ARCHER CAT EXAM 1

Which of the following statements indicates body image distortion in a client with anorexia nervosa? Correct A. "I wish I looked like my mom." [1%] B. "I hate how my body looks." [23%] C. "I wish I could wear tank tops." [2%] D. "I'm so overweight." [73%]

Explanation Choice D is correct. Clients with anorexia perceive themselves to look differently than they do. Despite being too thin, this client will not eat in hopes of getting the perfect body.

72-year-old male presents to the emergency department Item 2 of 6 Nurses' Notes 1430 - A 72-year-old white male stated he hasn't felt good lately and feels sad much of the time. He becomes tearful when telling you about the loss of his wife eight months ago. He states he feels lonely and hopeless. The client also stated that the osteoarthritis he was diagnosed with five years ago has worsened. He stated that lately, he gets tired easily but has difficulty falling and staying asleep. He reported that the only activity he has maintained is attending church services.

Based on these findings, it would be essential for the nurse to make which statement? "Would you tell me more about your bedtime routine?" "Could you describe the severity and quality of your pain?" "Are you having any thoughts of harming yourself?" CORRECT "Have you ever received mental health services before?"

Click to highlight the findings in the progress note that specify that the client is ready for discharge

Client statements and behavior indicating he is ready for discharge are alert and oriented. This is a positive cognitive finding. His mood and affect appear positive and harmonious and, thus, is also another indicator for discharge. The client stating that he will be staying with friends from church is reassuring as he will have a support system after discharge. Finally, working with an outpatient therapist is a reassuring finding. Findings that indicate that the client is not ready for discharge include his reluctance to attend inpatient group therapy and not being able to sleep. His report of insomnia will need to be mitigated to help decrease his further risk of suicide. Additional Info Suicide is a pervasive issue, and the nurse should work diligently to recognize individuals at risk for suicide. General risk factors for suicide include - Being divorced, separated, or widowed White males over the age of 45 A psychiatric diagnosis Previous suicide attempts Substance use Chronic illness Women attempt more; men are complete more suicide Feelings of hopelessness and loneliness

The licensed practical/vocational nurse (LPN/VN) cares for assigned clients. The LPN/VN should initially follow up on the client Correct A. taking lithium that reports nausea and vomiting. [68%] B. refusing their prescribed quetiapine and lamotrigine. [10%] C. reporting a headache following the first dose of citalopram. [15%] D. reporting drowsiness following a dose of alprazolam. [7%]

Choice A is correct. A client taking lithium needs to be monitored closely for nausea and vomiting. These are early manifestations of lithium toxicity. Lithium toxicity must be recognized promptly as it may lead to more severe symptoms such as cardiac dysrhythmias. Choices B, C, and D are incorrect. A client refusing a medication should always be followed up on because the client needs to be counseled on the purpose of the medication and its effects. Further, the nurse should inquire why the client is refusing the medicine. A headache following the administration of citalopram is a common side effect and warrants no immediate follow-up. Finally, drowsiness following the administration of a benzodiazepine is an expected finding. Drowsiness is the most common side-effect associated with a benzodiazepine. Additional Info ✓ Lithium levels should be maintained between 0.6 - 1.2 mEq/L. ✓ Lithium requires the client to maintain adequate fluid and salt. Failing to do so for the patient may result in lithium toxicity. ✓ The client should maintain a fluid intake of 2-3 liters daily. ✓ Lab findings expected with lithium include leukocytosis and hypothyroidism (long-term use). ✓ The client should avoid medications such as diuretics, NSAIDs, and ACE inhibitors, as these medications may cause lithium toxicity ✓ Lithium levels should be drawn twelve hours following the client's last dose. If not, this may falsely elevate the lithium level. ✓ Signs and symptoms of lithium toxicity include nausea, vomiting, lethargy, confusion, delirium, coma, seizures, and hypotension

The nurse is caring for a client who is receiving prescribed pregabalin. The client is experiencing the intended effect when they report less Correct A. neuropathic pain. [64%] B. cravings for cigarettes. [16%] C. binge eating. [7%] D. depressive symptoms. [13%]

Choice A is correct. Pregabalin is indicated in treating neuropathic pain, certain anxiety disorders, and focal seizures. This controlled substance is five times more potent compared to gabapentin. Choices B, C, and D are incorrect. Pregabalin does not reduce the craving for cigarettes or mitigate binge eating. Pregabalin is an effective agent for social anxiety but not depression. Additional Info Pregabalin is indicated for neuropathic pain and disorders causing neuropathic pain, such as fibromyalgia, herpes zoster, and phantom limb pain. This medication's common side effects include dizziness, drowsiness, and respiratory depression when combined with other CNS depressants. Considering the CNS depressant effects of this medication, the nurse should institute fall precautions for the client.

The nurse manager reviews client assignments. Which client assignment would be inappropriate for a licensed practical/vocational (LPN/VN) nurse? Correct A. Obtaining an occult blood sample from a 15-year-old client with ulcerative colitis. [10%] B. Assessing a 35-year-old client newly admitted for chest pain. [69%] C. Reinforcing education to a 25-year-old first-time mother on how to properly care for her new baby. [12%] D. Providing pin care and data collecting on neurovascular status for a client in cervical traction. [9%]

Choice B is correct. LPN/VNs should be assigned the most stable client with a predictable outcome. A client newly admitted for chest pain would not be stable or predictable and, thus, require intervention. Choices A, C, and D are incorrect. Reinforcing education, obtaining stool samples, and providing pin care to a client in cervical traction is within the scope of an LPN/VN.

In which age group is child abuse most likely to occur? Correct A. Ten-year-olds and older. [3%] B. 6 to 10 years old. [11%] C. 4 to 6 years old. [20%] D. Birth to 3 years old. [66%]

Choice D is correct. Children between birth and three years of age have the highest incidence of victimization to child abuse. The current rate is approximately 16 in 1,000 children. Also, the impact is higher in girls than in boys. Child abuse crosses all cultures, ages, economic levels, races, and religions, but is most prevalent in families living in poverty and those families composed of adolescent parents with young children. Nurses should never make assumptions about certain groups being at higher risk for child abuse but rather should be aware that social, economic, and personal stressors can contribute to the incidence of child abuse. Acts of commission in child abuse are situations in which the responsible person, often the parent, intentionally harms the child via physical, emotional, or sexual abuse. Acts of omission in child abuse are situations in which a parent or caregiver, to their best of abilities and often inadvertently, cannot provide adequate nutrition, shelter, warmth, appropriate seasonal clothing (i.e. winter coats), safety, and education for his or her child. These are considered significant categories of child abuse and situations identified must be reported. The idea of responding to both acts of commission and acts of omission is to provide safety for the child or provide what is necessary for the child to thrive and grow in a safe environment.

Which of the following statements made by a TB client being prepared for discharge indicate his understanding of the education provided? Select all that apply. 3/3 Your Score/Max +/- Scoring Rule "Everyone in my family needs to go and see the doctor for TB testing." "I will continue to take the isoniazid until I am feeling completely well." "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." "I will change my diet to include more foods rich in iron, protein, and vitamin C."

Choices A, C, and D are correct. A: Family members should be tested because of their repeated exposure to the client. C: Respiratory hygiene practices, such as covering the mouth and nose when coughing or sneezing and properly disposing of used tissues, are essential to prevent the spread of TB bacteria to others. D: Good nutrition, including foods rich in iron, protein, and vitamin C, can support the client's immune system and overall health during TB treatment. Adequate nutrition is important for the body's ability to fight off the infection and promote healing. Choice B is incorrect. Clients taking isoniazid must continue the drug for six months, regardless of whether symptoms seem to have improved or not. Additional Info ✓ TB, tuberculosis, is a severe bacterial disease. It is spread from person to person through the air. TB may scar the lungs and other parts of the body, including the kidneys, bones, or brain. Although medications are available to treat TB, not every person affected responds within the same time frame. ✓ Nurses are responsible for providing client education and making sure that the client understands what he/she is being taught to help prevent the spread of disease. To help prevent the spread of TB, clients should be instructed to: Make sure that family, friends, and close co-workers are tested. Avoid close contact with others until the physicians say it's OK. Keep your hands clean. Cover the mouth and nose with a tissue when sneezing Put used tissue in a closed bag and throw it away. ✓ LPNs can provide the client with written educational materials or pamphlets about TB, its treatment, and infection control measures. Written materials can serve as a reference for the client to review at home and share with their family members, further supporting the education process.

Diabetes insipidus is a potential complication of which of the following procedures? Correct A. Surgical removal of the pituitary gland [70%] B. Reduction of mass on the thyroid gland [19%] C. Hysterectomy [5%] D. Dilation and curettage [6%

Explanation Choice A is correct. Damage to the pituitary gland or hypothalamus from surgery increases the risk for diabetes insipidus. This is because the posterior pituitary is the gland that regulates the production, storage, and release of antidiuretic hormone (ADH). A decreased amount of ADH results in diabetes insipidus. Choice B is incorrect. A reduction of mass in the thyroid gland would not result in an increased risk for diabetes insipidus. Choice C is incorrect. A hysterectomy would not result in an increased risk for diabetes insipidus. Choice D is incorrect. A dilation and curettage

A client is diagnosed with a spontaneous pneumothorax, which results in the need to insert a chest tube. What is the BEST explanation for the nurse to provide this client? Correct A. "The tube will prevent you from having chest pains." [1%] B. "The tube will remove excess air from your chest." [73%] C. "The tube controls the amount of air that enters your chest." [21%] D. "The tube will seal the hole in your lung." [5%]

Explanation Answer and Rationale: The correct answer is B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space. A is incorrect. Chest tubes do not prevent chest pain. Many clients complain of pain and discomfort because of the machine. However, the necessity of removing air is paramount. C is incorrect. The purpose of the chest tube is to remove air that has accumulated, not control the amount of air entering the lung. D is incorrect. The chest tube does not seal a hole in the lung. Additional Info ✓ Assess and manage the client's pain related to the chest tube insertion. Administer pain medication as prescribed and use non-pharmacological pain relief interventions when appropriate. ✓ Offer emotional support and reassurance to the client during this challenging time. Address any fears or anxieties they may have about the procedure and recovery process. ✓ Provide the client and their family with essential information about chest tube care, drainage management, and activity restrictions. Reinforce education provided by the registered nurse or healthcare provider.

