zsrxdcfgvubhjnkmlzsxrdcfgbjhnkxdfSATA.pptx

The nurse is admitting a client with a diagnosis of right-sided heart failure
resulting from pulmonary hypertension. What clinical manifestations are most
likely to be assessed? Select all that apply.
1. Crackles in lung bases
2. Increased abdominal girth
3. Jugular venous distension
4. Lower extremity edema
5. Orthopnea

Heart:
Problem:
Nsg DX:
Decreased cardiac output
Activity intolerance
Ineffective peripheral tissue perfusion
Impaired renal perfusion

S/S L vs. R
1. Dyspnea
2. Hepatomegaly
3. Weight Gain
4. Air hunger
5. Fine Crackles
6. Edema
7. Distended Jugular Veins
8. DOB when supine
9. Tachycardia

10. Cough
11. Tight Shoes
12. Breath sounds lie rolling the hair
13. Increased HR
14. Using 2-3 pillows when lying down
15. Increased leg circumference

NURSING MANAGEMENT
1. DOC:
2. Position:
3. O2
4. Diet:
5. Rest
6. Rotating tourniquet
7. Weigh daily

The client is scheduled to have a cardiac catheterization. Which
findings will cause the nurse to question the safety of the test proceeding?
Select all that apply.
1. Allergy to shellfish
2. Elevated C-reactive protein
3. Prolonged PR interval on electrocardiogram
4. Serum creatinine of 2.5 mg/dL (221 μmol/L)
5. Took metformin today for type 2 diabetes

Cardiac Catheterization
-aka:
-introduction site:
-expected:
-R:

POST-OP
*extremities extended
*assess pulses
if circulation:
if bleeding:
*apply pressure:
*increase FI
*complication

The clinic nurse is taking vital signs on a client who reports being
fatigued every day and gaining weight lately despite not eating much. The
nurse should also ask about which symptoms? Select all that apply.
1. Cold intolerance
2. Difficulty concentrating
3. Fever
4. Menstrual irregularity
5. Night sweats
6. Tachycardia

O2 CONSUMPTION
>slow
>sleepiness
>slowed mental processes
>fatigue
NSG DX:
Problem:

METABOLISM
-Constipation
-Anorexia
-Weight Gain:
- Nutrients Absorption
 hair:
 nails:
 anemia

A nursing diagnosis for a patient with newly-diagnosed diabetes is
Risk for Injury related to sensory alterations. Which key points should
you
include in the teaching plan for this patient? (Select all that apply.)
1. “Clean and inspect your feet every day.”
2. “Be sure that your shoes fit properly.”
3. “Nylon socks are best to prevent friction on your toes from shoes.”
4. “Only a podiatrist should trim your toenails.”
5. “Report any nonhealing skin breaks to your health care provider.”

FOOT CARE (DM)
>X walking barefoot
>inspect feet:
>refer to podiatrist
>shoes:
>socks:
>use cornstarch
>cut toenails:
>lotion/lanolin  massage

Which actions can the school nurse delegate to UAPs who are
working with a 7-year- old child with type 1 diabetes in an elementary school?
(Select all that apply.)
1. Obtaining information about the child’s usual insulin use from the parents
2. Administering oral glucose tablets when blood glucose level falls below 60
mg/dL
3. Teaching the child about what foods have high carbohydrate levels
4. Obtaining blood glucose readings using the child’s blood glucose monitor
5. Reminding the child to have a snack after the physical education class

However, advanced medication administration (eg, IV medications) must be
performed by a registered nurse (RN)

The nurse teaches a client with diabetes mellitus about
differentiating between hypoglycemia and ketoacidosis. The clientdemonstrates
an understanding of the teaching by stating that a form of
glucose should be taken if which symptoms develop? Select all that apply.
1. Polyuria
2. Shakiness
3. Palpitations
4. Blurred vision
5. Lightheadedness
6. Fruity breath odor

HYPOGLYCEMIA
-blood glucose:
-RISK FACTORS:
D-ecrease food
I-nsulin overdose
E-xcessive Exercise
E-xcessive Alcohol

TYPES
MILD MODERATE SEVERE
GLUCOSE
LEVEL
S/S

MGNT
1. Assess
serum glucose
2. REVERSE HYPOGLYCEMIA (ASAP)
for conscious:
>10-15 grams
>eg.

for unconscious:
>1st
 SQ:
>2nd
:

client is taking Humulin NPH insulin and regular insulin every
morning. The nurse should provide which instructions to the client? Select all
that apply.
1. Hypoglycemia may be experienced before dinnertime.
2. The insulin dose should be decreased if illness occurs.
3. The insulin should be administered at room temperature.
4. The insulin vial needs to be shaken vigorously to break up the precipitates.
5. The NPH insulin should be drawn into the syringe first, then the regular
insulin.

INSULIN MGNT
>ROUTE
*___
*angle average/thin:
obese:
prefilled:
*instruction:
*rotate sites
*if (+) lipodystrophy:
*only IV insulin:

>STORAGE
*if closed:
*if opened:
*cold insulin
>MIXING 2 INSULINS
*inject air:
*withdraw:
*how:
-NPH %
-Regular %

>PREVENT HYPOGLYCEMIA
>risk:
>during peak:
>bring snacks:
>X alcohol

Short
Acting
Intermediate
Acting
Long
Acting
Onset
Peak
Duration

Short
Acting
Intermediate
Acting
Long
Acting
Onset
Peak
Duration
30 mins
- 1 hr 2-4 hours 6-8 hours
2-4 hours 6-8 hours
6-8 hours
18-24
hours
36-72
hours
18-24
hours

The nurse is administering NPH insulin at 7 am. When
will the nurse give snack?
a. 10 AM
b. 9 AM
c. 12 noon
d. 2 PM

client with a history of diverticular disease is being discharged after
an episode of acute diverticulitis. Which instructions should be included in
the discharge teaching plan to reduce the risk of future episodes? Select all
that apply.
1. Drink plenty of fluids
2. Exercise regularly
3. Follow a low-residue diet
4. Include whole grains, fruits, and vegetables in the diet
5. Increase intake of red meat

• NURSING MGNT
• 1. PROMOTE BOWEL REST
• -NPO
• -bed rest
• -IVF
• -X foods w/ seeds
•
•

• NURSING MGNT
• 1. PROMOTE BOWEL REST
• -NPO
• -bed rest
• -IVF
• -X foods w/ seeds
• -diet:
• if diverticulosis:
• if diverticulitis:
•
•

For every 7 g of fiber you eat
each day, your first-time
stroke risk drops by 7
percent, says a new study
review from the U.K.
Best sources include fruits,
vegetables, and whole
wheat carb staples!

