pt with cancer says not to tell pt

cultural considerations when hispanic older adult is admitted

hispanics id eldest female member as decision maker

what does nurse signature confirm when signing informed consent

pt signed in nurses presence, pt has legal right to sign paper, pt wasnt coerecred or have mental condition

first action if pt states "i have trouble sleep"

identify pt typical bedtime routine

what indicates need to increase frequency of position change following ab surgery

non blanching red area over pt trochanter

insructions for collecting stool specimen to CNA

record time & date stool was collected

what factor increases pt motivation to learn to give self heparin shots

pt believes needs will be met with education

proof pt understands teaching when mixing regular and NPH insulin

roll NPH between hands before drawing up

action for pt with colostomy and irritated peristomal skin

ensure pouch is 1/8in larger than stoma

priority intervention if pt has new diagnosis for cancer

discuss pt prior coping methods

what task can nurse delegate to CNA

assist pt with choosing food from menu

which family is experiencing maturational loss

oldest child moved away for college

indicates understanding of teaching with max support using 2 wheeled walker

pt moves walker ahead 25.4cm with each step

pt teaching for reducing adverse effects of immobility

perform ankle/knee exercises every hour

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Questions 59

Answers

1
appropriate action for romberg test
have pt stand with feet together & eyes closed
ask pt to extend arms in front of body
have pt place hands on hips
ask pt to walk straight line heel to toe
2
appropriate intervention for insomnia
drink cup of hot cocoa before bedtime
exercise 1hr before bed
take 30min nap daily
eat a light carb snack before bedtime
3
expected finding with fluid volume deficit
bradycardia
postural hypotension
distended neck veins
dependent edema
4
nurse action when pt states they dont see the point of living
ask pt if they plan to harm themselves
recommend pt to seek spirtiual guidance
tell pt its normal response to grief
request pt family for extra support
5
pt teaching for young male adults at fair?
obtain tetnus bosster every 5 years
obtain herpes zoster by age 50
have testicular exam every 2 years
get dental exam every 6 months
6
which shows understanding of buccal med admin
first dissolve in water
chew tablet
insert between cheek and teeth
place med under tounge
7
statement shows pt understands teaching for hydrochlorothiazide
take hot bath before bed
take new med in eve
leave light on in bathroom at night
weight self weekly
8
action if pt is having trouble voiding post surgury
allow pt to hear running water while attempting to void
provide pt a bedpan while lying supine
encourage increaed water up to 1000ml daily
insert foley cath and connect to gravity
9
appropriate care for pt with TPN and fat embolism orders?
admin TPN and fat embolism separate
random glucose check daily
change TPN bag Q 48hr
prep pt for central line access
10
action to take with pt order for wrist restraints
allow room for 2 fingers between pt skin and restraints
apply to allow as little movement as possible
attach to side of pt bed
remove every 4 hours
11
which action to take when doing admission assessment
assess pt for med reactions
evaluate pts understanding of meds
ask pt about their meds
compile list of current meds
12
expected physiological response to increase as a result of stress
blood glucose
peripheral blood vessels diamter
intestinal perstalsis
urine output
13
proper nonpharm action for pt with mild pain 1 hr after pain meds
remove distractins from pt room
instruct pt to take rhymic deep breaths
encourage pt to apply heating pad for 2 hours
apply ice pack to back for 1hr
14
action to take when performind admission assessment if pt reports ab pain
perform deep palpation at end of assessment
assess bowel sounds using bell of stethoscope
asculate then palpate
begin palpations at site of pain
15
proper steps when assessing for extraocular eye movements?
position pt 20ft away from snellen chart
hold finger 46cm in front of pt eye
instruct pt to follow finger for 6 cardinal gazes
ask pt to cover right eye during left eye assessment
16
pt statement to demonstrate understanding on home safety
set water heater to 140F
have fire escape plan with family
i need to check meds for exp dates
apply tape over frayed electrical cords
17
pt teaching home safety instructions
unplug electronics by grasping the cord
replace carpted floors with tile
use electrical tape to secure cords to baseboards on floor
use fire extinguisher aim high at top of flames
18
role of nurse manager watching new nurse perform tasks
case manager
pt educator
pt advocate
19
which finding indicates phlebitis at IV site
coolness of pt arm with IV
erytherma along path of vein
pallor of pt arm with IV
pitting edema at insertion site
20
action for using fracture bedpan with immobile pt
place shallow end of fracture pan under buttocks
encourage pt to stay on bedpan for 20mins
keep bed flat while pt is on bedpan
hyperextend pt back while bedpan is in place
21
which is an ethical delima
pt wont listen to therapists because he doesnt like him
family of pt with cancer says not to tell pt
surgeon removed wrong kidney and wont take responsibility for actions
pts says insurance wont cover meds
22
cultural considerations when hispanic older adult is admitted
hispanics expects to make own choices as death nears
hispanic view older adulthood as negative time in life
hispanics expect adult children to care for older adults
hispanics id eldest female member as decision maker
23
best action for pt loosing weight and worried wedding ring will fall off
put in locked unit for pt
pin it to pt gown
keep it until family can get it
put in pt drawer
24
what sound when nurse hears blowing sound over aorta
bruit
murmur
gallop
thrill
25
proper way to verify NG tube placement
