1. Clinical portfolio - Letters of support from family members and friends who are healthcare professionals2. External eye structures - An African-American client may have slightly yellow sclerae3. EDB - November 214. Aortic valve replacement - Keep client in bed in the supine position5. D/c to resolution of illness - Case-manager6. IV fluids - 617. Eye drop instillation - Close your eyelids8. TB, chest radiograph - Administer isoniazid (INH) daily for 6 to 9 months9. ETOH dependency - Monitor for increased blood pressure and pulse10. Toddler - Demonstrate the procedure using a doll11. PPE - Gloves, gown, mask, wash hands12. 95th percentile - Question the type and quality of foods eaten in a typical day13. Digoxin - Withhold the medication and contact the HCP14. 21 yo - Taking medication, with community follow-up15. Antisocial personality disorder - Confront the client about the consequences of the behavior16. Smoker - Headache and hyperirritability are common17. Asthma, HTN - Metoprolol tartrate (Lopressor)18. Intracavitary radiation - A nurse with Marfans syndrome who is postmenopausal19. Thoughts of anger toward hubby - Obsessive20. Mucomyst - 321. Addisonian crisis - Hypotension, rapid weak pulse, and rapid respiratory rate22. Taking drugs - Report the incident to the immediate supervisor23. 3 yo - Increased thirst24. Childbirth prep classes - Participants can identify at least three coping strategies to use during labor25. Criterion for occupational nurse - Implements health programs for construction workers26. Postpone teach session - Activity intolerance related to postoperative pain27. Undies - Tell me about your undergarments so we can discuss how you can have your examination comfortably.28. Cryosurgery - Use a sanitary napkin instead of a tampon29. I cant walk well - Identify the problem30. Yeast infection - Avoid tight-fitting clothing and do not use bubble-bath or bath salts31. HTN - Frequent blood pressure checks, including readings taken by automated machines, are recommended32. Corticosteroid - Erythrocyte sedimentation rate33. 6 yo - Rhinorrhea or otorrhoea with Halo sign34. Drug education class - Wanting the drug is all that matters to an addict35. Meperidine - 1.536. Abd surg, ABG - Encourage the use of an incentive spirometer37. Abd surg - NG tube - Apply a water soluble lubricant to the lips, oral mucosa and nares38. Renal fail, osteodystrophy - Serum potassium of 5.5 mEq and total calcium of 6 mg/dl39. Tet spell - Place child in knee-chest position40. Collaborator of care - Coordinating and educating about multidisciplinary services41. Imbalanced nutrition - Eat 50% of six small meals each day by the end of one week42. Cardiac cath - Valsalvas maneuver and coughing43. Scope - States Board of Nursing44. Wound packing - Demonstrate the wound care procedure to the PN while the PN assists45. IV tubing - A buretrol attachment46. NSAID, osteoarthritis - Provide anti-inflammatory response47. Cholecystectomy - Decrease the risk of bradycardia during surgery48. Pressure ulcer - Stage 349. Mechanical lift - Tolerance of exertion50. Report to HCP before surg - Recalls drinking a glass of juice after midnight51. Deceased hubby - Denial related to the loss of a loved one52. Lyme disease - Look for early signs of a lesion that increases in size with a red border, clear center53. Clonidine - How long had the client been taking the medication54. Propranolol - Ask the healthcare provider about tapering the drug dose over the next week55. Two UAP arguing - Deal with issues and not personalities56. Crisis situation - You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?57. Nutritional assess - A pregnant woman58. CRF - Avoid salt substitutes59. Moist skin, fine hair, prominent eyes, lid retraction, staring - Graves disease60. Accommodation - Ask the client to look at a distant object and then at an object held 10 cm from the nose61. Prioritizing care - The client who has a new onset of breathing difficulties62. Exraoyramidal rx to psych meds - Tell the receptionist to have the healthcare provider return the phone call63. Eval med effectiveness - Reports decrease in pain64. Saline enema - History of inflammatory bowel disorders65. Documenting narrative notes - S1 murmur auscultated in supine position66. BSE - Five to seven days after menses cease67. BF abuse - Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive.68. Low potassium diet - Dried prunes69. Phys assess, norm - Regular pulsation at the epigastric area when the client is supine70. Encephalopathy r/t hyperbilirubinemia - Lethargy or irritability71. Home phototherapy - I will keep the babys eyes covered when the baby is under the light.72. TB - Assign the client to a negative air-flow room73. DM 2 & Flu - One chronic and one acute illness74. ED code, POA - Stop the code immediately75. AMA, chart - The chart is the property of the hospital but I will see that a copy is made for you76. Tamoxifen - This anti-estrogen drug inhibits malignancy growth77. Alt. cerebral fxn - Change in level of consciousness78. 