• 2. DRUGS
• -Antispasmodics
• propantheline (ProBanthine)
• dicyclomine
• >given:
• -Anti-Infective
•
•

DIET
GERD
SFF
Bland
High Fiber
PUD
Bland
if (+) bleeding: NPO

DIET
DUMPING SYNDROME
Low CHO, Inc CHON
APPENDICITIS
prevention: Inc Fiber
DIVERTICULOSIS
Inc Fiber
DIVERTICULITIS
Dec Fiber

DIET
IBD
Dec Fiber
ULCERATIVE COLITIS
Dec Fiber
Without Milk
IRRITABLE BOWEL SYNDROME
High Fiber, Low Fat
HEMORRHOIDS
Inc Fiber

DIET
CHOLECYSTITIS
Dec Fat
PANCREATITIS
Dec Fat

Which interventions apply in the care of a client at high risk for an
allergic response to a latex allergy? Select all that apply.
1. Use nonlatex gloves.
2. Use medications from glass ampules.
3. Place the client in a private room only.
4. Keep a latex-safe supply cart available in the client’s area.
5. Avoid the use of medication vials that have rubber stoppers.
6. Use a blood pressure cuff from an electronic device only to measure the
blood
pressure

• 200 students at a
Twickenham (Middlesex)
school ( England ) were
helped through their exams
this year by eating bananas
at breakfast, break, and
lunch in a bid to boost their
brain power.
• Research has shown that
the potassium-packed fruit
can assist learning by
making pupils more alert.

ADHESIVE BANDAGES
ELASTIC BANDAGES

LATEX FREE PRODUCTS
C-loth barrier
A-mpules
P-olyvinyl chloride IV

The nurse caring for a client who is taking an aminoglycoside
should monitor the client for which adverse effects of the medication? Select
all that apply.
1. Seizures
2. Ototoxicity
3. Renal toxicity
4. Dysrhythmias
5. Hepatotoxicity

You are preparing to teach a patient with a new diagnosis of
osteoporosis about strategies to prevent falls. Which teaching points will you
be sure to include? (Select all that apply.)
1. Wear a hip protector when ambulating.
2. Remove throw rugs and other obstacles at home.
3. Exercise to help build your strength.
4. Expect a few bumps and bruises when you go home.
5. Rest when you are tired.

OSTEOPOROSIS NURSING MANAGEMENT
1. PREVENT FRACTURES
-side rails
-handrails
-X scattered rags
-lights

2. INCREASE BONE ABSORPTION
-drugs
- physical activities
-exercise:
-ALERT! SWIMMING
-non-weight bearing
-no absorption!!!

• 3. CLIENT TEACHINGS:
• -increase FI
• -sunlight exposure
• -avoid smoking
• -avoid alcohol
• -reduce caffeine
• -diet:

Which teaching instructions should the nurse provide to a client
with advanced chronic obstructive pulmonary disease (COPD)? Select all
that apply.
1. Follow a low-calorie diet
2. Obtain a pneumococcal vaccine
3. Report increased sputum
4. Take iron to improve anemia
5. Use an incentive spirometer

The nurse is preparing to administer medications through a client's
feeding tube. Which actions should the nurse implement? Select all that
apply.
1. Combine all medications before administering
2. Crush each medication separately before administration
3. Determine if the medications are available in liquid form
4. Flush the tube with sterile water before and after medication
administration
5. Mix medications with enteral feeding formula before administration

3. NASOGASTRIC TUBE
-indication:
-position: HF  during insertion
-measurement:
-form of the drug:
-if tablet:
-assessment before:

METHODS
1. X-RAY
-best method
-ALERT!!!!
-removed:
-X: pregnant women
2. ASPIRATION OF GASTRIC CONTENTS
-position:
-N gastric color:
-litmus paper color:

ASPIRATION OF GASTRIC CONTENTS

3. AUSCULTATION
-introduction of air
-NGT placement:
-procedures:
1. Clamp the tubing
2. Attach bulb syringe
3. Unclamp tubing
4. Allow med to run
5. Flush the medication:
6. After administration
Position:
Oral care

The nurse is preparing to administer eyedrops. Which interventions
should the nurse take to administer the drops? Select all that apply.
1. Wash hands.
2. Put gloves on.
3. Place the drop in the conjunctival sac.
4. Pull the lower lid down against the cheek bone.
5. Instruct the client to squeeze the eyes shut after instilling the eyedrop.
6. Instruct the client to tilt the head forward, open the eyes, and look down.

VA0054
To administer eye medications, the nurse should:
1. Wash hands and
2. Put gloves on.
3. Instruct client to tilt the head backward, open the eyes, and look up.
4. Pull the lower lid down against the cheekbone and holds the bottle like a
pencil with the tip downward.
5. Squeezes the bottle gently to allow the drop to fall into the conjunctival sac
6. Instruct patient to close the eyes gently and
7. Do not to squeeze the eyes shut to prevent the loss of medication.

The nurse is planning care for a client diagnosed with influenza who
has had fever, muscle aches, headache, and sore throat for 36 hours. The
health care provider prescribes ibuprofen and oseltamivir. Which of the
following should the nurse include in the plan of care? Select all that apply.
1. Instruct client to be 3 ft (0.91 m) away from others when coughing or
sneezing
2. Place client on contact precautions
3. Place mask on client when transporting
4. Question the oseltamivir prescription
5. Teach client about the importance of annual vaccination

A client is admitted to the hospital for evaluation of suspected
pulmonary tuberculosis (TB). The nurse assesses for which characteristic
presenting signs and symptoms associated with TB disease? Select all that
apply.
1. Dysuria
2. Jaundice
3. Low back pain
4. Night sweats
5. Purulent or blood-tinged sputum
6. Weight loss

The clinic nurse is assessing a child who is scheduled to receive a
live virus vaccine (immunization). What are the general contraindications
associated with receiving a live virus vaccine? Select all that apply.
1. The child has symptoms of a cold.
2. The child had a previous anaphylactic reaction to the vaccine.
3. Mother reports that the child is having intermittent episodes of diarrhea.
4. Mother reports that the child has not had an appetite and has been fussy.
5. The child has a disorder that caused a severely deficient immune system.
6. Mother reports that the child has recently been exposed to an infectious
disease.