The LPN enters her 5 year old patients room and finds him lying on the floor. His fall was unwitnessed. What is her priority nursing action? Correct A. File an incident report [1%] B. Assist the child back to bed [2%] C. Call for help [8%] D. Assess the child for any injuries [89%]

Explanation Answer: D

The nurse is caring for assigned clients. The nurse should initially follow-up with the client who Correct A. receiving mechanical ventilation and low-pressure alarm sounds. [56%] B. has a new colostomy and refuses to participate in care. [4%] C. has acute glomerulonephritis and has periorbital edema. [14%] D. has atrial fibrillation and an irregular pulse. [25%]

Explanation Choice A is correct. A client receiving mechanical ventilation requires multiple assessments. The low-pressure alarm is concerning for ventilator disconnection or low cuff pressure. The high-pressure alarm is concerned with obstruction, such as secretions. This client should be assessed first under the priority model of "ABCs" = airway, breathing, circulation. Choices B, C, and D are incorrect. A client with a new colostomy may be indifferent when caring for themselves as they adjust to the change in body image. Further, a client with acute glomerulonephritis will exhibit periorbital edema and high blood pressure. Finally, an irregular pulse is consistent with atrial fibrillation. Additional Info ✓ The client receiving mechanical ventilation should always be assessed over the alarm ✓ The nurse needs to ensure these alarms are functional, but the client's assessment is the priority if the alarm sound goes off ✓ The low-pressure alarm indicates either disconnection, extubation, or low cuff pressure ✓ The high-pressure alarm indicates airway obstruction by the client biting on the tube or secretions in the airway

The nurse is caring for a 16-year-old client with cystic fibrosis when they develop a temperature of 38.4 degrees Celsius. Which of the following medications does the nurse administer with top priority? Correct Answer(s): A A. IV antibiotic [63%] B. Pancreatic enzyme [18%] C. Fat soluble vitamin [4%] D. Albuterol [14%]

Explanation Choice A is correct. Administering the IV antibiotic is the top priority in a client with cystic fibrosis (CF) that develops a fever. Due to the excessive, thick mucus that builds up in their bronchi and bronchioles, children with CF are incredibly susceptible to respiratory infections. A fever is an indication of infection and aggressive management is the top priority. Choice B is incorrect. Pancreatic enzymes are administered to children with CF within 30 minutes of any meal and snack. These are given to aid in digestion since the excessive, sticky mucus clogs up the pancreatic duct in these clients . This is a standard medication given every day but is not the top priority when this client develops a fever. Choice C is incorrect. Fat-soluble vitamins are a daily medication for children with CF. Due to the buildup of excessive, sticky mucus in their bile duct, children with CF do not absorb fat normally. This leads to a deficiency in fat-soluble vitamins, which are vitamins A, D, E, and K. This is a standard medication given every day but is not the top priority when this client develops a fever. Choice D is incorrect. Albuterol is a bronchodilator frequently given as a nebulizer treatment to clients with CF. Although this medication might be given top priority if the client was experiencing respiratory difficulty, the question states they have developed a fever. Due to this finding, IV antibiotics are the top priority as these clients are very susceptible to infections. Additional Info ✓ Given the client's history of cystic fibrosis, closely monitor their respiratory status. Auscultate lung sounds for any changes, increased crackles, or wheezing. Document any changes in respiratory effort or oxygen saturation levels. ✓ Engaging in regular physical activity is important for teenagers with CF. Physical exercise can help improve lung function, cardiovascular fitness, and overall well-being. However, the intensity and type of exercise should be tailored to their individual health status and recommended by their healthcare provider. ✓ Document all assessments, interventions, medication administration, and client responses accurately and thoroughly. Clear and organized documentation ensures contin

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client's care? Correct A. Implement contact precautions when handling the client. [83%] B. Educate the client and family members on ways to prevent transmission of VRE. [2%] C. Monitor the results of the laboratory culture and sensitivity test. [3%] D. Collaborate with other departments when the client is transported for an ordered test. [12%]

Explanation Choice A is correct. All hospital personnel who care for the client are responsible for the correct implementation of contact precautions.

Which of the following client room assignments should the nurse question? Correct A. Placement of an 89-year-old client with acute delirium at the end of the hallway. [76%] B. Placement of a 79-year-old client with C. difficile with a 26-year-old client with C. difficile. [4%] C. Placement of a 56-year-old client with HIV and bronchitis in a private room. [17%] D. Placement of a 39-year-old client with mild head trauma with a 40-year-old client with an arm fracture. [3%]

Explanation Choice A is correct. Clients with delirium and those at high risk for safety events should be roomed close to the nurse's station to accommodate close monitoring. In addition to the delirium, this client's age poses a risk for injury related to falls. Choices B, C, and D are incorrect. All of these room assignments are appropriate, given the clients' ages and diagnoses. Additional Info ✓ Client placement plays a crucial role in ensuring client safety and optimizing healthcare delivery in various healthcare settings, including hospitals, clinics, and long-term care facilities. ✓ The distance of client rooms from the nurses' station is an essential factor to consider, as it directly impacts the efficiency of care delivery and the response time to emergencies. ✓ Clients located nearer to the nurses' station can be closely monitored, especially those requiring frequent assessments or interventions. This increased surveillance can help detect early signs of deterioration or complications, leading to timely interventions.

The client using over-the-counter nasal decongestant drops reports unrelieved and worsening nasal congestion. What is the appropriate instruction for this client? Correct Answer(s): A A. Discontinue the medication for several days. [63%] B. Use a combination of oral medications and drops for better results. [23%] C. Switch to a stronger dose of the decongestant drops. [7%] D. Increase the frequency of the nasal decongestant drops. [6%]

Explanation Choice A is correct. Due to their local action, intranasal sympathomimetics produces fewer systemic effects. However, one side effect associated with their use is rebound congestion. Prolonged use causes hypersecretion of mucus and worsened nasal congestion once the drug effects wear off. This rebound effect sometimes leads to a cycle of increased drug use as the condition worsens. Due to the risk of rebound congestion, intranasal sympathomimetics should be used for no longer than 3-5 days. Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks. Nasal congestion results from dilation of nasal blood vessels due to infection, inflammation, or allergy. With this dilation, there is a transudation of fluid into the tissue spaces, resulting in swelling of the nasal cavity. Nasal decongestants (sympathomimetic amines) stimulate the alpha-adrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. The result is a shrinking of the nasal mucous membranes and a reduction in fluid secretion (runny nose). Decongestants can make a client jittery, nervous, or restless. These side effects decrease or disappear as the body adjusts to the drug. When nasal decongestants are used for longer than 5 days, instead of the nasal membranes constricting, vasodilation occurs, causing an increased stuffy nose and nasal congestion. The nurse should emphasize the importance of limiting the use of nasal sprays and drops. As with any alpha-adrenergic drug (for example, decongestants), blood pressure and blood glucose levels can increase. These drugs are contraindicated and should only be used with extreme caution for clients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus.

The nurse is reinforcing education to a client with clinical depression about using monoamine oxidase inhibitors (MAOIs). While reinforcing client education, the nurse should instruct the client to Correct A. avoid chocolate and aged cheese. [72%] B. take frequent naps. [3%] C. take the medication with milk. [8%] D. avoid walking without assistance. [17%]

Explanation Choice A is correct. Foods high in tryptophan, tyramine, and caffeine, such as chocolate and cheese, may precipitate hypertensive crisis. MAOIs were the first type of antidepressants developed. They ease depression by affecting neurotransmitters in the brain. Although they are active, they've generally been replaced by antidepressants that are safer and cause fewer side effects. MAOIs can cause dangerously high blood pressure when taken with certain foods or medications. Due to this, diet restrictions and avoiding certain other drugs are required while on MAOI therapy. Despite the side effects, these medications are still a good option for some people. In some instances, they relieve depression when other treatments have failed. Choice B is incorrect. Taking frequent naps is not a relevant instruction in the context of using MAO inhibitors. Choice C is incorrect. The instruction to take MAO inhibitors with milk is not typically recommended. Choice D is incorrect. MAO inhibitors are used to treat depression and have no direct impact on a person's ability to walk or require assistance for mobility. Additional Info ✓ Emphasize the importance of taking the medication exactly as prescribed by their healthcare provider. Clients should not stop taking MAO inhibitors abruptly, and any changes to the medication regimen should be discussed with their healthcare provider. ✓ Stress the importance of attending follow-up appointments with their healthcare provider to monitor medication effectiveness, side effects, and overall progress in managing depression. ✓ Provide written materials or resources that clients can refer to for additional information and reinforcement of key points about MAO inhibitors and depression management.

The nurse is educating a new nurse starting on her unit about the causes of bacterial tonsillitis in children. She correctly explains that which of the following is the most common cause of bacterial tonsillitis? Correct A. Group A beta hemolytic streptococcus [35%] B. Streptococcus pneumoniae [21%] C. Group B streptococcus [41%] D. Neisseria meningitidis [3%]

Explanation Choice A is correct. Group A beta hemolytic streptococcus is the most common cause of bacterial tonsillitis. Choice B is incorrect. Streptococcus pneumoniae is a gram-positive bacterium that causes pneumonia; this bacterium does not cause tonsillitis. Choice C is incorrect. Group B streptococcus is a type of bacteria sometimes found in a pregnant woman's vagina or rectum; this bacterium does not cause tonsillitis. Choice D is incorrect. Neisseria meningitidis is a gram-negative bacterium that causes meningococcal diseases such as meningitis; this bacterium does not cause tonsillitis.

The nurse is caring for a client exhibiting signs of poor muscle coordination, stooped posture, and slow movements. Which medication is most likely to cause these symptoms? Correct A. haloperidol [62%] B. nifedipine [16%] C. venlafaxine [13%] D. prazosin [9%]

Explanation Choice A is correct. Haloperidol is a typical antipsychotic that may adversely cause extrapyramidal side effects (EPS). These effects include akathisia, dystonia, pseudo-parkinsonism, and/or tardive dyskinesia. Tardive dyskinesia is an adverse effect that occurs with antipsychotics and has an onset of months to years while on the medication. Choices B, C, and D are incorrect. Nifedipine is a calcium channel blocker indicated for the treatment of hypertension. It also may be used as a tocolytic to mitigate preterm labor. Venlafaxine is a serotonergic drug used to manage depressive and anxiety disorders. Prazosin is indicated for the treatment of hypertension as well as PTSD. Additional Info ✓ EPS is a concern when a patient is taking antipsychotic medication ✓ The highest risk is associated with typical antipsychotics (haloperidol, fluphenazine, etc.) compared to atypical antipsychotics ✓ The nurse must assess the patient for any abnormal movements during the therapy ✓ The most serious adverse effect of antipsychotics is neuroleptic malignant syndrome which may be life-threatening if not treated promptly

This nurse is caring for a client who is receiving prescribed hydralazine. Which of the following findings would indicate a therapeutic response? Correct A. Blood pressure 130/70 mm Hg [63%] B. Pulse (P) 67/minute [16%] C. Total cholesterol 185 mg/dL [13%] D. aPTT 45 seconds [7%]

Explanation Choice A is correct. Hydralazine is a vasodilator and is intended to treat hypertension. The client's blood pressure of 130/70 mm Hg is within normal limits and indicates a therapeutic effect. Choices B, C, and D are incorrect. The pulse and total cholesterol (< 200 mg/dL) are within normal limits. However, hydralazine does not impact the pulse or total cholesterol. The activated partial thromboplastin time (aPTT) is used as a monitoring parameter for heparin therapy, not hydralazine. The normal aPTT is 30-40 seconds. Additional Info ✓ Hydralazine is primarily an arteriolar vasodilation. ✓ The nurse should take the client's blood pressure before administering this medication. ✓ The client is at risk for falls with this medication related to orthostatic hypotension. ✓ Hydralazine toxicity or overdose produces hypotension, tachycardia, headache, and generalized skin flushing. ✓ Reflex tachycardia may occur with this medication because as the blood pressure declines, the heart rate will increase to maintain cardiac output.