14 yo - Early adolescence is a developmental stage of normal experimentation79. Comm primary prevention - Immunizations that decrease occurrences of many contagious diseases80. Prenatal dx testing - Diagnostic testing may indicate a fetal problem that could be treated prior to delivery81. Milwaukee brace - Remove the brace one hour each day for bathing only82. Durable POA - It will identify someone that can make decisions for your healthcare if you are in a coma or vegetative state83. Anabolic steroids - Describes working hard to develop muscles84. Fundus - Palpate above the symphysis for the bladder85. Diverse ethnic group - Individual beliefs86. Chronic back pain, opioid use - When did the symptoms begin after the last dose of opiate analgesic87. Emergency c-section - Stimulate contraction of the uterus88. Prescription, empty stomach - Give one hour before or two hours after a meal89. 16 yo - Obtain the permission of the custodial parent for the surgery90. Hx alcohol abuse & Tylenol - Liver91. Bacterial conjunctivitis - Avoid sharing towels and washcloths with siblings92. Care map - Multidiciplinary group93. Abd surg, posy op outcomes - Administer analgesics prior to encouraging progressive activities and ambulation94. Spouse answering questions - Ask the spouse to step out for a few minutes95. Triple marker screening test - Preparing for other diagnostic testing96. Unable to void - Drinks 240 mL of fluid five times during the shift97. Verapamil - Administer the dose as prescribed98. Petechiae - Purplish-red pinpoint lesions of the skin99. PKU - Assess the newborns feeding patterns of formula or breast milk which has come in100. Chest tube inserted - Rubber-tipped clamps101. Assist client to express feelings of anger - Ask a client to describe triggers of anger102. Reporter - Confidentiality103. 9 yo - To protect you because you can get an infection very easily104. Priority in pre-planning a schedule - Medication administration105. Neutrogenic shock - Spinal Cord injury106. Comp therapies - Recognizes the value of a clients input into their own health care107. STI - Chlamydia108. Chronic osteomyelitis - The infection has walled off into an area of infected bone creating a barrier to antibiotics109. Breech - Supine with the foot of the bed elevated110. Denver II screening tool - This tool identifies achievement of development milestones in infants and young children111. TKA - Progressive leg exercises to obtain 90-degree flexion112. Face mask smothering - Nasal cannula113. External otitis - Swimming lessons in an indoor pool114. Bruit over thyroid - Hyperthyroidism115. Lasix - Perform hand hygiene116. Planned unit change - Staff members are aware of the need for change117. Severe postpartum depression - Supervised and guided visits with infant118. Upper eyelid droop - Ptosis on the left eyelid119. 80 yo MS - Tricyclic antidepressants120. Care over 24 hr period - Primary nursing121. Antipsych med - Increase daily intake of raw fruits and vegetables122. Atenolol - Administer the medication123. Pneumonectomy - Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning124. 105% above ht/wt - Inadequate lifestyle changes in diet and exercise125. Abd surg - Mark the drainage on the dressing and take vital signs

Comprehesive Exam 21. 44 lb kid = 4002. High school senior, smoking = encourage the student to associate with non-smokers only while attempting to stop smoking3. Cope w/dx of cancer = a teacher who seeks information about her disease and wants to continue teaching4. MS & resps = attempt to arouse the client to stimulate respirations5. Resuscitation = the healthcare team must honor the written wishes of the client6. TPN, CVC = describe the placement and rationale for care of the catheter7. Mech vent = suction the clients endotracheal tube and auscultate following suctioning8. Bact pneu = stop the IV piggyback infustion and increase the oxygen flow to 3 L/min9. CKD = stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes10. Wound culture = areas containing purulent or pooled exudates11. UA = clamp drainage bag, label specimen, place in bio bag, document12. Med allergy = Tell the HCP that both of you should talk to the supervisor now13. ANS = QRS interval of 0.14 second14. Thyroidectomy = call for emergency assistance15. Tx postop from PACU = Take the clients VS16. Comm. Healthcare funds = Survivors of violence that occurred at least 5 years ago17. Toddler, snack = give the toddler nutritious snacks18. Teething 4 mth old = A slight fever is often associated w/teething, but a fever lasting more than three days requires medical attention19. Bonding = bonding is a process that occurs over time and begins with the first parent-newborn contact20. IM injection angle = 9021. HA presbycusis= Begin wearing the aids in quiet environments to experiment w/adjustments22. MAP = 11123. 