A nulliparous client asks about being in "real" labor. The nurse
should teach that which signs are most indicative of true labor? Select all
that apply.
1. Contractions that increase in frequency
2. Contractions that lessen after resting
3. Increased blood-tinged, mucoid vaginal discharge
4. Pain in lower back that moves to lower abdomen
5. Progressive cervical effacement and dilation

The nurse is performing an assessment on a client diagnosed with
placenta previa. Which of these assessment findings would the nurse expect
to note? Select all that apply.
1. Uterine rigidity
2. Uterine tenderness
3. Severe abdominal pain
4. Bright red vaginal bleeding
5. Soft, relaxed, nontender uterus
6. Fundal height may be greater than expected for gestational age.

The nurse is preparing to perform an admission assessment on a
client with a diagnosis of bulimia nervosa. Which assessment findings does
the nurse expect to note? Select all that apply.
1. Dental decay
2. Moist oily skin
3. Loss of tooth enamel
4. Electrolyte imbalances
5. Body weight well below ideal range

A client with advanced osteoarthritis (OA) is admitted for right total
knee arthroplasty. Which characteristic manifestations does the nurse expect
to assess in this client? Select all that apply.
1. Crepitus with joint movement
2. Low-grade temperature
3. Morning stiffness lasting several hours
4. Pain exacerbated by weight-bearing activities
5. Positive serum rheumatoid factor

S/S RA OA
INFLAMMATION
JOINT
STIFFNESS
PAIN
SJOGREN’S
SYNDROME

RA vs OA
RISK FACTORS:
1. Gender: Female
2. Aging
3. Obesity
4. Autoimmune
5. Trauma
6. Fracture
7. Exact Cause: Unknown
8. Degeneration

RA vs. OA
CHARACTERISICS & PATHOPHYSIO:
1. (+) Inflammation
2. Systemic
3. Non-inflammatory
4. Bilateral
5. Unilateral
6. Symmetrical
7. Attacks the joints
8. Pannus Formation

RA vs OA
CHARACTERISICS & PATHOPHYSIO:
9. Thinning of the Cartilage
10. Osteophyte
11. Ankylosis (pathologic Fusion)

RA vs OA
S/S
1. Early morning stiffness
2. Pain > than several hours
3. Pain relieved by rest
4. Sjogrens Syndrome
5. Ulnar Drift
6. Heberden’s Nodes
7. Swan Neck Deformities
8. Bouchards

Which cast care instructions should the nurse provide to a client
who just had a plaster cast applied to the right forearm? Select all that apply.
1. Keep the cast clean and dry.
2. Allow the cast 24 to 72 hours to dry.
3. Keep the cast and extremity elevated.
4. Expect tingling and numbness in the extremity.
5. Use a hair dryer set on a warm to hot setting to dry the cast.
6. Use a soft padded object that will fit under the cast to scratch the skin under
the
cast.

CAST MANAGEMENT:
1. NEUROVASCULAR ASSESSMENT
-C
-M
-S
-cx:

Cx: COMPARTMENT SYNDROME
>cause:
>mgnt:
proper fit:
elevate
notify
sx:
WINDOWING
BIVALVING

• 2. PROTECT CAST
• -elevate
• -handle the cast: _____
• -avoid covering
• -signs of dry cast:

• 3. ASSESS INFECTION SIGNS
• -(+)“HOT SPOTS”
• -odor:
• -drainage:
• -systemic:

• 4. MAINTAIN SKIN INTEGRITY
• -“PETALLING”
• -X inserting objects
• -avoid heat
• -do not scratch
• -if (+) itchiness:

• 5. HEALTH TEACHINGS
• -exercise:
• -keep it dry
• -cleaning:

The nurse is developing a plan of care for a child who is at risk for
seizures. Which interventions apply if the child has a seizure? Select all that
apply.
1. Time the seizure.
2. Restrain the child.
3. Stay with the child.
4. Place the child in a prone position.
5. Move furniture away from the child.
6. Insert

NURSING MANAGEMENT
̷ or X
1. Padded side rails
2. Avoid bright lights
3. Noise
4. Suction at bedside
5. Protect the head
6. Restrain the pt
7. Put tongue depressor
8. Loosen clothing
9. Ease the pt to the floor

NURSING MANAGEMENT
̷ or X
10. Remove sharp obects
11. position: Supine
12. Orient pt
13. Suctioning and O2 after
14. Rest
15. Oral hygiene

The nurse is teaching the mother of a newborn about
gastroesophageal reflux. What does the nurse suggest to help prevent
reflux? Select all that apply.
1. Burp during and after feeds
2. Engage baby in active play after the feeding
3. Feed baby in side-lying position
4. Hold baby upright 20-30 minutes after each feeding
5. Offer smaller but more frequent feeds

HIATAL HERNIA MGNT (ADULT):
H- OB elevated
I- nstruction: SFF
A- void: Alcohol, Smoking, Caffeinated
T- ake weight daily
U- se of drugs
S-X: Nissen Fundoplication

The nurse is preparing a list of self-care instructions for a
postpartum client who was diagnosed with mastitis. Which instructions
should be included on the list? Select all that apply.
1. Wear a supportive bra.
2. Rest during the acute phase.
3. Maintain a fluid intake of at least 3000 mL.
4. Continue to breast-feed if the breasts are not too sore.
5. Take the prescribed antibiotics until the soreness subsides.
6. Avoid decompression of the breasts by breast-feeding or breast pump.