The nurse is collecting data on a client with Paget's disease. Which of the following would be an expected finding? Correct A. Bone deformities [76%] B. Berry aneurysm [6%] C. Heberden's nodes [13%] D. Janeway lesions [5%]

Explanation Choice A is correct. Paget's disease is a disease caused by a bone becoming weakened and remodeled, which may result in deformities. The most common area this inappropriate bone remodeling affects is the skull, pelvis, and spine. Choices B, C, and D are incorrect. Berry aneurysm is an aneurysm that may cause an individual to have a hemorrhagic stroke. This is a common finding for an individual with polycystic kidney disease. Heberden's nodes are a physical feature associated with osteoarthritis. Janeway lesions are an expected finding associated with bacterial endocarditis. These lesions are commonly found on the soles of the feet and the hands. Additional Info ✓ Paget's disease is a disease characterized by accelerated bone remodeling ✓ The may cause an individual to be asymptomatic or have pain in the affected bone(s) ✓ The client will be at a higher risk for fracture during this disease process and may eventually develop bone deformities

The nurse is caring for a client requesting to leave against medical advice. The nurse barricades the client in their room because they feel that the client is not safe to go home. The nurse is demonstrating Correct A. false imprisonment. [81%] B. malpractice. [8%] C. negligence. [4%] D. invasion of privacy. [7%]

Explanation Choice A is correct. Refusing to let a client leave against medical advice (AMA) and physically obstructing the client from leaving is a form of false imprisonment. Choices B, C, and D are incorrect. Malpractice is professional negligence, that is, negligence that occurred while the person was performing as a professional. Malpractice applies to primary care providers, dentists, and lawyers and generally includes nurses. Negligence and professional negligence are unintentional torts that may occur in the health care setting. Negligence is misconduct or practice below the standard expected of an ordinary, reasonable, and prudent person. Such conduct places another person at risk for harm. Both nonmedical and professional individuals can be liable for the negligent act. Invasion of privacy is a right-wrong of a personal nature. It injures the person's feelings and does not consider the effect of revealed information on the person's reputation in the community. The right to privacy is the right of individuals to withhold themselves and their lives from public scrutiny. It can also be described as the right to be left alone. Additional Info False imprisonment is seen when clients want to leave against medical advice or when they are restrained. An adult who can make health care decisions and wants to leave the premises cannot be required to remain. The client must be informed about the consequences of this action, and organizational policies must be followed to address this issue. Nurses must also understand and follow their state's laws regarding clients restrained for psychiatric reasons (prevention of self-harm or harm to others), as these laws vary from state to state.

The nurse is reinforcing education regarding HIPAA. Which of these scenarios would the nurse use as an example of a violation of HIPAA laws? Select all that apply. 1/1 Your Score/Max +/- Scoring Rule Sharing client information with colleagues without obtaining consent. Safeguarding client information and refraining from sharing it on social media. Having private conversations about client care in appropriate settings with appropriate professionals. Storing client files securely and ensuring they are not accessible to unauthorized individuals. Respecting client confidentiality and only discussing client information with authorized individuals involved in the client's care.

Explanation Choice A is correct. Sharing client information with colleagues without obtaining consent. This violates HIPAA regulations as it involves disclosing protected health information (PHI) without client authorization. HIPAA binds nurses to maintain client confidentiality and can only share client information on a need-to-know basis or with explicit client consent. Choice B is incorrect. Safeguarding client information and refraining from sharing it on social media. Nurses should respect client privacy and adhere to HIPAA regulations by refraining from posting client information on social media or other public platforms. Client confidentiality is of utmost importance and should be maintained at all times. Choice C is incorrect. Having private conversations about client care in appropriate settings with appropriate professionals. Nurses should ensure privacy and confidentiality by discussing client care in private, secure areas with minimal risk of unauthorized individuals overhearing. This helps to comply with HIPAA regulations and protect client privacy. Choice D is incorrect. Storing client files securely and ensuring they are not accessible to unauthorized individuals. Leaving client files or documents unattended in an open area poses a significant risk to client privacy. It increases the likelihood of unauthorized access to protected health information and violates HIPAA regulations. Files must be secure and inaccessible to unauthorized individuals. Choice E is incorrect. Respecting client confidentiality and only discussing client information with authorized individuals involved in the client's care. Respecting client confidentiality and only discussing client information with authorized individuals involved in the client's care. Nurses should respect client confidentiality and only share client information with authorized individuals involved in the client's care. This ensures compliance with HIPAA regulations and protects client privacy.

The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive child. Which therapeutic action should the nurse take? Correct A. Draw a "magic circle" on the area before the injection. [69%] B. Have another nurse hold down the child. [13%] C. Apply EMLA cream to the area immediately before the injection. [15%] D. Administer the medication right after the child's nap. [2%]

Explanation Choice A is correct. Techniques to make an intramuscular injection less traumatizing include drawing a magic circle around the area, and after the injection, the nurse may fill in a smiley face. Choices B, C, and D are incorrect. These measures are not therapeutic. Having another nurse restrain the child is not therapeutic and would make the child agitated. EMLA cream may be utilized to attenuate the pain from the injection. However, this cream must be applied 30-60 minutes before the IM injection. Applying it and then immediately proceeding with the injection would not allow the medication to reach its effect. Delaying the injection until the child wakes up from a nap would not be an effective strategy because this would disrupt the dosing schedule of the medication. Additional Info ✓ The nurse can strategize ways to make medication administration less upsetting for a child. ✓ Let the child handle a syringe, vial, and alcohol swab and give an injection to a doll or stuffed animal. ✓ Have the child count to 10 or 15 during the injection. ✓ Draw a "magic circle" on the area before injection; draw a smiling face in the circle after injection but avoid drawing on the puncture site.

The emergency department (ED) nurse cares for a client with severe intrabdominal bleeding. The client has tachycardia, hypotension, and a thready pulse. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product? Correct A. Packed red blood cells (PRBCs) [66%] B. Platelets [14%] C. Granulocytes [2%] D. Fresh frozen plasma (FFP) [18%]

Explanation Choice A is correct. The client is experiencing intraabdominal bleeding with manifestations confirming shock. The client will need to have the blood volume replaced with emergent surgery. Type-specific PRBCs would be preferred; however, if the client is critical, O-negative blood may be transfused. Choices B, C, and D are incorrect. FFP would not be prescribed because this client is not experiencing blood loss related to warfarin or DIC. Platelets would be prescribed to treat thrombocytopenia. Granulocytes are rarely prescribed, but if they are prescribed, they are indicated for severe aplastic anemia, neutropenia, and neonatal sepsis. Additional Info ✓ FFP is indicated for deficiency of certain clotting factors. ✓ This blood product may also be used for warfarin toxicity and Vitamin K. ✓ FFP may also provide some volume resuscitation; however, its primary purpose is to assist with clotting. ✓ FFP is administered to a client over 15-30 minutes.

The LPN is caring for the following clients. The nurse should identify which client is at the highest risk for falling? A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia. [72%] B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide. [11%] C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone. [12%] D. 28-year-old admitted with bacteremia, is receiving intravenous fluids via central line, and is diaphoretic. [5%]

Explanation Choice A is correct. This client has advanced age, has a medical device that impedes their mobility, and has cognitive impairments. Thus, all these risk factors put this client at a very high risk of falling. Choices B, C, and D are incorrect. All these clients have risk factors for falls; however, none have advanced age or cognitive impairment. Thus, universal fall precautions should be instituted, but it is the 88-year-old client who requires aggressive fall reduction measures. Additional Info Risk factors for falls include ✓ Advanced age ✓ Cognitive impairments (delirium, dementia) ✓ History of previous falls ✓ Medical/Assistive device(s) (chest tube, peripheral IV, cane) ✓ Medications (anticholinergics, benzodiazepines) ✓ Increased urinary frequency and nocturia Universal fall precautions include ✓ Hourly rounding that addresses needs such as toileting ✓ Thorough room orientation and frequent reminders ✓ Adequately lit room with appropriate markings ✓ Accessible call light that is within reach ✓ Pathways clear of clutter and grab bars in the bathroom ✓ Additional measures that may be taken include relocating the client closer to the nursing station, enhanced observation, and using a bed alarm

The emergency room nurse is caring for a patient on 24-hour observation for signs of alcohol intoxication. While administering as-needed pain medication for headache, the nurse notes that the patient is diaphoretic and agitated, with shaking hands and eyes darting around the room. Which initial action would be most important for the nurse to take? Incorrect Correct Answer(s): A A. Implement seizure precautions [58%] B. Ask patient to rate pain on a scale from 0-10 [2%] C. Call security to restrain the patient [1%] D. Assess the patient's neurological status [39%]

Explanation Choice A is correct. This patient is presenting with signs of alcohol withdrawal: headache, tremors, visual hallucinations, diaphoresis, and agitation. Alcohol withdrawal puts this patient at risk for seizures. Of the options provided, the nurse's first priority would be to initiate seizure precautions immediately. Choice B is incorrect. The nurse should already have assessed the patient's pain prior to giving the PRN medication. This would not be a higher priority than the patient's safety. Choice C is incorrect. The question does not indicate that the patient is presenting with aggressive or threatening behaviors at this time, so restraints would not be appropriate. Choice D is incorrect. Assessment of neurological status is appropriate due to the patient's new symptoms but is not a higher priority than the patient's safety with suspected alcohol withdrawal.

A patient presents to the emergency department with a dissecting aortic aneurysm. The patient needs immediate surgery to save his life. He is unconscious and there is no family contact information on file. Which action is appropriate for obtaining informed consent for the surgery? Correct Answer(s): A A. There is no need for obtained consent. Send the client to surgery. [72%] B. Call the hospital lawyer. [4%] C. Search for people who may know the patient and can provide informed consent. [2%] D. Notify the on-call nursing supervisor and request her permission to waive informed consent. [22%]

Explanation Choice A is correct. When emergency surgery is needed, delaying the surgery to obtain informed consent may result in the patient's morbidity or death. In such urgent cases, informed consent is unnecessary. It is most appropriate to begin the surgery to save the patient's life. Choice B is incorrect. This is inappropriate. The hospital lawyer does not need to be called. Choice C is incorrect. This is inappropriate and unnecessary. In an emergency, it is both legally and ethically appropriate to start the operation without informed consent. Choice D is incorrect. The nursing supervisor on-call does not need to be notified, nor does she have the authority to waive the informed consent. Informed consent is unnecessary due to the rationale in answer choice A

You are caring for an elderly woman who is a practicing Orthodox Judaism. Which meal would you most likely offer this client? Incorrect Correct Answer(s): A A. Cottage cheese and fruit [81%] B. Beef lasagna [9%] C. Hamburger and milk [4%] D. Pork cutlet parmigiana [5%]

Explanation Choice A is correct. You would offer this client a meal consisting of cottage cheese and fruit because Orthodox Jewish people are not permitted to have dairy products and meat in one meal. Choice B is incorrect. You would not offer this client a meal consisting of beef lasagna because Orthodox Jewish people are not permitted to have dairy products and meat in one meal. Beef lasagna has both meat and cheese. Choice C is incorrect. You would not offer this client a meal consisting of a hamburger and milk because Orthodox Jewish people are not permitted to have dairy products and meat in one meal. Choice D is incorrect. You would not offer this client a meal consisting of pork parmigiana because Orthodox Jewish people are not permitted to have dairy products and meat in one meal. Pork parmigiana has both meat and cheese.