8 mth old, assess = auscultate heart and lungs24. Hep A = Ensure that all enrolled children have been immunized for Hep A25. Teaching, DM 2, MI = Storing nirtoglycerin26. Enviro influences = economics, technology, legislation/regulation27. RN delivery = functional nursing28. Cocaine, VT to VF = Defib at 200 joules29. Elderly phys assess = Arrange the exam sequence to minimizes position changes30. Anorexia nervosa = Consume at least 50% of all meals31. Precipitous delivery = ensure an adequate airway in the newborn32. Delusional fem pt = I dont talk about thinks like that anymore33. Hydronephrosis = Obstruction at the urinary bladder neck34. Uterine atony = massage the fundus35. CBI = stop the irrigation flow36. MODS = an older client w/intestinal obstruction and septic shock37. Numerous txs = prioritize tasks w/the most crucial needs first38. cardiac workload = increase in size39. Emergency admits = a client scheduled for a femoro-popliteal bypass tomorrow40. Management style = patient focused and primary nursing41. Tracheostomy care = Oxygenate w/100% oxygen42. RN & PN = A client w/an epidural infusion reports lower extremity parasthesia43. Deep tendon reflexes = Reflex hammer44. Abd surgery = Record these findings in the clients record45. Duchenne muscular dystrophy = develop an active ROM exercise schedule46. ANS = assess breathing pattern after transport is completed47. Amniocentesis = presence of genetic disorders48. Med error, diltiazem = measure VS, Review meds, Notify HCP, Incident report49. Dopamine = UO to 55 ml/hr50. Elderly phys assess = functional abilities51. r/o skin cancer =border irreg, lesion w/asymmetry, lesion w/color variations52. ANS = refer for further diagnostic eval53. Float RN = Arrange for someone to be available to assess and assist the float nurse54. Fam assess = an exploration of the group relationships, structure, functions, and roles55. RN float pt = An adult who had a colon reception yesterday and has an IV56. BP variation = retake the BP in the same arm, deflating the cuff slowly57. IV gravity infuse = gather the supplies needed to d/c the IV fluid58. Demographic screen, RN, UAP = close the demographic screen on the computer59. Oral care unconscious = raise bed, lower rail, position in flat side-lying position, emesis basin60. Free radicals, destruction of cell mem = enzyme release from lysosomes61. Infection, risk = assess & document skin condition around the incision and IV site at each shift62. Pain 7/10 = Airway & breathing, Pain, Sleep/Rest, definitive therapy63. Ulcerative colitis = cleanse perianal area w/mild soap & H2O after each diarrhea stool64. Biological practices = Standard precautions, N-95, Blood-bourne pathogen standard65. Tooth viability = place the tooth in milk or H2O66. Psych, distort sense percept =Place the client in mechanical restraints until calm67. PN assignment = Administer a bolus tube feeding through a gastrostomy tube68. Bowel resection = Unrelieved pain impairs resp & GI function & can impair recovery from surgery69. Dry, brittle hair = current hair care practices70. Overwt adolescent = ask if she is going to the bathroom frequently71. Wrong med written = Contact HCP to clarify prescription intended for the client72. Cardiac cirrhosis = Peripheral edema73. Life is sacred = A terminally ill and depressed client w/cancer74. Yellow liquid out of eyes = an abx ointment is placed in newborns eyes to prevent infection75. I do not use many drugs = Tell me about the drugs you use now76. DVT, Heparin = Avoid any intramuscular meds to prevent bleeding77. Sub q inject teach = Method used to aspirate medication from a vial78. Terminal panc ca pt = Morphine sulfate (roxanol) 5 to 10 mg SL as needed79. Empty O2 tank = Complete an adverse occurrence report and submit it to the nurse-manager80. Trach occlusion pressure = Inject air until no sound is auscultated over the tracheostomy during a deep breath81. Est. date of birth = November 2182. 41 wk gestation = Place the client on her left side83. 10 yo diabetic = Peanut butter crackers84. GTPAL = 4-1-2-0-485. Severe depression = I have known many clients w/depression who have felt better after several weeks of treatment 86. Blood transfusion = VS87. 6 yo imbalanced nutrition = encourage family members to bring foods from home88. ANS = confabulation89. Confrontation eye exam = Sit facing client and while look directly at the clients face, move an object inward from the periphery90. RN manager role = Delivery of client care while meeting agency goals91. Paint fumes = Abuse of any of the inhalants can eventually lead to addiction92. UAP BP = Observe the UAP performing BP measurements93. Immigrant = Continue the interview process and record the findings94. Intervention STAT = A young adult who is reporting an anaphylactic response to an abx95. OCD = Participates in one social or recreational activity each morning and afternoon96. ANS = Atropine sulfate 0.4 mg IM on call to operating room97. IV infusion & abx = Evaluation of the need for continued IV abx to achieve the desired outcomes98. Ulcerative colitis & J pouch = Stool is eventually expelled through the rectum99. Vag delivery, lochia = Review the CBC100. Spinal surg C7 = SPO2 is 88% w/shallow, slow respirations101. Acute pancreatitis = Intensity of pain102. Multiple trauma MVA = Renal function103. Paranoid schizo = Approach the client w/the medication 30 minutes later104. Refuse fluids = Offer the child a popsicle and allow him to pick the flavor he prefers105. Hx heart fail = Get up and walk around frequently during the day106. Chemotherapy = Start the first transfusion of blood107. Insert urinary catheter = Apply a sterile lubricant to the end of the catheter108. Nephrotic syndrome = Protein109. DJD = Contact the clients HCP to report assessment findings110. Implement teach plan = Teach the info that the client wants to learn first111. Tylenol antidote = Acetylcysteine (Mucomyst) 140 Mg/kg112. Contact precaution = Dispose of soiled dressings in plastic bags that are securely closed113. 