The nurse cares for a child newly diagnosed with cystic fibrosis.
What should be included in the client's multidisciplinary plan of care to be
discussed with the parents? Select all that apply.
1. Chest physiotherapy
2. Genetic counseling
3. Low-calorie diet
4. Oral fluid restriction
5. Spiritual support

A client with an asthma exacerbation has been using her albuterol
rescue inhaler 10-12 times a day because she cannot take a full breath. What
possible side effects of albuterol does the nurse anticipate the client will
report? Select all that apply.
1. Constipation
2. Difficulty sleeping
3. Hives with pruritus
4. Palpitations
5. Tremor

The nurse plans to administer 9:00 AM medications via the
nasogastric (NG) route to a client with an NG tube. The nurse contacts the
primary health care provider (PHCP) to clarify which prescriptions that are
contraindicated using this route? Select all that apply.
1. Enteric-coated ibuprofen 200-mg tablet
2. Extra-strength acetaminophen 500-mg tablet
3. Metoprolol extended-release 50-mg tablet
4. Sulfamethoxazole double-strength 800-mg tablet
5. Tamsulosin 0.4-mg slow-release capsule

A client receives intermittent bolus enteral feedings through a
nasogastric tube. Which are appropriate nursing actions prior to starting the
feeding? Select all that apply.
1.Discard aspirated residual volume in a biohazard container
2. Flush the tube before and after the feeding
3. Place the client in the semi-Fowler position
4. Start the feeding after obtaining a gastric residual volume <100 mL
5. Start the feeding when the residual volume has pH of 6

The clinic nurse prepares to perform a focused assessment on a
client who is complaining of symptoms of a cold, a cough, and lung
congestion. Which should the nurse include for this type of assessment?
1. Auscultating lung sounds
2. Obtaining the client’s temperature
3. Assessing the strength of peripheral pulses
4. Obtaining information about the client’s respirations
5. Performing a musculoskeletal and neurological examination
6. Asking the client about a family history of any illness or disease

The nurse assesses a client receiving peritoneal dialysis. Which
assessment findings are most important for the nurse to report to the health
care provider? Select all that apply.
1. Cloudy outflow
2. Low-grade fever
3. Oliguria
4. Pruritus
5. Tachycardia

B. PERITONEAL DIALYSIS
-acts as a membrane:
-instillation in the abdominal cavity:
-purpose:
-cleansing fluid 
*sol’n type:
*volume:
*temperature:
*appearance:
*risk:

PRINCIPLES:
1. Abdominal cath:
-site:
-sutured
-anesthesia:
2. Duration:
-infusion time:
-dwell time:
-drainage time:

3. Characteristics
-frequency:
-correction of F&E:
-drainage:
1st
exchanges:
cloudy:
brownish:

NURSING MANAGEMENT:
1. ASSESSMENT
-weight
-VS
-catheter patency
-strict asepsis
-WBC

2. PROMOTE DRAINAGE
-change position
-ambulation
-fowler’s
-dressing  if water spills: CHANGE

3. COMPLICATIONS
A. ABDOMINAL CRAMPS
-warm dialysate
-subsides after 1st
few exchanges
-slow infusion
B. PERITONITIS
-agent:
-S/S: 1st
sign:
-antibiotics

The nurse monitoring a client receiving peritoneal dialysis notes
that the client’s outflow is less than the inflow. Which actions should the
nurse take? Select all that apply.
1. Check the level of the drainage bag.
2. Reposition the client to his or her side.
3. Contact the health care provider (HCP).
4. Place the client in good body alignment.
5. Check the peritoneal dialysis system for kinks.
6. Increase the flow rate of the peritoneal dialysis solution

The nurse is preparing a client with a new diagnosis of
hypothyroidism for discharge. The nurse determines that the client
understands discharge instructions if the client states that which symptoms
are associated with this diagnosis? Select all that apply.
1. Tremors
2. Weight loss
3. Feeling cold
4. Loss of body hair
5. Persistent lethargy
6. Puffiness of the face

While caring for a postoperative client with an invasive arterial line,
the nurse identifies a large discrepancy between the arterial line reading and
the manual cuff pressure. Arterial line reading: 100/62 mm Hg; manual cuff
reading: 120/76 mm Hg. What interventions should the nurse take to facilitate
accurate functioning of the arterial line? Select all that apply.
1. Perform a square wave test on the monitor
2. Position the client flat for all blood pressure (BP) readings
3. Recheck and compare with an automatic BP machine
4. Verify that the zero reference stopcock is leveled with the client's
phlebostatic axis
5. Zero balance the system

Invasive arterial line and manual cuff readings measure BP via 2 different
methods.
The arterial line measures flow of the blood past a catheter, and the manual cuff
measures pressure based on compression of the artery. Because of the
differences, the 2 pressures may not match. The arterial line can be highly useful
to
the clinician as it gives a continuous measurement of accurate BP. The manual
cuff
will give a reading of the pressure only at the moment the pressure is measured.

The following steps should be instituted to ensure accuracy of invasive pressure
readings:
• Position the client supine, flat, prone, or with the head of the bed <45 degrees
• Confirm zero reference stopcock (port of the stopcock nearest to the
transducer) to be at the level of the phlebostatic axis (4th intercostal space,
midaxillary line), which approximates the level of the atria of the heart
• Zero the system after initial setup, with disconnection of the transducer or
when accuracy of the measurements is questioned
• Perform a dynamic response test (square wave test) every 8-12 hours, when
the system is opened to air or when accuracy of measurements is questioned
• Measure pressures at the end of expiration
• (Option 2) The client does not need to be flat for all pressure readings. As long
as the zero reference stopcock is level with the phlebostatic axis, the position
can be supine, flat, prone, or with the head of the bed <45 degrees.