assess pt gag reflex
asculate while injecting air
place end in water & watch for bubbles
measure ph of gastric aspirate
26
what does nurse signature confirm when signing informed consent
pt signed in nurses presence
pt speaks same language as nurse
pt has legal right to sign paper
pt wasnt coerecred or have mental condition
27
proper isolation for pt with Tb?
droplet
airborne
contact
protective
28
priority assessment finding?
blood pressure 148/92
pulse of 105
blood glucose of 45
BMI of 28
29
first action if pt states "i have trouble sleep"
recomend pt avoid coffee in evening
teach stress reduction techniques
encourage pt to exrecise regularly during daytime
identify pt typical bedtime routine
30
manifestations of allergic reaction to new med?
nausea
ptosis
urticartia
hematuria
31
what indicates need to increase frequency of position change following ab surgery
flat rash on ankle
non blanching red area over pt trochanter
petechiae on pt right anterior thigh
ecchymosis on pt left shoulder
32
nurse overhear coworker saying he will give pt injection if they wont swallow pills. what tort is he comitting?
battery
defamanation
assault
malpractice
33
which team member to help if stroke pt need assistance with morning ADLs?
occupational therapy
dietician
speech lanuage pathologist
physical therapist
34
which assessment to perform first
elimination needs
peripheral pulses
skin intergrity
comfort levels
35
insructions for collecting stool specimen to CNA
collect atleast 2in of formed stool
use culturette for collection
wear sterile gloves to obtain stool
record time & date stool was collected
36
what factor increases pt motivation to learn to give self heparin shots
pt agrees to teaching due to family wishes
nurse explains need for education to pt
nurse empathy about pt self admin
pt believes needs will be met with education
37
statements showing understanding of teaching for pt wth MRSA
tell visitors to wear mask when within 3 feet
remove gown after leaving pt room
place pt in private room
wear N95 when caring for pt
38
documentation for tx change with granulation tissue?
translucent, red tissue
stringy white tissue
soft, yellow tissue
thick, black tissue
39
which shows understanding of braden scale?
each element ranges from 1-5 points
higher score= higher pressure sore risk
pt age is part of the results
scale measures 6 elements
40
proof pt understands teaching when mixing regular and NPH insulin
draw NPH up first
wait 10 mins after mixing to inject insulin
roll NPH between hands before drawing up
inject air it regular insulin first
41
manifestation of mild allergic reaction
nausea
urticaria
hematuria
ptosis
42
action for pt with colostomy and irritated peristomal skin
ensure pouch is 1/8in larger than stoma
apply pouch when skin is damp
change pouch daily
rub skin until dry after cleaning
43
priority intervention if pt has new diagnosis for cancer
teach pt progressive relaxation techniques
help pt find support groups
develop list of goals with pt
discuss pt prior coping methods
44
what task can nurse delegate to CNA
evaluate pt response to pain meds
assist pt with choosing food from menu
monitor pt chest tube drainage
teach deep breathing and couging to pt
45
which family is experiencing maturational loss
oldest child moved away for college
family home destroyed in fire
family whose child recently died of cancer
head of household lost job
46
action when nurse is suctioning trach pt and pulse/o2 sat drops
stop suctioning
remove inner cannula
elevate head of bed
irrigate the stoma
47
indicates understanding of teaching with max support using 2 wheeled walker
pt picks walker up with each step
pt stands withelbow slightly while holding walker
pt steps sligtly forward when moving walker
pt moves walker ahead 25.4cm with each step
48
contrainidication for acupuncture
migranes
obesity
cellulitis
hypertension
49
which data to include with background info for shift report
pain 5/10
code status: FULL
blood pressure 160/92
started first ABT dose at noon
50
contraindication for application of cold with ankle joint stiffness?
3in bruise on the ankle
warts on the affected ankle
2+ pitting edema
cap refill 4 seconds
51
pt teaching for reducing adverse effects of immobility
perform ankle/knee exercises every hour
remove antiembolic stockings while in bed
hold breath when rising from sitting position
change positions every 4 hours
52
appropriate action for weber test on pt
place activated tuning fork in middle of pt forehead
hold activated tuning fork on mastoid process
whisper series of words into one ear
series of high pitched sounds at random intervals
53
action to take when measuring oral temperature
provide oral care before getting temp
place tip along pt cheek
ask pt if they've smoked in past 30min
attach red tip probe to the unit
54
instructions for collecting blood glucose sample
gently squeeze site until large drop forms
hold finger above heart level
puncture site after cleaning & before alcohol dries
don streile gloves
55
action to perform for pt reporting insomnia
provide late supper
perform range of motion
offer washcloth to wash face
prepare hot cocoa or tea for pt
56
priority for pt on bedrest for few weeks
musculoskletal weakness
increased heart rate during exercise
left lower extremity tenderness
loss of appetite
57
which order is best for pt with right sided paralysis to prevent plantar flexion contracture of affected extremity
abduction splint
continous passive motion machine
ankle-foot orthotic
sequential compression device
58
proper pt teaching info for trach care at home
use trach cover when outside
remove inner cannula for routine cleaning
clean around stoma with providine-iodine
maintain sterile technique for trach care
59
appropriate action for IV pyelogram
monitor pt for pain in suprapubic area
assist pt with bowel cleansing
ensure pt is free of metal objects
admin 240ml of oral contrast before procedure

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