26 wks gestation = The cervix is effacing and dilated to 2 cm114. CKD risk 2nd to DM = Type 1 DM and retinopathy and mild vision loss115. Diuretic, ACE inhibitor, carvedilol = Explain the rationale for the admin of all three meds to the client116. Crutch walking = Observe the client while demonstrating crutch walking117. Elder abuse = The caregivers stress level is overwhelming118. Barbiturate withdrawal = Notify the HCP of the clients status119. Hearth rhythm change = Reassess the rate and characteristics of the clients pulse120. Cephalexin = Determine if the client has ever had a hypersensitivity reaction to penicillins121. Normal newborn wt & length = Abover average in wt but avg in length122. Interior eye structure assessment = Adjust the diopters123. NG tube insertion = Let us review the procedure, then I will supervise you while you perform the procedure124. C-section, infected wound = A private room on a med unit125. Preeclampsia = RR of 10

Comprehensive Exam 31. Hydrocephalus & ventriculoperitoneal shunt shunt malfunction or infection requires immediate treatment2. Terminally ill, N/V offer high protein foods3. NG comatose gastric residual of 150 mL4. Cholelithiasis upper right abdominal pain that occurs after meals and radiates to the back or right shoulder5. Adolescent diet incorporate favorite foods into the adolescents diet6. Podofilox Redness, peeling, and itching may occur at the site of application7. Cellulitis, Ampicillin a malpractice suit based on lack of reasonable and prudent care8. Phase of therapeutic relationship orientation phase9. Best documentation 0830IV fluid rate increased to 100ml/hour according to protocol10. Informatics the input and retrevial of electronic data about a clients medical history11. Heating pad, PVD all elements are present to find the nurse liable for damages12. Eriksons development model Generativity vs stagnation13. Trisomy 21 use a bedside cool mist vaporizer during naps and night time14. Peptic ulcer a ridged, board like abdomen15. IM landmarks ventrogluteal the anterosuperior iliac spine and the greater trochanter16. Saliva presence of gag reflex17. Open reduction notify HCP18. Pregestational diabetes diet and insulin needs will change significantly throughout my pregnancy19. IV insulin insulin regular (humulin R) 20. Continuous Quality Improvement the benchmark was not met and an action plan should be developed21. Carbohydrate loading rest and increased carbohydrate intake22. DM 1, exercise shakiness23. Abd-perineal resection maintain dry perineal dressings24. Pediculosis capitis use a fine toothed comb or tweezers to remove nits25. Assessment interview tell me about your family26. Chinese cupping to remove colds and coughs27. Local pop utilization conduct a focus group in community to gather data on culturally significant needs28. Myasthenia gravis ptosis29. Nissen fundoplication irrigate the NGT w/normal saline30. Drug dosages for a child body surface area31. NG feeding check residual volume every four hours32. Nitroglycerin this is a common side effect due to the vasodilatory effects of the medication33. MM O2 sat smoking, jaundice, hypotension, DM 134. Bone marrow aspiration use a compression dressing for firm pressure to the site35. d/c payment continue the clients d/c process36. External fetal monitor, FHR umbilical cord compression37. Withdrawing sol from ampule flick stem, wrap neck, break neck, stabilize, withdraw sol38. Cardiac cath, stent obtain UO for the past 4 hours39. Paracentesis a needle is inserted to remove excessive fluid from the abdominal peritoneal cavity40. 6 yo report the situation to appropriate authorities41. 38 yo assess the clients needs for food, liquids, and rest42. Colon resection aspirate the tube contents to test the pH43. Management model operational shared governance44. 8 yo supervisor of nurses providing care45. Reminiscence strategies stimulate memory chains through associations46. Sleep deprivation mood swings and irritability47. Glasgow coma scale a nasopharyngeal tube48. Terminal cancer of liver I notice you have a bible. Is that a source of spiritual strength for you?49. Report FHA late decelerations50. Hypomania firmly inform the client that acting out anger is not acceptable51. 2 yo removes a reinforce that a child is receiving52. Ankylosing spondylitis initiate a smoking cessation program53. Family centered care enabling and empowering54. Intractable pain respiratory acidosis55. 32 yo reassure the client that he is safe and should rest56. Trache suction, rhonchi each pass of the suction catheter should take no longer than five seconds57. Atropine blurred vision58. Living will allow the client to die with dignity and without life prolonging techniques59. 50 lb wt loss amenorrhea60. Fat embolism petechiae of the anterior chest wall61. Pressure ulcer risk tissue ischemia62. Med effectiveness assign nurse manager63. ETOH w/d monitor VS64. Diuretic therapy I/O & daily wt65. Advocate ask the surgeon to return to clarify questions for the client66. Cirrhosis, hepatic encephalopathy apply a pressure relieving mattress under the client67. HIV/AIDS safe & effective care environment68. Practice context factors and systems that contribute to delivery of nursing care69. 