The nurse cares for a client admitted to the hospital due to
confusion. The client has a nonmetastatic lung mass and a diagnosis of
syndrome of inappropriate antidiuretic hormone (SIADH). Which action(s)
should the nurse expect to implement? Select all that apply.
1. Fluid bolus (normal saline)
2. Fluid restriction
3. Salt restriction in the diet
4. Seizure precautions
5. Strict record of fluid intake and output

SIADH DIABETES
INSIPIDUS
RISK
FACTORS
Head Injury
Tumor
Head Injury
Aneurysm
Surgery:
Problem

S/S
1. U/O
2. Thirst
3. Weight
4. BP
Complication

DIAGNOSTIC
TESTS
1. URINE
SPECIFIC
GRAVITY
2. SERUM

NURSING
MGNT
SIADH DI
1. I/O
2. Weight
3. Fluid
4. Diet

The nurse administers a prescribed oral dose of radioactive iodine
(RAI) to a female client with hyperthyroidism. The nurse should instruct that
the client utilize which of the following home precautions during the first 3-7
days after ingestion? Select all that apply.
1. Continue breastfeeding if applicable; RAI is not secreted through breast
milk
2. Do not use bare hands to handle food that is to be served to others
3. Isolate personal clothing, towels, and linens; wash them separately from
the rest of laundry in the home
4. Stop using any prescribed antithyroid drugs or beta-adrenergic blockers
5. Use a separate toilet and flush 2-3 times after each use

RAI
-primary form of treatment for individuals with hyperthyroidism
-action: It destroys or damages the thyroid gland
-maximum effect: 3 months
-clients who receive RAI should be taught to use the following precautions
for up to 1 week:
Avoid close proximity to pregnant women or children
Do not breastfeed as RAI may be excreted through breast milk and
could harm the infant
Do not share utensils with others or use bare hands to handle food that
is to be served to others

Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash
it separately
Use a separate toilet from the rest of the family and flush 2-3 times after
each use
Wash hands frequently and thoroughly, especially after restroom use
Drink plenty of fluids
Sleep in a separate bed from others and do not sit near others in an
enclosed area for a prolonged period of time (eg, train or flight travel)

The clinic nurse evaluates a client's response to levothyroxine after
8 weeks of treatment. What therapeutic responses to the medication should
the nurse expect? Select all that apply.
1. Apical heart rate of 88/min
2. Elevation of mood
3. Improved energy levels
4. Skin is cool and dry
5. Slight weight gain

DRUGS
THYROID HORMONES
-levothyroxine (Synthroid)
-liothyronine (Cytomel)
>action:
>Mgnt:
taken:
V/S:
instruction:

A client is suspected of having Graves' disease (hyperthyroidism).
Which signs and/or symptoms are expected to be present in this client?
1. Anxiety
2. Bradycardia
3. Dry skin
4. Heart palpitations
5. Protrusion of the eyeballs
6. Weight gain

HYPERTHYROIDISM vs. HYPOTHYROIDISM
CAUSES:
1. Hyperplasia
2. Thyroiditis
3. Hashimoto Thyroiditis
4. Grave’s Disease
5. Excessive intake of thyroid hormones
6. Overdose of PTU & Tapazole
7. Thyroidectomy

SIGNS/SYMPTOMS:
1. Slow /Weak
2. Heat Intolerance
3. Diarrhea
4. VS
5. Sleepiness & Lethargy
6. Fever
6. Constipation
7. Hyperactivity
8. Insomnia

SIGNS/SYMPTOMS:
9. Cold intolerance
10. Anorexia
11. Exophthalmos
12. VS
13. Weight Gain
14. Tremors & Nervousness
15. Dry & Scaly Skin
16. Dec nutrient absorption

SIGNS/SYMPTOMS:
17.Amenorrhea
18. Diaphoresis
19. Sparse hair & brittle nails
20. Weight loss
21. Slowed mental process
22. Puffy Appearance
23. Warm & moist skin

NURSING MANAGEMENT:
1. Warm Environment
2. Thick clothing
3. Diet: inc fiber
4. Apply lotion
5. Cool quiet environment
6. Dec fat & cholesterol
7. Light clothing
8. Inc CHO and CHON
9. Balanced activity & rest

A 58-year-old with type 2 diabetes was admitted to your unit with a
diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation.
When you prepare a care plan for this patient, what would you be sure to
include? (Select all that apply.)
1. Fingerstick blood glucose checks before meals and at bedtime
2. Sliding-scale insulin dosing as ordered
3. Bed rest until the COPD exacerbation is resolved
4. Teaching about the Atkins diet for weight loss
5. Demonstration of the components of foot care

In the care of a patient with type 2 diabetes, which actions can you
delegate to a UAP? (Select all that apply.)
1. Providing the patient with extra packets of artificial sweetener for coffee
2. Assessing how well the patient’s shoes fit
3. Recording the liquid intake from the patient’s breakfast tray
4. Teaching the patient what to do if dizziness or lightheadedness occurs
5. Checking and recording the patient’s blood pressure

You are caring for a diabetic patient admitted with hypoglycemia
that occurred at home. Which teaching points for treatment of hypoglycemia
at home would you include in a teaching plan for the patient and family before
discharge? (Select all that apply.)
1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness,
headache, and blood glucose less than 60 mg/dL.
2. Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or 1⁄4
cup of fruit juice.
3. Retest blood glucose in 30 minutes.
4. Repeat the carbohydrate treatment if the symptoms do not resolve.
5. Eat a small snack of carbohydrate and protein if the next meal is more than
an hour away.

You are preparing a care plan for a patient with Cushing disease.
Which nursing diagnoses would you be sure to include? (Select all that
apply.)
1. Risk for Injury related to the potential for bruising
2. Disturbed Body Image
3. Imbalanced Nutrition: Less than Body Requirements
4. Risk for Injury related to the potential for hypertension
5. Risk for Infection

GLUCOCORTICOIDS
inc glucose:
risk:
skin: thin & fragile  risk:
bruising
abnormal fat deposits
>moon face
>truncal obesity
>thin extremities
>buffalo hump

MINERALOCORTICOIDS
Hypernatremia
-BP:
-Edema
Hypokalemia
-muscle weakness
-constipation
-ECG:

ANDROGEN
Hirsutism
Acne
Virilization
Amenorrhea

Which actions should you delegate to the LPN/LVN for the care of a
patient with hypothyroidism? (Select all that apply.)
1. Assessing and recording the rate and depth of respirations
2. Auscultating lung sounds every 4 hours
3. Creating an individualized nursing care plan for the patient
4. Administering sedation medications every 6 hours
5. Checking blood pressure, heart rate, and respirations every 4 hours
6. Reminding the patient to report any episodes of chest pain or discomfort