The nurse is visiting the home of a client with Clostridium difficile. Which infection control measure should the nurse include? Correct A. Ask the client to wear a surgical mask during the visit. [6%] B. Obtain vital signs with a disposable blood pressure cuff. [76%] C. Interview the client while maintaining 3 feet distance. [10%] D. Use sterile gloves when performing venipuncture. [9%]

Explanation Choice B is correct. C. diff is a spore-producing bacterium that allows it to be transmitted between clients, environmental surfaces, and contaminated hands. Obtaining vital signs with disposable equipment is recommended to prevent the transmission of this pathogen. Choices A, C, and D are incorrect. The client transmits this pathogen by contact means, not droplets; thus, a mask is unnecessary. Interviewing the client at a spatial distance is not necessary as the pathogen is spread via contact with infected surfaces - not respiratory droplets. Venipuncture requires the use of clean gloves and handwashing. Sterile gloves are not necessary. Additional Info According to the Centers for Disease Control, the transmission of C. diff can be disrupted through: Meticulous hand hygiene with soap and water. Avoid using alcohol-based hand sanitizers. Using disposable healthcare equipment, such as blood pressure cuffs and stethoscopes. Disinfect surfaces with a bleach solution. Discontinuing unnecessary antibiotics.

While working on the pediatric floor, you are assigned a client with impetigo. Which of the following actions do you take to prevent the spread of this disease? Correct A. Initiate standard precautions [24%] B. Initiate contact precautions [69%] C. Initiate droplet precautions [6%] D. Initiate airborne precautions [2%]

Explanation Choice B is correct. Clients with impetigo need to be placed on contact precautions to prevent the spread of this highly contagious disease. According to the CDC, these precautions are "for clients who may be infected or colonized with specific infectious agents for which additional precautions are needed to prevent infection transmission. Contact precautions will be used for any disease in which direct contact with the infectious organism can cause illness. This includes impetigo and other conditions such as viral gastroenteritis, MRSA, and scabies. Contact precautions will be required before entering the room; a gown and gloves are donned. Choice A is incorrect. According to the CDC, "standard precautions are used for all client care. They're based on a risk assessment and make use of common-sense practices and personal protective equipment (PPE) use that protect healthcare providers from infection and prevent the spread of infection from client to client." Standard precautions include performing hand hygiene, using PPE when there is possible exposure to infectious material, properly cleaning equipment and instruments as well as following safe injection practices. For impetigo, standard precautions are not enough. This is a highly contagious disease that will require more precautions. Choice C is incorrect. Droplet precautions are not the appropriate type of precautions for a client with impetigo. Droplet precautions should be initiated for any client with an illness that may be spread through droplet particles. This includes influenza, pertussis, rubella, and many others. Impetigo is transmitted through direct contact with the bacteria on the skin, not through droplet particles. In droplet precautions, a face mask and gloves must be donned to prevent transmission. Choice D is incorrect. Airborne precautions are not the appropriate type of precautions for a client with impetigo. Airborne precautions should be initiated for any client with an illness that may be spread through particles that survive in the air. This type of transmission occurs with diseases such as TB, varicella, and measles. Particular kinds of respirators must be used to prevent transfers, such as an N95 or a PAPR. Additional

The nurse is performing data collection on a client experiencing psychosis. The client states, "I am convinced my wife and brother-in-law want to kill me." The nurse interprets this statement as a Correct A. delusion of reference. [16%] B. delusion of persecution. [64%] C. delusion of grandeur. [15%] D. delusion of erotomania. [6%]

Explanation Choice B is correct. Delusion of persecution is when an individual is falsely convinced someone is out to get them or intends to cause them harm. This is a serious delusion because the client may react with violence. Choices A, C, and D are incorrect. A delusion of reference is when an individual is convinced that something they are observing is explicitly meant for them. For example, a client is watching a television newscast about a wanted individual and is convinced that the individual is them. Delusion of erotomania occurs when an individual is convinced that someone is in love with them. Delusion of grandeur is when an individual has a self-inflated view of themselves. Additional Info Key interventions for a client experiencing a delusion include - Build trust by being open, honest, genuine, and reliable. Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner. Ask the client to describe their beliefs. Do not use avoidance. Inquire about the delusion and its content. Never debate the delusional content. Validate if part of the delusion is real. Example - "Yes, there was a package at the nurses' station, but it did not contain a recording device."

The nurse is discharging a client following knee arthroplasty. Which of the following information should the nurse reinforce in the discharge teaching? Correct A. "After this procedure, you will use a wheelchair to get around." [9%] B. "You will need to resume your anticoagulants." [51%] C. "Placing a pillow under your knee will help with the pain." [31%] D. "You may ice the site for one hour at a time." [9%]

Explanation Choice B is correct. Following a knee arthroplasty, the cliets will not be as mobile and require crutches. This may increase their risk of developing venous thromboembolism (VTE). Thus, the nurse should reiterate that the clients resume their prescribed anticoagulants or initiate them if they are newly prescribed. Evidence-based guidelines recommend that clients undergoing total hip or total knee arthroplasty receive anticoagulant prophylaxis for a minimum of 14 days. Choice A is incorrect. A wheelchair is not typically utilized following knee arthroplasty. Choice C is incorrect. Using a pillow underneath the knee may increase the risk of flexion contracture and should be avoided following the procedure. Choice D is incorrect. Ice may be applied for no more than twenty minutes during the first twenty-four hours. Prolonged ice application may cause skin damage. Learning Objective Recognize that venous thromboembolism is a significant complication of relative immobility following knee arthroplasty and other major lower extremity surgical procedures. The clients should be on venous thromboembolism (VTE) prophylaxis. Additional Info ✓ Knee arthroplasty is a procedure used to correct problems with the joint. The provider may do certain repairs ( joint resurfacing, reconstruction, or replacement ) during the procedure. The nurse must preoperatively ensure that the client is NPO, has completed consent, and has not taken any anticoagulants for a specified amount of time. ✓ Total knee replacement is the most common procedure done during knee arthroplasty, where the joint is entirely replaced by a metal prosthesis. ✓ Deep vein thrombosis and pulmonary embolism ( venous thromboembolism) are the most significant threats after total hip or total knee arthroplasty. Anticoagulant prophylaxis reduces the incidence of venous thromboembolism after these procedures. ✓ Evidence-based guidelines from the American College of Chest Physicians (ACCP) recommend a minimum of 14 days of prophylactic anticoagulation and extending up to 35 days following the surgery.

Which of the following is a priority for assessing a client who is taking digoxin and furosemide? Correct A. Night sweats and headache. [7%] B. Vomiting and halos around lights. [58%] C. Stomach upset and headache. [5%] D. Low blood pressure and dark urine. [29%]

Explanation Choice B is correct. Furosemide causes the client to lose potassium. If taken with a low potassium level, Digoxin can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights. Furosemide and digoxin are often used together but may require more frequent evaluation of digoxin, potassium, and magnesium levels. Clients are encouraged to notify their healthcare provider if they experience any symptoms such as weakness, tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or irregular heartbeats. Additional Info ✓ Other symptoms of digoxin toxicity may include: Confusion or changes in mental status Blurred vision Green or yellow-tinged vision Arrhythmias Weakness or fatigue Palpitations Loss of appetite ✓ Perform frequent nursing assessments to detect any changes in the client's condition, especially during dosage adjustments or when other medications are introduced or discontinued. ✓ Monitor the client's serum potassium levels regularly, as hypokalemia can increase the risk of digoxin toxicity. If the client in question is also receiving furosemide such as the client in this example they would be at a greater risk for hypokalemia.

Which of the following tasks would be appropriate for an LPN (Licensed Practical Nurse) to take? Select all that apply. 3/3 Your Score/Max +/- Scoring Rule Reinforcing teaching to a 24-year-old first-time mother on how to care for her new baby. Adjustment of a 68-year-old patient's cervical traction as ordered by the attending doctor. Obtaining an occult blood sample from a 16-year-old patient with ulcerative colitis.

Explanation Choices A, B, and C are correct. Initial teaching is not within the LPN's scope of practice. However, the LPN may reinforce teaching to a client. Obtaining stool samples and following orders to adjust cervical traction are all within an LPN's scope of practice. A comprehensive admission assessment is also referred to as an initial database, nursing history, or nursing assessment. It is completed when the client is admitted to the nursing unit. These forms can be organized according to health patterns, body systems, functional abilities, health problems/risks, nursing models, or type of health care setting (e.g. labor and delivery, pediatrics, mental health). The registered nurse completes an initial assessment and generally records ongoing assessments or reassessments on flow sheets or nursing progress notes.

The licensed practical/vocational nurse (LPN/VN) is assisting a registered nurse (RN) in gathering supplies for a prescribed transfusion of packed red blood cells (PRBCs). The nurse should obtain which intravenous (IV) fluid to accompany this transfusion? Incorrect Correct Answer(s): B A. Lactated Ringers (LR) [22%] B. 0.9% saline [69%] C. 0.45% saline [8%] D. 3% saline [1%]

Explanation Choice B is correct. Normal saline is the most appropriate intravenous fluid for blood transfusions. 0.9% saline (normal saline) is an isotonic solution and will not cause red blood cell (RBC) hemolysis or clumping. Choices A, C, and D are incorrect. Lactated Ringers (LR) can cause RBC clumping and hemolysis. Additionally, LR has calcium that promotes blood clotting. Therefore, LR is not a preferred fluid with blood transfusions. 0.45% saline is a hypotonic solution, and 3% saline is a hypertonic solution. Both of these IV solutions are inappropriate to co-administer with PRBCs. Learning Objective Recognize that the current guidelines recommend that only normal saline be administered with blood products. Additional Info ✓ The nurse should remain with the client during a transfusion's first fifteen to thirty minutes to observe for a hemolytic or allergic reaction. ✓ The universal blood donor type is O negative; the universal blood type for recipients is AB positive. ✓ A unit of PRBCs should be transfused over 2-4 hours using Y-type tubing.