11 yo tell the child to go to the gym to play basketball70. 50 yo spiritual distress71. CKD explore options with the regional dialysis center about reducing the cost of home dialysis72. Rh incompatibility infant of an Rh negative mother and a father who is Rh positive and homozygous for the Rh factor73. False positive occult stool fish, beef, vitamin C, advil74. Constipation inadequate intake of dietary fiber and fluids75. EBP Id practice problem, review research, implement data, Id & develop plan76. Gram stain gonorrhea is often asymptomatic in women because the infection is not visible77. Puerperal infection temperature of 100.8 F 24 hours after delivery78. Informatics a new sense of order to a problem that facilitates cost effective analysis and evaluation of care79. Bipolar maintain an environment that reduces stimulation of the client80. 7 yo insert 5 ml of 2% lidocaine lubricant into the urethra81. UAP delegate the scope of practice defines which nursing interventions that can be delegated82. Timolo maleate receives carvedilol (Coreg) for heart failure83. Degenerative arthritis How intense does the client rate his pain on a scale of 1 to 1084. Addisons disease adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex85. Labs calcium, potassium, sodium86. JVD observe the vertical distention of the veins as the client is gradually elevated to an upright position87. Chinese reliance on family members to assist with care88. Primiparous arrest of active phase89. Mass causality prioritize care for victims with life threatening problems according to likelihood of survival90. Hepatitis C Intravenous drug abuse91. IOP use of prescribed eye drops since last exam by ophthalmologist92. Trache care hydrogen peroxide93. Fluid volume excess elevated BP94. Risperidone wt gain95. Dysphagia divides solid food items into one inch cube pieces96. Ammonia failure of the liver to convert ammonia absorbed from the bowel to urea97. Informed consent a 16 yo mother for her newborn98. 32 wk gest providing breast milk ensures the premature newborn can easily digest and absorb the nutrients99. Sleep pattern has a decline in stage 4 sleep100. 76 yo powerlessness101. 32 wks gest ensure patency of the ET tube102. Alzheimers encourage verbal and nonverbal communication, maintain a calm demeanor during all interactions103. Leadership style fosters positive behavior changes in staff members104. Total gastrectomy Vitamin B12105. Antabuse Vomiting106. Adolescent, impulsivity explain the consequences for breaking the unit rules107. Need for home care clients are more acutely ill when d/c from acute care facilities108. GERD aspiration pneumonia109. Self worth plan regular visits with the client throughout the day110. Anthrax flu like symptoms, GI distress, and papular lesions111. Biliroth I Notify the HCP112. 4 wk old infant Social smiling begins at approximately 2 months of age113. Suicide A loaded gun114. Sterile technique point out the observation immediately to the surgical team115. Allergies, surg document a possible Type 1 latex allergy116. 5 yo the child focuses on another connection because the siblings death is misunderstood117. External otitis media decreases inflammation and pain118. Accountability evaluating a clients outcomes after implementation of care119. 4 mth old assign the same nurse to care for the child each day120. IOP, glaucoma identify coping mechanisms r/t the eventual loss of peripheral vision121. 4 yo impaired social interaction122. Fecal impaction decrease risk for bradycardia123. DKA Kussmaul respirations124. Eating disorder dance and movement therapy125. Research utilization the value of calcium channel blockers use over ACE inhibitors

Multidiciplinary Assignment Quiz1) Dry, brittle hair current hair care practices2) 35-yo married woman how did this happen to you3) PTCA give a SL nitro tab4) Triple lumen cath flush lumen with the saline solution and administer the medication through the lumen5) First stage of active labor help her breathe into a paper bag6) Handle linens that are soiled place the soiled linens in a pillow case7) Newborn colostomy potential for fluid volume deficit8) 4 mth old normal growth curve of a bf infant9) Diuretic, ACE, Coreg explain the rationale10) 6 mth old let us talk about the child care options11) Instrument for deep tendon reflex hammer12) Ineffective health maintenance r/t lack motivation eats anything and does not think diet13) 37 wks gestation wrap, collect, restrain, cleanse14) Written learning objective upon discharge15) Auditory hallucinations ensure that there is physical space16) Hx ETOH w/cmpd fx ask the client about the quantity, freq17) Inguinal herniorrhaphy determine the time the client last voided18) UAP lift bend at the knees 19) Assess first 55 yo w/jaw pain & indigestion20) Occupation: Set goals, formulate policy manager21) Positive sign of pregnancy FHT heard with a Doppler22) OTC pregnancy test using an anticonvulsant for epilepsy23) Sickle cell eval effectiveness of narcs24) Occupation: est. provider network, recommend tx plans case manager25) Oncology teacher26) 8 wks gestation the heart develops in the third to fifth wks after conception27) Menopause onset smoking, oophorectomy w/hyster, early menarche, genetic influence, chemo28) 14 yo scoliosis record I&O, assess BS