The nurse should implement which interventions for a child older
than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60
mg/dL? Select all that apply.
1. Administer regular insulin.
2. Encourage the child to ambulate.
3. Give the child a teaspoon of honey.
4. Provide electrolyte replacement therapy intravenously.
5. Wait 30 minutes and confirm the blood glucose reading.
6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being
treated in the emergency department. Which findings would the nurse expect
to note as confirming this diagnosis? Select all that apply.
1. Increase in pH
2. Comatose state
3. Deep, rapid breathing
4. Decreased urine output
5. Elevated blood glucose level
6. Low plasma bicarbonate level

COMPLICATIONS
1. DIABETIC KETOACIDOSIS
-cx of:
-out of control DM:
-causes:
S-kipping insulin
S
S
S
(-) INSULIN  ↑ Glucose  Features: DHN

FAT breakdown
product:
>S/S 1. breath:
2. ↓ LOC
Ketones: Acidic pH imbalance:
 pH:
 HCO3:
 NV & anorexia

compensatory: breathing 
term:

A client has been diagnosed with hyperthyroidism. Which signs
and symptoms may indicate thyroid storm, a complication of this disorder?
1. Fever
2. Nausea
3. Lethargy
4. Tremors
5. Confusion
6. Bradycardia

The health care provider (HCP) prescribes an oral iron suspension for
3 months for a 2-year-old with iron deficiency anemia. Which instructions
should be given to the parent? Select all that apply.
1. Administer doses between meals
2. Administer doses with citrus juice
3. Obtain a full 3-month supply from the pharmacy
4. Place medicine at the back of the mouth
5. Report black, tarry stools to the HCP immediately

A client is being discharged today following a partial gastrectomy.
Which instructions for recuperating at home should be included? Select all
that apply.
1. Avoid high-fiber foods
2. Avoid intake of fluids with meals
3. Consume low-carbohydrate meals
4. Decrease intake of fat
5. Eat small, frequent meals

• COMPLICATIONS OF SX
• 1. Dumping Syndrome
• -onset:
• -abrupt EMPTYING of stomach contents
• jejunum:
•

• S/S:
• 3 D-
• D-
• D-
• 2 P-
• P-
• HYPOGLYCEMIA
•
•

NURSING MANAGEMENT:
1. DELAY GASTRIC EMPTYING
-position:
-SFF  X 3 large meals
-X fluid with meals
-diet:
*
*
*resumption of N meal patterns: 6-12 months

The nurse is caring for a client with cirrhosis. Assessment findings
include ascites, peripheral edema, shortness of breath, fatigue, and
generalized discomfort. Which interventions would be appropriate for the
nurse to implement to promote the client's comfort? Select all that apply.
1. Encourage adequate sodium intake
2. Place client in semi-Fowler position
3. Place client in Trendelenburg position
4. Provide alternating air pressure mattress
5. Use music to provide a distraction

• 3. MANAGE ASCITES
• -assessment:
• -position:
• -diet:
• -restrict:
• -DOC:
• -procedure:
• +before:
• +position:
• +gauge
• +withdraw:

When assessing a client with cholelithiasis and acute cholecystitis,
which findings might the nurse note during the health history and physical
examination? Select all that apply.
1. Flank pain radiating to the groin
2. High-protein food ingestion before the onset of pain
3. Low-grade fever with chills
4. Pain at the umbilicus
5. Right upper-quadrant (RUQ) pain radiating to the right shoulder

CHOLELITHIASIS & CHOLECYSTITIS
RISK FACTORS: 5 F’s
F-at
F
F
F
F

Water it down! H2O
remains to be the
best weight loss
potion.
A study published in the
journal Obesity found
that dieters who
drank a large glass of
water before each
meal lost significantly
more weight than
those who didn't.

cholesterol bile production:
bile salt cannot fully dissolve
biliary stasis
bile precipitation
Stone formation
inflammation

•  BILIARY SPASM
• Pain >site:
• >term: biliary colic
• >radiation:
• >aggravated:
• Murphy’s Sign
• Fever
• Nausea & Vomiting
•

BILE FLOW INTO THE COLON
>stool:
>malabsorption of fats:
BILIRUBIN INTO BLOOD
>sclera/skin:
>urine:
>pruritus

PAIN
1. Burning pain (pyrosis) 
2. Gnawing (epigastric) 
3. LLQ + dull 
4. RLQ + Steady 
5. RUQ + radiating to the R shoulder 
6. Midepigastric + radiating to the back 

The nurse is reviewing anticipatory guidance with the parents of a 6-
month-old infant with phenylketonuria. Which statements by the nurse are
appropriate? Select all that apply.
1. "A low-phenylalanine diet is required."
2. "Meat and dairy products should not be introduced into the diet."
3. "Phenylketonuria is self-limiting and usually resolves by adulthood."
4. "Special infant formula is required."
5. "Tyrosine should be removed from the diet."

The nurse is caring for a client who has a postoperative paralytic
ileus following a bowel resection for colon cancer. The client is receiving
patient-controlled analgesia (PCA) with morphine. Which nursing diagnoses
(NDs) are appropriate to include in the client's care plan? Select all that
apply.
1. Acute pain
2. Dysfunctional gastric motility
3. Imbalanced nutrition, less than body requirements
4. Ineffective self-health management
5. Risk for infection

The nurse is developing teaching materials for a client diagnosed
with ulcerative colitis. The client will receive sulfasalazine. Which of the
following instructions are included in the discharge teaching plan? Select all
that apply.
1. Avoid small, frequent meals
2. Can have a cup of coffee with each meal
3. Eat a low-residue, high-protein, high-calorie diet
4. Increase fluid intake to at least 2000 mL/day
5. Medication should be continued even after the resolution of symptoms
6. Take daily vitamin and mineral supplements

No. of stools
Stool
Characteristic
Depth
ULCERATIVE
COLITIS
CROHN’S
DISEASE
Site

Course of
disease
ULCERATIVE
COLITIS
CROHN’S
DISEASE
prolonged and
variable
remission and
exacerbation

• S/S:
• Diarrhea 
• >risk:
• Anemia
• Abdominal Pain
• Anorexia
• NSG DX:
•

NURSING MANAGEMENT
1.RELIEVE PAIN
-NPO
-lying  legs flexed
-report:
-drugs:
>antibiotic:
>steroids
>antispasmodics:

Pineapple contains
manganese, which
helps boost your
memory.