The nurse is caring for a client who has just been diagnosed with peritonitis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? Correct A. Pantoprazole [14%] B. Ciprofloxacin [73%] C. Lactulose [6%] D. Loperamide [6%]

Explanation Choice B is correct. Peritonitis is an intra-abdominal severe infection that has a significant mortality rate. Peritonitis may originate from perforation (appendix, intestine, etc.), which causes a significant amount of fluid and bacteria to shift into the peritoneum. The priority treatment in peritonitis is administering prescribed antibiotics such as ciprofloxacin, metronidazole, or ceftriaxone. Choices A, C, and D are incorrect. Pantoprazole is a proton pump inhibitor used to treat esophageal reflux and peptic ulcer disease. Lactulose is indicated in the management of hepatic encephalopathy that reduces the amount of ammonia by having the client stool more often. Loperamide is an antidiarrheal effective in the treatment of diarrhea. None of these medications are directly used in the management of peritonitis. Additional Info Clinical manifestations of peritonitis include ✓ Rigid, board-like abdomen ✓ Distended abdomen ✓ High fever ✓ Tachycardia ✓ Diffuse abdominal pain that continues to intensify ✓ Decreased bowel sounds and GI motility

The nurse is caring for a client taking prescribed captopril. What abnormal laboratory values should the nurse prioritize when notifying the healthcare provider? Correct A. Serum creatinine 1.3 mg/dL [Male: 0.6-1.2 mg/dL] [9%] B. Serum potassium 5.2 mEq/L [3.5-5 mEq/L] [62%] C. Serum phosphorus 4.6 [2-4.5 mEq/L] [2%] D. Blood glucose 135 mg/dL [70-110 mg/dL] [25%]

Explanation Choice B is correct. The nurse should prioritize notifying the RN or healthcare provider about the serum potassium level. Captopril, an ACE inhibitor, can cause hyperkalemia (elevated levels of potassium in the blood). Hyperkalemia can lead to cardiac arrhythmias and other serious complications. Choice A is incorrect. A serum creatinine level of 1.3 mg/dL is slightly elevated but not a critical value requiring immediate notification over the potassium level. Choice C is incorrect. A serum phosphorus level of 4.6 mEq/L is slightly elevated but not a critical value that requires immediate notification. Choice D is incorrect. A 135 mg/dL blood glucose level is slightly elevated but not significantly high. It is not an urgent concern that requires immediate notification to the healthcare provider. Additional Info ✓ The ACE inhibitors are a large group of antihypertensive drugs. Currently, there are 10 ACE inhibitors available for clinical use. ✓ Hyperkalemia from ACE inhibitors directly results from its mechanism of action. The blockade of angiotensin II prevents the downstream secretion of aldosterone. ✓ Aldosterone causes reabsorption of sodium and, subsequently, water. Consequently, protons and potassium get secreted into the urine. ✓ Without potassium secretion through aldosterone, potassium can easily increase in clients on ACE inhibitors. ✓ Potassium plays a crucial role in maintaining the heart's electrical activity. When potassium levels are too high, it can disrupt the normal electrical signals in the heart, leading to cardiac arrhythmias. ✓ Angioedema is the most serious adverse effect associated with ACE inhibitors, as it may cause airway obstruction

This nurse is caring for a client who is receiving prescribed tolvaptan. Which of the following findings would indicate a therapeutic response? Correct A. Fasting blood glucose 100 mg/dL [16%] B. Urine specific gravity 1.010 [40%] C. Total cholesterol 176 mg/dL [30%] D. BUN 5 mg/dL [14%]

Explanation Choice B is correct. Tolvaptan is a vasopressin antagonist and is indicated in treating the syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, the client retains water which causes fluid retention without edema. Classic manifestations of SIADH include polydipsia, hemodilution, and oliguria. This medication promotes free water excretion, normalizing sodium levels and increasing urine output. This urine-specific gravity is normal (1.005 - 1.025) and indicates that the medication is having its therapeutic effect because a client with SIADH would have a high USG from the limited water spilled into the urine. Choices A, C, and D are incorrect. Tolvaptan has no direct impact on cholesterol or glucose. A BUN of 5 mg/dL would be expected with SIADH as the excessive water causes a decrease in this value. The normal level for BUN is 10-20 mg/dL. Additional Info ✓ SIADH may be caused by pulmonary tuberculosis and certain lung malignancies. ✓ Clinical features of SIADH include hyponatremia because of excessive water. Other features include increased urine-specific gravity, oliguria, and hemodilution. ✓ Treatment includes prescribed fluid restrictions and tolvaptan. ✓ Tolvaptan causes the excretion of free water, which raises sodium levels. ✓ The client's sodium needs to be monitored carefully while administering this medication because it may cause hypernatremia. ✓ This medication is very hepatotoxic, and the liver function tests should be monitored closely.

The nurse has received four physician orders. The nurse should initially implement which order? See the image below. Correct A. irrigate a wound for a client with a stage III pressure ulcer. [6%] B. complete pin care for a client with a halo fixation device. [8%] C. administer diazepam for a client with delirium tremens (DTs). [55%] D. insert an indwelling urinary catheter for a client with retention. [32%]

Explanation Choice C is correct. Delirium tremens (DTs) is a severe form of alcohol withdrawal. This prescription should be implemented immediately, as the risk of seizure activity is quite significant. Choices A, B, and D are incorrect. These prescriptions require quite a bit of time and are low priority compared to the client experiencing an acute threat of a seizure. The nurse must prioritize actions based on acuity and the time necessary to complete each task. Activities related to discharge are low priority and any dressing changes are also a low priority. Additional Info ✓ Delirium tremens (DTs) are the most severe form of alcohol withdrawal. ✓ Manifestations of DTs include disorientation, hyperthermia, psychomotor agitation, hypovolemia, hallucinations, hypertension, and seizure activity. ✓ To prevent seizure activity and mitigate agitation, benzodiazepines are commonly used. ✓ Maintenance dosing of benzodiazepines may be used along with PRN dosing for additional mitigation of symptoms. ✓ DTs occur within 48 to 96 hours following the last alcoholic drink.

Which of the following healthcare providers are responsible for documenting care provided to a patient? Correct A. The LPNs should document the care they provided and the care given by unlicensed assistive staff. [2%] B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care. [3%] C. All staff members should document all of the care that they have provided. [84%] D. All staff should document all of the care that they have provided, but the registered nurse is the only independent practitioner that signs it. [10%

Explanation Choice C is correct. All staff members, including unlicensed assistive staff like nursing assistants, document and sign all of the care that they have personally provided. For example, the nursing assistants will document the vital signs that they have taken, the licensed practical nurses will document all of the treatments and medications that they have given to the patient, and the registered nurse will document nursing diagnoses and assessments that they have completed. There is an old saying among healthcare professionals that have been passed on to new generations. The saying is, "I don't care what you did; if you didn't document it, you didn't do it." Documentation is an essential part of patient care. A patient's complete medical record is a legal document. Proper documentation means 1. The person who provided care should document what care/treatment/medication was given and how the patient responded. 2. If responsibility is delegated to another person, it should be noted to whom the care was assigned, and proper documentation and follow-up should be done.

Chronic pain is most effectively relieved when analgesics are administered in what manner? Correct A. On a PRN basis [16%] B. Conservatively [4%] C. Around the clock [70%] D. Intramuscularly [10%]

Explanation Choice C is correct. Around-the-clock doses of analgesics are more useful for managing chronic pain. Choice A is incorrect. A PRN protocol is inadequate for clients experiencing chronic pain. Choice B is incorrect. Conservative protocols may prove ineffective. Choice D is incorrect. Intramuscular administration for pain management is not practical on a long-range basis for a client with chronic pain. Additional Info ✓ In chronic pain management, the goal is to achieve consistent pain relief while minimizing the risk of side effects and maintaining the client's overall well-being. ✓ For chronic pain that requires continuous relief, analgesics are often prescribed on a scheduled basis. This means the medication is taken at specific intervals throughout the day, such as every 4, 6, or 8 hours, depending on the drug's duration of action. Scheduled dosing helps maintain a steady level of medication in the bloodstream, providing more stable pain control. ✓ Regular pain assessments are essential to determine if the current analgesic regimen is providing adequate pain relief. Healthcare providers may adjust the dosing frequency or change medications based on the client's feedback and pain scores.

The nurse has received a prescription for celecoxib. Which finding in the client's medical history should prompt the nurse to question the administration of this medication? Correct Answer(s): C A. osteoarthritis [15%] B. gout [15%] C. recent myocardial infarction [61%] D. migraine headaches [9%]

Explanation Choice C is correct. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) used to treat osteoarthritis, gout, dysmenorrhea, and migraine headaches. NSAIDs cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction (MI) and stroke. Choice A is incorrect. Osteoarthritis and rheumatoid arthritis are approved indications for NSAIDs. This is an appropriate indication for celecoxib and does not require follow-up. Choice B is incorrect. Gout attacks can be managed by administering prescribed antiinflammatories such as naproxen, colchicine, or ibuprofen. This is an appropriate indication for celecoxib and does not require follow-up. Choice D is incorrect. During an acute migraine headache, the client may be prescribed an NSAID, such as celecoxib. This is an appropriate indication for celecoxib and does not require follow-up. Additional Info ✓ NSAIDs include ibuprofen, naproxen, oxaprozin, celecoxib, and ketorolac Naproxen, salicylate acid, acetaminophen, ibuprofen, ketoralac ✓ NSAIDs are efficacious for pain or pyrexia ✓ NSAIDs are nephrotoxic; therefore, monitoring renal function (BUN and creatinine) is essential ✓ NSAIDs may adversely cause gastrointestinal bleeding, renal insufficiency, myocardial infarction (MI), or stroke ✓ Clients with peptic ulcer disease, congestive heart failure, renal injury, or a previous MI should not use NSAIDs

The nurse is setting up the room for a patient newly diagnosed with Celiac disease. She knows to place the patient on which of the following precautions? Correct A. Droplet precautions [3%] B. Contact precautions [12%] C. Standard precautions [70%] D. Neutropenic precautions [15%]

Explanation Choice C is correct. Celiac disease requires standard precautions. It is not an infectious disease and is not transmitted from person to person; therefore, there is no reason to initiate any additional precautions. Choice A is incorrect. Droplet precautions are not indicated for the patient with Celiac disease. It is not an infectious disease and is not transmitted from person to person. Droplet precautions are indicated when there is an infection that can spread by speaking, sneezing, or coughing near someone. Examples include influenza, adenovirus, and rhinovirus. Choice B is incorrect. Contact precautions are not indicated for the patient with Celiac disease. It is not an infectious disease and is not transmitted from person to person. Contact precautions are indicated when there is an infection that can spread by touching the patient or items in the room. Examples include MRSA and VRE. Choice D is incorrect. Neutropenic precautions are not indicated for the patient with Celiac disease. Neutropenic precautions are indicated when the patient is immunocompromised and at additional risk for infection. This is not true with Celiac disease. Examples of patients on neutropenic precautions may be those who have received a transplant, or who have a low absolute neutrophil count due to cancer or chemotherapy.

Which of the following statements regarding mass casualty events are true? Select all that apply. 3/3 Your Score/Max +/- Scoring Rule Mass casualties are events that overwhelm local medical capabilities. When a mass casualty occurs, there is a need to increase the staff at the hospital. Many local agencies will collaborate to handle a mass casualty situation. An example of a mass casualty event is a fight between visitors in the intensive care unit.

Explanation Choices A, B, and C are correct. A is correct. Mass casualties are events that overwhelm local medical capabilities. Another term for a mass casualty event is a disaster. B is correct. When a mass casualty occurs, there is a need to increase the hospital staff to provide safe client care to everyone involved in the event. C is correct. Many local agencies will collaborate to handle a mass casualty situation. Collaboration between multiple agencies and health care facilities will be necessary to provide safe care and proper handling of the crisis. Choice D is incorrect. A fight between visitors in the intensive care unit is a security and local law enforcement issue, not a mass casualty event.