q4, initiate logrolling, give MS29) Syphilis gloves 30) Older client phys assess arrange the exam sequence to minimize31) Acute panc intensity of pain32) Implement teach plan teach info wanted to learn33) 16 yo hep b34) Prednisone the dose must be tapered35) 25 wks gest fetus can respond36) Preeclampsia RR 1037) WHO - # of people w/o access to health care38) 28 wks gest changes in fetal heart rate patterns39) 4 yo IV ask for mothers presence40) Borderline personality do you frequently have temper tantrums 41) Ritalin ADHD admin at least six hours before bedtime42) PET scan results show activity in various portions of the brain43) Tx bed to chair pre medicate, inform the client, ask the client to push the IV pole, assess BP44) Hydronephrosis obstruction at the urinary bladder neck45) Pain 7/10 air, pain, sleep, definitive therapy46) Occupation: deves research questions, conducts research researcher47) Terminal panc ca MS48) Well baby, blanket, block object permanence49) Peptic ulcer, Nexium take at same time eqch day one hr before meal50) First trimester calcium eat more green, leafy veggies

1) Assess 1st 55 yo new admit c/o jaw pain and indigestion2) POA the client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so3) BP 100/88, norm 120/60 retake the BP in the same arm, deflating the cuff slowly4) Kawasaki disease high risk for alt tissue perfusion, cardiopulmonary5) Hep A ensure that all enrolled children have been immunized6) Oral contraceptives take 2 pills a day for 2 days7) Man puts small box in cafeteria use nearest phone to notify hosp security8) 4 yo IV ask mother to be present9) Child skin turgor poor skin turgor10) UAP, VS, mastectomy apply BP cuff to the arm on the unop side11) 40 wks gestation Intensity of contractions is 130 mm Hg12) Comm health nurse, sources for funding offers healthcare services to comm membs in local factories, schools, and churches13) Barbiturates withdrawal notify the HCP of clients status14) Neonate high pitch cry, jittery, twitch obtain serum glucose and serum calcium levels15) Nitrostat place under tongue PRN q 5 min x 316) Student takes copy of med admin rec explain that the records are hospital property and may not be removed17) ETOH withdrawal prepare the environment to prevent self injury18) Peptic ulcer c/b Helicobacter pylori clarithromycin, omeprazole, metronidazole19) 75 yo hx end stage renal failure determine who is legally empowered to make decisions20) Role of nurse-midwife the pregnancy should progress normally and be considered low risk21) Hemicolectomy notify the surgeon22) UAP heart rhythm reassess the rate & characteristics of the clients pulse23) RN hears MD lying to pt HCP24) Cefadroxil use an additional form of contraception until your menstrau cycle25) PPH risk a multiparous pt receiving mag sulfate during induction for severe preeclampsia26) GTPAL 4,1,2,0,427) Single mom, two teenagers tell me what you would like to see happen with you children in the future28) Inguinal herniorrhaphy determine the time the client last voided29) GI finding 28 wks gestation pica30) 35 yo female w/cancer eval the clients mental status for competence to refuse tx31) 2nd day postop, pulseless, apneic, unresponsive call, initiate, vent, delegate32) Oral care, unconscious raise, lower, position, place33) HIV discuss retesting to verify the results which will ensure continuing contact34) Wet sounding lung sounds turn client q2h35) Emotional intelligence- interpersonal and intrapersonal skills36) Graduate nurse folder on food cart biculturalism37) Midazolam (versed) withhold the drug until the client validates understanding of the surgical procedure and signs the consent form38) Stridor on exhalation call for emergency assistance39) Negative comments and antagonistic behavior psychoanalytical40) Meperidine (Demerol) for laboring client narcan41) Bloodtinged sputum, bronshoscopy allow the client nothingby mouth until the gag reflex returns42) CKD, epoetin alfa stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes43) Divorce 4 years44) 5 yo assess last throat45) 3 yo swing the mother is slurring her words and is not attentive to discharge instructions46) Chvosteks sign ask the client about numbness or tingling in the hands47) Comm health nurse adjunct issue retirement issues48) Topiramate do not crush the tablet prior to admin49) SIDS infanst should be positioned supine or supported laterally to sleep50) Blood bank, x-ray return the blood to the blood bank for refrigeration within 30 min

1) Crying toddler, BP quiet the child and retake the BP2) Short high-pitched sounds in lungs crackles in the right and left lower lobes3) Importance of keeping infant warm a large body surface area favors heat loss to the environment4) Chemo 2 wks ago, acute leukemia start the first transfusion of blood5) Snake bite secure the antivenin6) Cyclosporine renal allograft creatine 28 mg/dl7) 12 yo bacterial meningitis admin broad spectrum abx before results of C&S are returned8) 3rd day postop, constipation prune juice before bed9) MS RR 6 attempt to arouse the client to stim resps10) Furosemide, digoxin, lab potassium11) IV infuse at 250, need 125 slow infusion to KVO12) Agency nurse, new trache ask the nurse about her competency to care for the client13) Renin HTN14) 3 mths prego, pee q 5 min