• 2. DECREASE DIARRHEA
• -diet:
• -avoid milk/soda
• -bed rest  ↓ peristalsis
• -avoid seeded foods
• -for DHN:
• -antidiarrheal

3. HEALTH TEACHINGS
- stress
-monitor CX
megacolon
perforation
hemorrhage
small bowel obstruction (Crohn’s)
-surgery: COLOSTOMY
ILEOSTOMY

The nurse in the emergency department is assessing a 12-month-old
diagnosed with intussusception. Which findings should the nurse
expect?
1. Palpable olive-shaped mass in epigastrium
2. Palpable sausage-shaped mass in upper right quadrant
3. Projectile vomiting containing blood
4. Screaming and drawing the knees up to the chest
5. Stool mixed with blood and mucus

Which of the following nursing interventions would the nurse
implement when caring for a client newly diagnosed with acute viral
hepatitis? Select all that apply.
1. Administer antiemetic medications as needed
2. Encourage a good breakfast and small, frequent meals
3. Promote rest periods alternating with periods of activity
4. Provide a diet high in protein and low in fat
5. Teach the client to abstain from alcohol

The nurse is caring for an adult client at the clinic who asks the
nurse to look at a "black skin lesion." What assessment findings would be a
classic indication of a potential malignant skin neoplasm? Select all that
apply.
1. Blanches with manual pressure
2. Half of the lesion is raised and half is flat
3. History of purulent drainage
4. Lesion is the size of a nickel
5. Various color shades are present

A client is receiving a continuous heparin infusion and the most
recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical
incision and IV insertion sites. What interventions should the nurse
implement? Select all that apply.
1. Continue heparin infusion and recheck aPTT in 6 hours
2. Prepare to administer vitamin K
3. Redraw blood for laboratory tests
4. Review guidelines for administration of protamine
5. Stop infusion of heparin and notify the health care provider (HCP)

HEPARIN WARFARIN
ROUTE
ANTIDOTE
LAB
THERAPEUTIC
LEVEL
PREGNANCY

A client with terminal cancer is being discharged with a fentanyl
patch and is to receive hospice care at home. What teaching related to this
drug should the nurse include? Select all that apply.
1. Apply local heat over the patch to aid drug absorption
2. Cut the patch in half before application if less medication is needed
3. Fold used patch in half so edges adhere and then discard it immediately
4. Place patch 1 inch from the source of pain for maximum effectiveness
5. Remove the old patch when applying a new patch every 72 hours

A client is hospitalized for a broken leg. The client has a history of
breast cancer and is receiving outpatient chemotherapy; the last infusion was
about a week ago. Which staff members can safely care for this client?
1. Nurse floated from another medical-surgical floor
2. Nurse who is 24 weeks pregnant
3. Nurse with erythematous rash and honey-color crusts on the hand
4. Unlicensed assistive personnel who just received the yearly injectable flu
vaccination
5. Unlicensed assistive personnel with a cold

A home health nurse is visiting a client who underwent right-sided
mastectomy with lymph node removal. The client is concerned about
swelling in her arm on the affected side. Which instructions should the nurse
discuss with the client? Select all that apply.
1. Avoid massaging the area
2. Avoid receiving vaccinations in the affected arm
3. Elevate the arm above the heart
4. Perform isometric exercises
5. Use an intermittent pneumatic compression sleeve

PREVENT LYMPH EDEMA
-elevate:
-no BP taking
-no IV
-no blood extraction
-arm exercises

A client with throat cancer receives radiation therapy to the head and
neck. Which strategies are appropriate to increase oral intake? Select all that
apply.
1. Avoid irritants such as acidic, spicy foods
2. Discourage the use of topical analgesics
3. Encourage liquid nutritional supplements
4. Perform oral hygiene once a day
5. Use artificial saliva to control dryness

People at risk are the target populations for cancer screening
programs. Which of these asymptomatic patients need extra encouragement
to participate in cancer screening? (Select all that apply.)
1. A 21-year-old white American woman who is sexually inactive, for a Pap test
2. A 30-year-old Asian-American woman, for an annual mammogram
3. A 45-year-old African-American man, for a prostate-specific antigen test
4. A 50-year-old African-American man, for a fecal occult blood test
5. A 50-year-old white American woman, for a colonoscopy
6. A 70-year-old Asian-American woman with normal results on three previous
Pap tests, for a Pap test

4. Pap Smear
3.Mammogram
2. BCE
1. BSE
FREQUENCY
BASELINE
DIAGNOSTIC TESTS - SCREENING

8. Sigmoidoscopy
7. Colonoscopy
6. DRE
5. TSE
FREQUENCY
BASELINE
DIAGNOSTIC TESTS - SCREENING

In the care of a patient with neutropenia, what tasks can be
delegated to a UAP? (Select all that apply.)
1. Taking vital signs every 4 hours
2. Reporting temperature of more than 100.4° F (38° C)
3. Assessing for sore throat, cough, or burning with urination
4. Gathering the supplies to prepare the room for protective isolation
5. Reporting superinfections, such as candidiasis
6. Practicing good hand-washing technique

The nurse is conducting staff in-service training on von Willebrand’s
disease. Which should the nurse include as characteristics of von
Willebrand’s disease? Select all that apply.
1. Easy bruising occurs.
2. Gum bleeding occurs.
3. It is a hereditary bleeding disorder.
4. Treatment and care are similar to that for hemophilia.
5. It is characterized by extremely high creatinine levels.
6. The disorder causes platelets to adhere to damaged endothelium.