The nurse is caring for a client prescribed dutasteride. The nurse understands this medication had achieved its therapeutic effect when the client reports decreased symptoms of Correct A. pyrosis. [13%] B. hypothyroidism. [7%] C. urinary retention. [64%] D. anxiety. [15%]

Explanation Choice C is correct. Dutasteride works by inhibiting this enzyme 5-alpha reductase, which normally converts testosterone to 5-alpha dihydrotestosterone (DHT). DHT is a more potent form of testosterone and is the principal androgen responsible for stimulating prostatic growth. The growth of the prostate may cause BPH, therefore, causing overflow incontinence which is manifested as urinary retention. Decreased size of the prostate and less urinary retention is a therapeutic findings of this medication. Choices A, B, and D are incorrect. Dutasteride is not indicated for any of these conditions. Additional Info BPH is often treatable with a 5-alpha reductase inhibitor. There are currently two such drugs: finasteride and dutasteride. Finasteride (Proscar), the prototypical drug for this class, works by inhibiting this enzyme, which normally converts testosterone to 5-alpha dihydrotestosterone (DHT). DHT is a more potent form of testosterone and is the principal androgen responsible for stimulating prostatic growth, as well as the expression of other male primary and secondary sex characteristics. Because these medications suppress DHT, the biggest adverse effect for men is decreased libido and erectile dysfunction. Caution must be taken when handling these medications because they are quite teratogenic, and pregnant women should handle the drug while wearing gloves.

The nurse supervises a student nurse assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse Correct A. puts the client's affected (weaker) arm in the shirt's sleeve first. [12%] B. places shoes with velcro straps on the client's feet. [6%] C. places the wheelchair as close to the bed as possible on the client's affected (weaker) side. [78%] D. places the hairbrush in the client's unaffected (stronger) hand. [3%]

Explanation Choice C is correct. Placing the wheelchair as close to the bed as possible on the client's affected (weaker) side requires follow-up because the client should be mobilized by having the wheelchair on their unaffected (stronger) side. This requires follow-up because the client is at risk of falling and injury. Choice A is incorrect. This action is appropriate, and the client should be instructed to use their unaffected (stronger) arm to dress the affected (weaker) side first. Choice B is incorrect. This action is appropriate. In lieu of using laces and frustrating the client, velcro straps on clothing and shoes are encouraged. Choice D is incorrect. The hairbrush should be placed on the client's stronger side so they can effectively comb their hair. Additional Info ✓ The client should use the arm that is still mobile to put on clothing, starting with the affected side first. To undress, the client should start by taking off clothes from the unaffected side. ✓ Velcro shoes are preferred over shoes with laces. ✓ When mobilizing a client, they should be positioned on their unaffected (stronger) side to be transferred to a chair or wheelchair.

Which of the following healthcare team members is paired with the primary function related to their role? Correct A. An occupational therapist assisting with gait exercises. [6%] B. A physical therapist offering the provision of assistive devices to be used with activities of daily living. [21%] C. A speech or language therapist addressing swallow disorders. [66%] D. An RN case manager ordering therapies and medications. [6%]

Explanation Choice C is correct. Speech/language therapists assess and treat patients with swallowing disorders, and with communication and speech problems that occur following a stroke. Understanding the role of each member of the healthcare team is essential. It helps foster accountability within the organization and also helps to ensure that each person acts within his/her role. Choice A is incorrect. Occupational therapists assist clients with ADLs and provide assistive devices. Choice B is incorrect. Physical therapists perform restorative and rehabilitative care including helping clients with balance/gait exercises and ambulation. Choice D is incorrect. Case managers coordinate care along the continuum of care, and they manage insurance reimbursements. Physicians order medications and therapies.

The nurse working on a medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? Correct A. Initiates a referral for a patient needing home health care. [5%] B. Performs a central line dressing change on a patient receiving 0.9% saline infusion. [14%] C. Collects a urine specimen from a patient's indwelling urinary catheter. [10%] D. Obtains capillary blood glucose for a patient receiving continuous regular insulin. [70%]

Explanation Choice D is correct. A client receiving continuous regular insulin infusion requires hourly capillary blood glucose checks because of the high risk of hypoglycemia. Regular insulin via intravenous infusion peaks within fifteen to thirty minutes. Thus, the nurse needs to watch for signs of hypoglycemia, including tachycardia, palpitations, and diaphoresis. Choices A, B, and C are incorrect. Initiating a client referral, performing a central line dressing change, and obtaining a urine specimen are low priority items compared to a client receiving a high-risk medication, especially via a route that allows for a rapid peak. Additional Info ✓ Prioritizing client care is central to functioning as a nurse. ✓ While obtaining blood glucose may appear as an intermediate priority, when a client is receiving a high-risk medication such as insulin, the nurse must assess the client for any potential complications. ✓ Prioritizing care involves identifying and addressing the most critical needs of clients based on their condition, the severity of their symptoms, and the potential impact on their health outcomes.

Which of the following are potential complications of cleft lip and cleft palate in the infant? Select all that apply. 3/3 Your Score/Max +/- Scoring Rule Ear infections Feeding difficulties Weight gain Speech delay

Explanation Choices A, B, and D are correct. A is correct. When a child has a cleft lip and cleft palate, the tissue and bone inside their mouth are not appropriately fused. This means there is a space between their upper lip and palate. Ear infections will be a frequent complication for these patients due to the dysfunction of the eustachian tube, which connects the middle ear and the throat. B is correct. Feeding issues are a common complication of cleft lip and cleft palate because it is harder for these infants to eat with the abnormality in their palate. The space in the roof of the mouth makes it very hard to suck and get a good seal around the bottle or nipple. D is correct. Speech delays and language delays are both common complications of cleft lip and cleft palate. This is because the roof of the mouth and lip have spaces where they should not, which decreases muscle function and leads to delayed or abnormal speech. Many of these infants will require consultation with a speech-language pathologist.

The nurse is speaking with a client that underwent an ileostomy one month ago. The client states that the ostomy's odor is causing embarrassment. The nurse investigates the food that the client consumes and initiates further health teaching when the client mentions the following menu item: Correct Answer(s): D A. Buttermilk [17%] B. Parsley [12%] C. Yogurt [11%] D. Eggs [59%]

Explanation Choice D is correct. Eggs, asparagus, alcohol, fish, onions, cabbage, and grapes are just a small sampling of the foods known to cause foul-smelling stools, gas, and/or increased foul odors, which ostomy clients often report as concerning. These clients should be educated and provided with a comprehensive list of foods to avoid to reduce the likelihood of omitting foul odors from their ileostomy. Choice A is incorrect. Buttermilk helps alleviate gas and odor in ileostomy clients. Therefore, it is considered a deodorizing food for these clients. Choice B is incorrect. In ileostomy clients, parsley is considered a deodorizing food, as it helps alleviate gas and odor. Choice C is incorrect. Yogurt (with active cultures) is considered a deodorizing food, as it often helps relieve gas and odor in clients with an ileostomy. Learning Objective When speaking with a client that underwent an ileostomy one month ago and currently reporting embarrassment caused by the ostomy's odor, identify the need for further health teaching once the client mentions the consumption of eggs in their diet due to the connection between eggs and foul-smelling stools, gas, and/or increased foul odors in ostomy clients.

The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take? Correct Answer(s): D A. Place a box of disposable respirators inside the client's room [14%] B. Remove alcohol-based sanitizers from the client's room [1%] C. Assign the client to a private room with a positive airflow [28%] D. Remove the portable fan from the client's bedside table [56%]

Explanation Choice D is correct. For a client on either airborne or droplet precautions, the nurse should not allow (and remove) any portable fans, as these may propel pathogens and assist in disease transmission. If the client has a fever, nonpharmacological treatment options such as a cool compress or a tepid bath should be used. Choices A, B, and C are incorrect. These actions are not appropriate. The respirators should be kept outside the client's room to prevent contamination. The nurse should walk into the client's room with the respirator donned. Therefore, the nurse should apply the respirator outside of the room. Alcohol-based sanitizers (ABS) should be kept inside the room as an effective method for hand hygiene. ABS should be removed from rooms housing clients with pathogens such as C. diff as they are ineffective against this spore bacteria. The client with pulmonary tuberculosis should be assigned to a private room with negative air pressure. The purpose of negative pressure (airflow) rooms is to prevent infectious particles from flowing from one room to another room and the air handling system.

The nurse is caring for a 5-year-old patient whose family is of Orthodox Jewish faith. The mother expresses that she wishes for the patient to remain kosher while in the hospital. Which of the following actions would best respect that request while assisting the child with his lunch? Incorrect Correct Answer(s): D A. Finding metal utensils instead of plastic. [13%] B. Placing the food on plastic plates instead of paper. [5%] C. Helping the child unwrap the plastic utensils from their packaging. [5%] D. Allowing the child and his mother to unwrap the eating utensils. [77%]

Explanation Choice D is correct. It is appropriate to allow the child and the mother to unwrap the eating utensils. This is the only action listed that allows the child and the mother to remain kosher as requested. Choice A is incorrect. It is inappropriate for the nurse to replace metal utensils in place of the utensils that come with the tray. Kosher meals will arrive on paper plates with sealed plastic utensils which the nurse should not open. Choice B is incorrect. It is inappropriate for the nurse to transfer the food to another dish. The nurse should deliver the tray to the client on the paper plate that it arrives on. Choice C is incorrect. It is inappropriate to help the child unwrap the plastic utensils from their packaging. The nurse should deliver the paper plate and sealed plastic utensils directly to the client and the mother. The mother can assist in the unwrapping, but the nurse should not do it for the client unless otherwise instructed.

The nurse is caring for a client with schizophrenia. The nurse should anticipate a prescription for which medication? Correct A. lithium [25%] B. bupropion [10%] C. sertraline [12%] D. risperidone [52%]

Explanation Choice D is correct. Schizophrenia is treated with antipsychotic medications. Typical (or first-generation) antipsychotic drugs include haloperidol, fluphenazine, and chlorpromazine. Atypical (second generation) antipsychotic medications include quetiapine, ziprasidone, and risperidone. Choices A, B, and C are incorrect. Lithium is indicated for the treatment of Bipolar disorder. Bupropion is an atypical antidepressant indicated in major depressive disorder. Sertraline is a selective serotonin reuptake inhibitor and is indicated for major depressive and anxiety disorders. Additional Info ✓ Schizophrenia is a psychotic disorder characterized by positive (hallucinations) and negative symptoms (lack of motivation). ✓ Most cases of schizophrenia have an onset in adolescence. ✓ Acute stabilization and maintenance treatment is accomplished by prescribed antipsychotic medications such as risperidone, haloperidol, or fluphenazine.