the growing uterus is putting pressure on the bladder15) CBC, adolescent, AML risk for injury16) Bleed from patch of hair loss, hubby require the hubby to leave the cubicle while the client is being treated17) 1 yo pulse apical18) STI cervical ca human papillomavirus19) Outpt therapy apt drunk tell client that therapy cannot take place while shes intoxicated20) 60 yo homeless refer for further diagnostic eval21) RN & PN medicare reimbursement documentation of skilled care service provided during the visit22) Liver transplant no more express concern over his disappointment23) RN meds in pocket accused of diversion24) Prioritizing care admin insulin per sliding scale to pt w/ bg 28525) 18 mth old w/pot belly, lordosis, bowed legs document general physical appearance of normally developed toddler26) 4 yo old ventilator acknowledge, set, refuse, ask27) Older female w/cog impairment confabulation28) Pagets disease, calcitonin observe the client for signs of hypersensitivity29) Position for gravity during delivery squatting30) Tension pneumothorax a deviation of the trachea toward the side opposite the pneumothorax31) UAP dele accompany a d/c client w/chronic renal failure to a private car32) Placents early fxn secretes both estrogen and progesterone33) Barrier gloves emptying urinary catheter drainage bag for a client w/Alzheimers34) Falls, group therapy, psychosis ask a group member to seek help35) Homeless female Im feeling really isolated and cannot seem to find help36) Newborn drug withdrawal swaddle the infant snugly and hold tightly37) Spanish speaking a PN working on another unit who speak fluent English38) Occupation: advanced PM who provides workers with primary care services clinician nurse practitioner39) Major depression, suicide search the client personal belongings40) PKU from newborn after ingestion of a source of protein41) 41 wks gestation one fetal movement noted in an hour42) Hospice, gurgling inform the family that death is imminent43) Coping behaviors of parents endowing the illness with meaning44) Therapeutic tool, care to psychiatric pt self-analysis45) Passive ROM cradle the client heel46) Substance addiction therapy, freq relapse the client must participate in making decisions about their own physical and mental health47) Male newborn VS assess the infants BG level48) Sternum tents continue the planned nursing interventions to restore fluid vol49) Imipramine decreases transmission of pain impulses by altering serotonin and norepi activity50) Anencephaly prepare the fam to explore ways to cope with the imminent death of the infant51) Meperidine narcan52) 5 yo, bilat eye patches orient child to immediate surroundings53) Hysperectomy comp psychological adjust 29 yo whose uterus ruptured54) CBI, Prostatectomy stop the irrigation flow55) DRE, PSA stony, irreg nodules palpated on the prostate should be further eval56) Gabapentin continue gabapentin57) MMR, CDC 4 to 6 yoa58) Further assess for preschooler gains 2 lbs in 12 mths59) Teacher pass down legacy Generativity60) Norm UA older adult pH 6, sugar neg, bili neg, sg 1.01561) carisoprodal alcoholic beverages62) knee needle aspiration witness the clients signature on the consent form63) rectum, tap water enema ask the client to relax and run a small amt of fluid into the rectum64) experienced UAP obtain a sterile UA from an indwelling cath with a closed drain sys65) raynauds disease biofeedback allwas the client to control invol responses to promote peripheral vasodilation66) stage 4 pressure ulcer wet to dry dressing67) newborn, diffuse edema,scalp caput succedaneum68) PRBC VS69) Non-Hodgkins lymphoma check stools for occult blood70) UA from indwell cath clamp, label, place, document71) Cardiovasc findings, 20 wks gestation decrease in pulse rate72) Hemophilia a sons, hemophilia73) Low birth wt infant, neutral thermal enviro maintain a high humidity atmosphere74) Sterile liquid to sterile field consider the sterile field contaminated if it becomes wet75) Child w/fever prolonged exhalations76) WHO, healthcare issue - # of people w/o access to healthcare77) Chronic a-fib, slow vent response an electrical stimulus is d/c when no vent response is noted78) 3rd day postpartum exhibit interest in learning more about infant care79) 24 hr old newborn, rash document the finding as erythema toxicum80) Script to admin to newborn to reduce complications r/t birth trauma vitamin k81) Paranoid schizo, meds poison approach w/meds 30 min later82) Major depression, single episode increased thyroid stimulating hormone (TSH)83) Labor augmented w/oxytocin FHR is 180 bpm w/o variability84) One-to-one interaction, mom death self-awareness85) Immobile client, RN dx impaired gas exchange86) Rectal bleeding withhold the admin of the suppository until contacting the HCP87) 3 yo mistreated the injury sustained is highly unusual for 3 yo children88) High risk neonate, radiant warmer report findings to HCP89) 85 yo renewal of meds measure BP90) 8 wks gestation, CHD the heart develops in the 3rd to 5th weeks after conception91) Program for disabled children approval by the network HCP92) Miscarriage ask the client what name she had picked out for the infant93) In evaluating client care, which action should the nurse take first determine if the expected outcomes of care were