The nurse is caring for a client with bladder cancer and bone
metastasis. What signs/symptoms would the nurse recognize as indications
of a possible oncological emergency? Select all that apply.
1. Facial edema in the morning
2. Serum calcium level of 12 mg/dL
3. Weight loss of 20 lb in 1 month
4. Serum sodium level of 136 mg/dL
5. Serum potassium level of 3.4 mg/dL
6. Numbness and tingling of the lower extremities

The nurse is monitoring the intravenous (IV) infusion of an
antineoplastic medication. During the infusion, the client complains of pain at
the insertion site. On inspection of the site, the nurse notes redness and
swelling and that the infusion of the medication has slowed in rate. The nurse
suspects extravasation and should take which actions? Select all that apply.
1. Stop the infusion.
2. Notify the health care provider (HCP).
3. Prepare to apply ice or heat to the site.
4. Restart the IV at a distal part of the same vein.
5. Prepare to administer a prescribed antidote into the site.
6. Increase the flow rate of the solution to flush the skin and subcutaneous
tissue.

ANTIDOTES
Antimetabolites
-methotrexate 
Vinca Alkaloids
-Vincristine
Alkylating
-Cytoxan 
Anitumor Antibiotics
-doxurubicin (Adriamycin) 

cWhich home care instructions should the nurse provide to the
parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all
that apply.
1. Monitor the child’s weight.
2. Frequent hand-washing is important.
3. The child should avoid exposure to other illnesses.
4. The child’s immunization schedule will need revision.
5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).
6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to
occur
and do not require special intervention.

• NURSING MANAGEMENT
• 1. PROMOTE STANDARD
PRECAUTION
• -hand washing
• -PPE:
• -never recap needles
• -container:
• -if blood spills:

The nurse is planning care for a client with human
immunodeficiency virus (HIV). She’s being
assisted by a licensed practical nurse (LPN).
Which statements by the LPN indicate her
understanding of HIV transmission?
1. “I’ll wear a gown, mask, and gloves for all client
contact.”
2. “I don’t need to wear any personal protective
equipment because nurses have a low risk of
occupational exposure.”
3. “I’ll not wear mask if the client is coughing with
blood.”
4. “I’ll wear mask, gown, and gloves when splashing
of body fluids is likely.”
5. “I’ll wash my hands after client care.”
a. 145 c. 125
b. 45 d. 245

Which principle of precaution should the
nurse implement when obtaining the
blood pressure of a client who has AIDS?
a. Use of mask
b. Wearing sterile gloves
c. Hand Washing
d. Use of clean gown

• 2. SLOW DISEASE PROCESS
• -rest
• -diet :
•
• -DOC:
•
•
•
•

• 3. PREVENT INFECTION SPREAD
• *X sharing of needles/razor
• *X multiple sexual partners
• *X blood donation
• *X sources:
• *Guidelines:

A female client arrives at the health care clinic and tells the nurse
that she was just bitten by a tick and would like to be tested for Lyme disease.
The client tells the nurse that she removed the tick and flushed it down the
toilet. Which nursing actions are most appropriate? Select all that apply.
1. Tell the client that testing is not necessary unless arthralgia develops.
2. Tell the client to avoid any woody, grassy areas that may contain ticks.
3. Instruct the client to immediately start to take the antibodies that are
prescribed.
4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect
the presence of the disease.
5. Tell the client if this happens again to never remove the tick but vigorously
scrub
the area with an antiseptic.

PLACENTA PREVIA
PROMOTE OXYGENATION/CIRCULATION
-bed rest
-position:
-O2
-tocolytics
-FHR

ASSESS/PREVENT BLEEDING
-VS
-pad count
-if (+) shock:
-NO IE/enema
 if necessary: done in 

NASOGASTRIC TUBE
-indication:
-position:
-measurement:
-form of the drug:
-if tablet:
-assessment before:

FOODS TO AVOID
>meat
>eggs
>dairy product
>cola
>beans
>hamburger
>hotdog

The following NDs are appropriate to include in this client's care plan:
Acute pain related to tissue damage as evidenced by the use of PCA
with an opioid.
Pain is usually most intense 12-36 hours after surgery
Dysfunctional gastric motility related to bowel manipulation during surgery,
anesthesia, and opioid analgesia as evidenced by absent or hypoactive
bowel sounds 48-72 hours following surgery secondary to a paralytic ileus.
It is a common complication following abdominal surgery
Imbalanced nutrition, less than body requirements related to the increased
metabolic demand needed for tissue and wound healing as
evidenced by the inability to ingest adequate caloric intake secondary to
a paralytic ileus and the lack of interest in eating secondary to the ileus,
the adverse effects of anesthesia, and analgesic medications.

Risk for infection – The risk for being invaded by pathogenic organisms is
increased in this client due to loss of primary defenses (ie, protective skin
barrier), lack of adequate nutrition to meet the body demands, and altered
immunity due to the presence of cancer cells (Option 5).
Option 4 Ineffective self-health management is the inability to integrate a
therapeutic treatment regimen into one's own activities of daily living to meet
specific health goals. There are no data to support this ND at this time.

VIRAL HEPATITIS
Nursing interventions for the acute phase of hepatitis focus on resting the liver
and providing nutrition for healing:
• Rest
Alternate periods of rest and activity (Option 3)
Avoid alcohol and other drugs that increase liver metabolism (Option 5)
Medications
appetite stimulants
antipruritics
analgesics should be used cautiously to allow hepatocytes to heal.
Antiemetics can be used to prevent nausea

• Nutrition
Encourage small, frequent meals to decrease nausea. Anorexia is
lowest in the morning; promote eating a larger breakfast (Option 2).
Provide oral care and avoid extremes in food temperature to increase
appetite
Drink adequate amounts of fluid (2500-3000 mL/day) and encourage a diet
high in carbohydrates and calories

Interventions to manage lymphedema include:
 Decongestive therapy (massage technique to mobilize fluid)
Compression sleeves or intermittent pneumatic compression sleeve
Compression sleeves are graduated with increased distal pressure and
less proximal pressure.
Clothing should also be less constrictive at the proximal arm and over the
chest.
Elevation of arm above the heart (Option 3)
Isometric exercises (Option 4)
Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood
pressure measurements, and injections (eg, vaccinations) on the affected limb
(Option 2)
Injury prevention (limb less sensitive to temperature changes)
Infection prevention (limb more prone to infection through skin breaks)

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