Which of the following is not an example of an inspection? Select all that apply. Heart rate and rhythm irregular Abdomen tympanic Lungs clear Skin is clear

Explanation Choices A, B, and C are correct. Each of these answer choices is an example of auscultation. Inspection is the first technique of the overall general survey and should be done for each body part because it generally provides a wealth of information. The purpose of gathering data during the initial phase is to gain an overall impression of the client and assess for severity. Observing for cues that might indicate a position that needs immediate attention is essential. The nurse should first consciously see the client for physical characteristics, behaviors, and note any odors. The client should be seen for overall attributes, including gender, level of alertness, body size and shape, skin color, hygiene, posture, and level of discomfort or anxiety. Global observation is called the general survey and is done intentionally. With experience, gathering information from inspection becomes automatic. Choice D is incorrect. Assessing that the skin is clear is achieved by inspecting the skin. Additional Info ✓ The nurse begins by visually inspecting the skin, looking for any changes in color, texture, temperature, and integrity. They assess the entire body, paying attention to areas that are commonly prone to skin problems, such as bony prominences, pressure points, and areas covered by medical devices or dressings. ✓ Ensure the client's privacy and maintain their comfort during the skin inspection. Provide a warm and well-lit environment for the assessment. ✓ Collaborate with other healthcare team members, such as registered nurses, wound care specialists, or physicians, as needed, to share findings and develop a comprehensive care plan.

The nurse has become aware of the following client situations. The nurse should first assess the client Incorrect Correct Answer(s): D A. with chronic obstructive pulmonary disease (COPD), who is using pursed-lip breathing and reporting a productive cough. [15%] B. who had a laparoscopic cholecystectomy three hours ago and is reporting right shoulder pain and abdominal cramping. [22%] C. with ulcerative colitis, who had three bloody stools in the past two hours and reporting abdominal cramping. [12%] D. two hours postoperative following a tonsillectomy and is reporting throat pain while vomiting. [52%]

Explanation Choice D is correct. The client's vomiting following a tonsillectomy requires immediate follow-up because vomiting and coughing may trigger hemorrhage. This client requires immediate follow-up so the nurse may treat the vomiting with prescribed anti-emetics and assess the client for potential hemorrhage. Choices A, B, and C are incorrect. A client with COPD experiencing a productive cough and experiencing pursed-lipped breathing is an expected finding. Further, coughing indicates a patent airway. This client does not require immediate follow-up. A client recovering from laparoscopic procedures will likely have abdominal cramping and shoulder pain because of gastric insufflation (the process of instilling air or carbon dioxide into the abdominal cavity to visualize the abdominal organs); this is often relieved by having the client ambulate. An exacerbation of ulcerative colitis often causes a client to have multiple blood stools that accompanied by abdominal cramping. This is an expected finding. Additional Info ✓ Following a tonsillectomy, the nurse should discourage coughing as this may stress the operative site and lead to hemorrhage ✓ Nausea and vomiting following a tonsillectomy should be promptly treated to prevent stress to the operative that may lead to hemorrhage

After receiving a report on the medical-surgical floor, which of the following clients should the nurse see first? Incorrect Correct Answer(s): D A. A client with a respiratory rate of 24 and an oxygen saturation of 92%. [23%] B. A client that is scheduled for stomach surgery in two hours related to peptic ulcer disease. [1%] C. A client that is six hours post-op from a hysterectomy and is complaining of nausea. [7%] D. A client that had a cast applied two hours ago and now has complaints of her arm feeling like it is "asleep". [69%]

Explanation Choice D is correct. The patient with a cast that describes her arm as feeling like it's asleep is likely experiencing impaired circulation. This patient should be assessed first, and the physician should be notified. Prioritizing patient care related to each patient's status is a critical skill. While all patients are essential and must be monitored, the ability to recognize a potential complication before it gets out of hand and causes more damage is crucial. Choice A is incorrect. Although the increased respiratory rate and lower O2 saturation may cause concern, there is nothing in this scenario that suggests the patient is in distress. Choice B is incorrect. This patient has no complaints and can be evaluated after the patient is experiencing compromised circulation. Choice C is incorrect. Complaining of nausea after a hysterectomy is a potential problem that is often expected. It is not, however, of immediate concern.

he nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication? Correct A. 19 gauge, 1 1/2" (3.8 cm) needle [3%] B. 18 gauge, 1" (2.5 cm) needle [11%] C. 20 gauge, 1" (2.5 cm) needle [14%] D. 25 gauge, 5/8" (1.6 cm) needle [71%]

Explanation Choice D is correct. This needle size and gauge are appropriate for a neonate. When administering IM medications to a neonate or young child, the vastus lateralis is the preferred site. For the volume to be administered in an IM, it is recommended to be 0.5 mL or less for infants; up to 2 mL for children. Choices A, B, and C are incorrect. These needle sizes are not recommended for infants as they can cause excessive pain and trauma to the muscle. Additional Info ✓ A key advantage of using the vastus lateralis is that an intramuscular (IM) injection may be given if the client is supine, side-lying, or sitting. ✓ Aspiration for routine injections into deltoid or vastus lateralis is not indicated because there are no large blood vessels in these locations. ✓ To locate the vastus lateralis, the nurse should palpate to find greater trochanter and knee joints; divide vertical distance between these two landmarks into thirds; inject into middle third.

When assessing the posterior tibial pulses, what is the correct method to document that the client's pulse is weak and thready? Correct A. Grade C posterior tibial pulse. [7%] B. Posterior tibial pulse is Grade B. [5%] C. The client's posterior tibial is +2. [22%] D. Posterior tibial pulse is +1. [65%]

Explanation Choice D is correct. When assessing pulses, the strength, volume, and fullness of the peripheral pulses are categorized and documented as follows: 0: Absent pulses 1: Weak pulse 2: Normal pulse 3: Increased volume 4: Abounding pulse Choices A and B are incorrect. Alphabetical grades and grading are not used to document pulses. Choice C is incorrect. The pulse is weak and thready, not normal. Additional Info ✓ Use gentle and consistent pressure while palpating the posterior tibial pulses to accurately assess their strength. Assess the pulses on both sides for comparison and to ensure accuracy. ✓ If the pulses are consistently weak and thready, as this problem states, the LPN should collaborate with the healthcare team to determine the appropriate interventions or follow-up assessments. ✓ Provide privacy during the assessment to ensure the client's comfort and dignity.

Which of the following are important nursing interventions for a client before going down for a cardiac catheterization? Select all that apply. 2/2 Your Score/Max +/- Scoring Rule Verify if they have any allergies. Check their BUN and creatinine levels. Check their CBC for WBC level. Administer acetaminophen.

Explanation Choices A and B are correct. A is correct. It is essential to verify if a client has any allergies before any procedure. We must know if there are medications that are unsafe to administer to this client. We are explicitly verifying that the client is not allergic to iodine or shellfish. This is important because an iodine-based dye is used during cardiac catheterization to visualize the vessels. Should you discover that the client is allergic to iodine or shellfish, contact the health care provider immediately, and do not administer the dye. B is correct. Verifying that the client has a normal BUN and creatinine is essential before beginning a cardiac catheterization. Because there is a large amount of iodine-based dye injected during this procedure, the kidneys must be functioning well to excrete the dye. If the client has poor BUN and creatinine, it can lead to severe kidney injury.

Which of the following should the nurse include in the education provided to a client who is taking lisinopril? Select all that apply. 2/3 Your Score/Max +/- Scoring Rule "It may take several months for your blood pressure to return to normal." "You must have your potassium monitored from time to time." "This medication may change your vision at times." "You may notice a change in your sensation of taste."

Explanation Choices A, B, and D are correct. A: Lisinopril may require 2-3 weeks of adjustment to reach maximum effectiveness. Several months of therapy may be needed for a client's functional status to return to normal. B: High potassium levels may occur during therapy. The use of potassium supplements or potassium-sparing diuretics should be avoided. Electrolyte levels should be monitored periodically. D: Other side effects associated with lisinopril include cough, taste disturbances, and hypotension. Angiotensin-converting enzyme (ACE) inhibitors reduce the afterload on the heart and lower blood pressure. They are drugs of choice in the treatment of heart failure. ACE inhibitors have been shown to slow heart failure progression and reduce deaths from heart disease. The first action of ACE inhibitors is to lower blood pressure and reduce blood volume. Choice C is incorrect. Visual disturbances are not an anticipated possible side effect associated with lisinopril. Additional Info ✓ Advise clients to avoid taking potassium supplements or consuming high-potassium foods while on lisinopril, unless specifically instructed by their healthcare provider. ✓ Emphasize the importance of taking lisinopril exactly as prescribed by the healthcare provider. Clients should understand that consistent and regular dosing is critical for the medication's effectiveness in controlling blood pressure and managing their condition. Skipping doses or stopping the medication abruptly can lead to uncontrolled blood pressure and may result in complications. ✓ Inform clients about the risk of orthostatic hypotension when starting lisinopril or increasing the dose. Instruct clients to rise slowly from a sitting or lying position to minimize the risk of dizziness, lightheadedness, or falls. If they experience any symptoms of orthostatic hypotension, they should report it to their healthcare provider.

The licensed practical/vocational nurse (LPN/VN) has reinforced medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply. 2/3 Your Score/Max +/- Scoring Rule "I may still need pain medication while this patch is applied." "If the patch comes loose, I may reinforce it with a piece of tape." "I can apply heat to the patch site to increase the pain relief." "I should remove this patch while I am sleeping." "The patch will need to be changed every 72 hours."

Explanation Choices A, B, and E are correct. A variety of routes, including transdermal patches, can deliver fentanyl. This patch is effective for around-the-clock pain control, but the client may still experience breakthrough pain requiring a more immediate release type of pain control. The client may reinforce the patch with tape if it starts to loosen. The fentanyl patch should be changed every 72 hours, with a new patch applied to a new site. Choices C and D are incorrect. Heat should not be applied to a fentanyl patch. This may result in the medication being rapidly discharged and could cause the client to experience opioid toxicity. The fentanyl patch is intended to provide around-the-clock pain control; thus, it would be inappropriate for the client to remove it while sleeping. Additional Info ✓ Fentanyl is an opioid that can be delivered in various preparations (intravenous, transdermal, buccal). ✓ The transdermal patch effectively provides a patient with continuous pain control for 72 hours. ✓ This medication will take 24 hours to reach its peak effect, and the nurse should anticipate the patient to experience breakthrough pain. ✓ Fentanyl patches should be applied to a clean area with minimal hair. Hair may be clipped but not shaven to ensure appropriate adhesion to the skin.

The nurse is caring for a client who is struggling with severe depression. Which of the following statements would demonstrate effective therapeutic communication with this client? Select all that apply. 2/2 Your Score/Max +/- Scoring Rule "Great work today in group therapy Steve, you were really talkative today!" "I'd like to just sit with you for a while Steve." "Tell me how you're feeling Steve. I'd like to understand." "Why are you feeling depressed today Steve?" "I know exactly how you feel. I've been through the same thing."

Explanation Choices B and C are correct. B is correct. In this scenario, the nurse offers to sit in silence with the client. Therapeutic silence with individuals struggling with depression can create a safe and reflective space, foster deeper communication, encourage self-reflection and emotional processing, reduce pressure and anxiety, enhance active listening, and promote self-expression. C is correct. Effective therapeutic communication aims to establish trust, provide support, and encourage the client's expression of thoughts and feelings. Asking open-ended questions in a supportive, non-judgmental way offers support to the depressed client.