achieved94) Minocycline (minocin) loss of balance and dizziness95) Panic disorder, break up drugs taken in last 7 days96) Bedrest, progress activity advise client to sit on side of bed for a few minutes before standing97) Bacterial pneumonia, ticarcillin stop IV piggyback infusion and increase oxygen flow to 3 L/min98) Low sodium, protein diet snack of, lunch of, breakfast, bedtime99) Adolescent, bulimia, low K+ - cardiac arrhythmias100) Amitriptyline avoid consumption of ETOH101) Infant, diarrhea, lethargy tachycardia 102) Korean-american the RN case manager for the unity with 1 years experience103) Ondansetron (Zofran) headache104) Cerebellar fxn 5 yo finger to nose105) Sacral ulcer position prone with small pillow below the diaphragm106) Neurological soft signs poor coordination and sense of position107) 79 yo, increasingly forgetful cannot mentally retrace objects that were recently misplaced108) PTCA give SL nitro109) 5 yo examine last throat110) 30 yo, g2, p1, 26 wks gestation maternal and FHR111) Asymptomatic primary syphilis deficient knowledge112) Meningitis cefotaxime cefotaxime provides therapeutic CNS concentrations113) 35 wks gestation check-up periodic abdominal pain114) Older client can stand not ambulate place transfer belt around client, assist stand, pivot chair at right angle to bed115) Neonate 10 min, nonpathologic cyanosis feet and hands116) Pregnancy induced hypertension (PIH) blurred vision117) Consequence of radiation therapy pathologic fracture of two ribs on the right chest118) 6 mth old vaccines Hib, IPV, Hep B, DTaP119) Sexual activity after AMI sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs120) 2nd trimester, drink abstinence is strongly recommended throughout pregnancy121) Delegate UAP bathe an unconscious client with decubitus ulcers122) Glaucoma, hx allergic rhinitis, OTC avoid allergy medications that contain pseudoephedrine or phenylephrine123) Pressure sore one inch pressure sore draining serous fluid124) Cuffed tracheostomy, spontaneous breathing observe client for coughing colored sputum after drinking small amount of colored water125) Daughter dress as tomboy and plays baseball adolescents try on different roles while seeking their identity126) Jaundice, Rh incompatibility bilirubin127) 12 wks gestation, dairy canned sardines128) 2 yo laceration allow the child to hold a favorite toy or blanket129) Acute asthma exacerbation wheezing becomes louder130) Cystitis, cephalexin determine if the client has ever had a sensitivity rxn to penicillins131) Bomb threat obtain current roster of clients assigned to the unit132) 15 yo wants a baby can you tell me how your life will be if you have an infant133) ACE inhibitor renal artery stenosis134) Rxn to contrast media epinephrine135) Sterile field contimanate identify the break in surgical asepsis and provide another set of sterile supplies136) Penetrating eye injury apply a fox shield to affected eye and any type of patch to the other eye137) Police officer threats, hears voices, reports, says138) Diazepam OD prepare a set up for endotracheal intubation139) Chronic pain which activities during a routine day are impacted by your pain140) 37 wks gestation, bag of water place client in knee-chest position141) Nursing process in planning care as a tool to organize thinking and clinical decision making about clients healthcare needs142) Teenage smoking the incidence of smoking among teenage population143) Smash head against doors place client in mechanical restraints until calm144) get out of my room what is concerning you this morning145) Irregular bluish hue on sacral are of 1 day old Mongolian spots146) Sims position raise bed to waist height working level147) Purpose of beginning chemo tumor small the cell count of the tumor reduces by half with each dose148) Implement change in work environ solicit input from coworkers at the beginning of the process149) Skin changes from pregnancy striae gravidarum150) 18 mth old crying breath sounds allow child to play with steth and distract during auscultation151) 15 yo criticizing teens create psychological distance from parents in order to separate from them 152) 2 mth old DTaP mild reactions are common and most frequently include low-grade fever153) Muslium ask one of the female nurses to bathe you154) 6th unit PRBCs flushed skin and headache155) Nephrotic syndrome, prednisone protein156) Coumadin INR of 2 to 3 157) Step after visual inspection of abd auscultation158) Boggy displaced uterus assist client to bathroom159) Female homosexual relationship domestic violence interventions160) Nulliparous ask client to describe why she thinks she is in labor161) HIV, MAC return to pre-illness weight162) Aminoglycoside abx admin initial dose of aminoglycoside abx asap163) Accurate info assess of older client use reliable assessment tools for older adults164) 28 wks gestation bright red blood, painless vag abd ultrasound165) 28 wks gestation, abd trauma changes in fetal heart rate patterns166) First pass effect oral167) Curettage for hydatidiform mole diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy168) Multiparous 8 hr labor, ROM assess the FHR and pattern169) Measure 14 mth old child supine recumbent position170) Fecal impaction for client pulse rate decreases from 78 to 52 beats/min171)