1820: 42-year-old male endorsing right-sided flank pain, nausea, vomiting, dysuria, increased urinary frequency, and hematuria. The symptoms started twelve hours ago and have worsened. The client reports the pain as a '9' (0-no pain; 10-extreme pain). He states the pain is further exacerbated with urination, described as 'sharp and throbbing.' He says he recently ran out of prescribed medications because he lost his job. He has a medical history of major depressive disorder, gout, hypertension, and hyperlipidemia.

Explanation If a client is discharged with nephrolithiasis, they should be instructed to increase their daily fluid intake to three liters or more per day. These fluid choices should not be caffeinated because caffeine is a bladder irritant and may cause fluid depletion. The client should report intensification of pain, anuria, fever, or chills. Fever or chills should be reported because this could be suggestive of pyelonephritis. The client should strain their urine and hold onto their stone until the follow-up appointment. The stone can be sent for processing to determine its type (cystine, uric acid, struvite, calcium oxalate). Additional Info Nephrolithiasis is when stones form in the kidney ➢ Risk factors include dehydration, metabolic conditions such as gout, male gender, and previous urinary stone ➢ Treatment depends on the size of the stone, as most stones < 5 mm pass with minimal medical intervention ➢ Treatment goals include saturating the urine with water to facilitate passage and other prescriptive treatments such as tamsulosin to dilate the urinary tract ➢ Pain control is a priority and is accomplished with NSAIDs such as ketorolac or naproxen ➢ The client should be educated to prevent recurrence by increasing fluid intake and modifying their diet

72-year-old male presents to the emergency department Item 4 of 6 Orders Additional Nursing Note Admit to involuntary status Provide enhanced observation Regular diet Consult psychiatry

Explanation When a client is admitted involuntarily, they still retain the client bill of rights. It would be appropriate to provide information on how a client may obtain their medical record because this is a right afforded to the client. It would also be appropriate to inform the client that leaving the facility is prohibited while being admitted involuntarily. It is not appropriate to restrict visitors or open postal packages prior to giving them to the client. The client has the right to privacy, opening postal packages, and denying the client phone privileges would violate their bill of rights. Finally, rounding the client at regular intervals is discouraged. It would be appropriate to round on the client at irregular intervals to decrease predictability and enhance client surveillance. The nurse updates the nursing note with an entry at 1450 and receives orders from the primary healthcare provider (PHCP) The nurse is developing the plan of care for this client. For each possible intervention, click to specify whether or not the intervention is appropriate Restrict the client's visitors NOT Open letters and packages before giving them to the client NOT Provide information on how to obtain their medical record YES Round at frequent and regular intervals NOT Inform the client that they may not leave the facility YES Explanation When a client is admitted involuntarily, they still retain the client bill of rights. It would be appropriate to provide information on how a client may obtain their medical record because this is a right afforded to the client. It would also be appropriate to inform the client that leaving the facility is prohibited while being admitted involuntarily. It is not appropriate to restrict visitors or open postal packages prior to giving them to the client. The client has the right to privacy, opening postal packages, and denying the client phone privileges would violate their bill of rights. Finally, rounding the client at regular intervals is discouraged. It would be appropriate to round on the client at irregular intervals to decrease predictability and enhance client surveillance.

The nurse is caring for a client who is immediately postoperative. It would be appropriate for the nurse to initially data collect on the client's Correct A. respiratory status. [65%] B. level of consciousness. [29%] C. level of pain. [4%] D. ability to move extremities. [1%]

Explanation Choice A is correct. Respiratory status should always be given priority in any assessment. Data collection for a client immediately postoperative is continuous, using preoperative and intraoperative data as bases for comparison. The data collection performed on a client who is immediately postoperative includes respiratory status (airway, pulse oximetry), cardiovascular status (blood pressure), temperature, central nervous system status (level of alertness, movement, shivering), fluid status, wound status, GI status (nausea and vomiting), and general condition. These assessments are initially made every 10 to 15 minutes. Choices B, C, and D are incorrect. Although all of these answer options should be addressed, the nurse's first priority is that of stable respiratory status.

Which action taken by the school nurse will have the most impact on the incidence of infectious disease in the school? Correct Answer(s): A A. Ensure that students are immunized according to national guidelines. [59%] B. Provide written information about infection control to all patients. [2%] C. Make soap and water readily available in the classrooms. [26%] D. Teach students how to cover their mouths when coughing. [12%]

Explanation Choice A is correct. The incidence of once-common infectious diseases such as measles, chickenpox, and mumps have been most effectively reduced by immunization of all school-aged children. School-aged children are at risk for exposure to viruses, respiratory infections, and parasitic infections (such as scabies or lice). Vaccination protects children from severe illness and complications of vaccine-preventable diseases, including amputation of an arm or leg, paralysis of limbs, hearing loss, convulsions, brain damage, and death.

The nurse should understand the regulations of nursing practice as put forth by the Nurse Practice Act. Which of the following statements are correct? Select all that apply. Some other issues covered by the Nurse Practice Act include grounds for disciplinary action, licensure requirements, and the rights of the nurse licensee if disciplinary action is taken. The Nurse Practice Act defines the scope of nursing practice. All nurses have the responsibility to know the provisions of the act for the state or province in which they work. The Nurse Practice Act is a series of statutes enacted by the federal government in order to regulate the practice of nursing.

Explanation Choices A and B are correct. Nurse practice acts (NPAs) contain a provision that creates and empowers a state board of nursing to regulate nursing practice in that state. All 50 states, the District of Columbia, and the four U.S. territories have established nursing boards. Although NPAs can vary from state to state, they all have standard components because states used ANA guidelines in developing their regulations. A state's nurse practice act usually includes the following: The authority of the board of nursing, its composition, and powers A definition of nursing and the boundaries of nursing practice Standards for the approval of nursing education programs The requirements for licensure of nurses Grounds for disciplinary action against a nurse's license

The emergency department (ED) nurse is caring for a 42-year-old reporting flank pain Item 2 of 6

For each finding below, click to specify if the findings are consistent with the disease process of cystitis or urolithiasis. Each finding may support more than one disease process. Note: Each column must have at least one response option selected Dysuria. C/N Flank pain. N Increased urinary frequency. C/N Nausea and vomiting. N

72-year-old male presents to the emergency department Item 3 of 6 Nurses' Notes 1430 - A 72-year-old white male stated he hasn't felt good lately and feels sad much of the time. He becomes tearful when telling you about the loss of his wife eight months ago. He states he feels lonely and hopeless. The client also stated that the osteoarthritis he was diagnosed with five years ago has worsened. He stated that lately, he gets tired easily but has difficulty falling and staying asleep. He reported that the only activity he has maintained is attending church services.

The greatest concern for this client is SUICIDE evidenced by the client's FEELINGS OF HOPELESSNESS

1820: 42-year-old male endorsing right-sided flank pain, nausea, vomiting, dysuria, increased urinary frequency, and hematuria. The symptoms started twelve hours ago and have worsened. The client reports the pain as a '9' (0-no pain; 10-extreme pain). He states the pain is further exacerbated with urination, described as 'sharp and throbbing.' He says he recently ran out of prescribed medications because he lost his job. He has a medical history of major depressive disorder, gout, hypertension, and hyperlipidemia.

The nurse is prioritizing emergency care for this client Complete the sentence below by choosing the correct option The priority nursing for this client is administering prescribed pain control.

72-year-old male presents to the emergency department Item 1 of 6 Nurses' Notes 1430 - A 72-year-old white male stated he hasn't felt good lately and feels sad much of the time. He becomes tearful when telling you about the loss of his wife eight months ago. He states he feels lonely and hopeless. The client also stated that the osteoarthritis he was diagnosed with five years ago has worsened. He stated that lately, he gets tired easily but has difficulty falling and staying asleep. He reported that the only activity he has maintained is attending church services.

Which four (4) assessment findings require further investigation by the nurse? Feelings of hopelessness CHECK Worsening osteoarthritis Only attending church services Feelings of loneliness. CHECK Loss of his wife eight months ago CHECK Sleep disturbances. CHECK Explanation The client is exhibiting depressive symptoms that are a concern for suicidality. His hopelessness, loneliness, the recent loss of his wife, and sleep disturbances were all quite concerning. Hopelessness is a very significant risk factor for suicide because it inhibits forward-thinking by the client. Consequently, the client's loneliness from losing his wife is also a risk factor for suicide. This significant disruption in a support system likely stems from the client's dysphoria. Insomnia is a risk factor for suicide ideations and further characterizes the client's depression.

The emergency department (ED) nurse is caring for a 42-year-old reporting flank pain Item 1 of 6 Triage Note Triage Vital Signs 1820: 42-year-old male endorsing right-sided flank pain, nausea, vomiting, dysuria, increased urinary frequency, and hematuria. The symptoms started twelve hours ago and have worsened. The client reports the pain as a '9' (0-no pain; 10-extreme pain). He states the pain is further exacerbated with urination, described as 'sharp and throbbing.' He says he recently ran out of prescribed medications because he lost his job. He has a medical history of major depressive disorder, gout, hypertension, and hyperlipidemia.

Which two (2) client findings require follow-up? pain dysuria

Which of the following meals would be appropriate for a nurse to assign to a client of Orthodox Judaism faith on a kosher diet? A. Pork belly roast, rice, vegetables, mixed fruit, milk [7%] B. Crab salad on a croissant, potato salad, milk, vegetables with dip [11%] C. Sweet and sour chicken with rice and vegetables, juice, mixed fruits [74%] D. Fettuccini Alfredo with shrimp and vegetables, salad, mixed fruit, iced milk tea [7%]

explanation Choice C is correct. Orthodox Judaism believers adhere to kosher dietary laws; for this group, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed. Other meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and those that are ritually slaughtered. Choices A, B, and D are incorrect. All of these options are prohibited in orthodox Judaism because meat and dairy cannot be combined.

The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who Correct A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C). [59%] B. has an indwelling urinary catheter and reports burning at the insertion site. [31%] C. has scant blood in their newly established ostomy pouch. [7%] D. has friends writing words on their fiberglass cast with different colored markers. [2%]

xplanation Choice A is correct. A major complication of Hirschsprung's disease is the development of enterocolitis manifested by fever, abdominal distention, vomiting, and increased abdominal pain. Emergent intervention is necessary because the child may develop sepsis leading to septic shock. Choices B, C, and D are incorrect. Burning at the insertion site of the indwelling urinary catheter site is concerning because this may be an early manifestation of a catheter-associated urinary tract infection. This client does require follow-up but would not prioritize over the client experiencing life-threatening enterocolitis. Scant blood in a newly established ostomy is expected. This is expected, along with a reddened stoma that is edematous. This will resolve in a couple of days. Writing on a fiberglass cast with markers is permitted and does not require follow-up. Additional Info ✓ Hirschsprung disease is a congenital disease that is characterized by insufficient peristalsis because of the absence of ganglion cells ✓ Clinical features of this disease include abdominal distention, failure to pass meconium as an infant, bilious vomiting, and altered bowel habits such as constipation alternating with diarrhea ✓ Treatment is with surgical intervention such as a colectomy ✓ Enterocolitis is the most severe complication manifested by severe abdominal pain, abdominal distention, and fever