ARCHER REVIEW 5 EXAMS 55Q Missed Qs only REVIEW AND STUDY

What is the first assessment the nurse should make when a patient reports he hurt his knee playing baseball and the knee appears swollen? A. Feel the knee for warmth B. Compare the swollen knee with the other knee C. Palpate for crepitus in the knee D. Assess active range of motion in the knee

Choice B is correct. The first step of any assessment is always inspection. The first step the nurse should take is to compare the knees for symmetry.

The nurse is caring for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina. Place the priority actions in the correct order.

Apply pressure to lift the presenting fetal part Stay with the client and call for help Place the client in Trendelenburg position Administer oxygen Prepare for delivery

Hospitalization may affect or delay the progression of which physical development of a 1-yr-old patient? A. Walking B. Running C. Sitting D. Crawling

Choice A is correct. At 1-year-old, children should be beginning to walk. Hospitalization during this age could delay this stage of development.

You are taking care of a 7-year-old female in the pediatric bone marrow transplant unit. She has been in the hospital for about a year and is working on her school work with the hospital teacher. You note that she is growing increasingly frustrated with her math homework. You know that her successful completion of academic demands is vital to her psychosocial development, as she is in which stage of psychosocial development? A. Industry vs. Inferiority B. Autonomy vs. Shame and Doubt C. Trust vs. Mistrust D. Initiative vs. Guilt

Choice A is correct. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in inferiority.

The nurse is caring for a four-year-old child. While developing a plan of care, the nurse recognizes the child is in which stage of Erikson's stages of psychosocial development? A. Initiative vs. Guilt B. Autonomy vs. Shame and Doubt C. Industry vs. Inferiority D. Trust vs. Mistrust

Choice A is correct. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds, so this is correct for your four-year-old client. In Initiative vs. Guilt, children assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval and may feel a sense of guilt.

The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)? A. Muscle rigidity of the neck B. Hyperactive bowel sounds C. Frequent diarrhea D. Abdominal distention

Choice A is correct. Metoclopramide is a dopamine antagonist in treating gastroparesis, nausea, and vomiting. Dopamine antagonists may induce dystonia which is depicted in this option. This finding is highly concerning.

The nurse is caring for the following assigned clients. It would be a priority for the nurse to assess the client antacid for indigestion. B. reporting nervousness following the administration of albuterol. C. requesting pain medication for their chronic knee and back pain. D. awaiting discharge teaching on their insulin pump and glucometer.

Choice A is correct. Reports of indigestion could be a symptom associated with myocardial infarction. This atypical sign is concerning because the client is already being evaluated for chest pain. Thus, the nurse needs to follow up with this client.

You have just finished a physical examination of an 8-year-old girl and discovered bruises on her body in places that make you suspect that she has been physically abused. Before you investigate that line of reasoning, you stop and think about the other likely ways a child her age could obtain bruises in those locations. Which thinking process in the critical-thinking model are you demonstrating? A. Contextual awareness B. Inquiry C. Considering alternatives D. Reflecting skeptically and deciding what to do

Choice A is correct. The 'Critical Thinking Model organizes critical thinking into five major categories—contextual awareness, inquiry, analyzing assumptions, considering alternatives, and reflecting. Contextual awareness involves being alert to what's happening in the whole situation, including values, cultural issues, interpersonal relationships, and environmental influences.

Your 78-year-old client has been receiving antibiotics for ten days and tells you that he is having frequent watery stools. Which action will you take first? A. Place the client on contact precautions. B. Instruct the client about correct handwashing. C. Obtain stool specimens for culture. D. Notify the physician about the loose stools.

Choice A is correct. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be to place him on contact precautions in order to prevent the spread of C. difficile to other clients. Clostridium difficile (C. difficile), a spore-forming bacillus that infects the gastrointestinal (GI) tract following treatment of other infections with antibiotics is one of the few hospital-acquired infections (HAIs) increasing in frequency. C. difficile spores are transferred to clients mainly via the hands of health care personnel who have touched a contaminated surface or item.

The nurse assists the client in developing goals while hospitalized. This phase of the nurse-client relationship is best described as which of the following? A. Orientation phase B. Working phase C. Termination phase D. Pre-interaction phase

Choice A is correct. The orientation phase is characterized by the nurse and the client becoming familiar with each other. Establishing goals that are reasonable and important to the client is a classic component of the orientation phase.

The nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following would indicate the client is achieving treatment goals? A. Blood Pressure 128/63 mmHg B. Creatinine 2.3 mg/dL C. Proteinuria 2+ D. Sodium 132 mEq/L

Choice A is correct. Treatment goals for a patient with Polycystic Kidney Disease (PKD) include maintaining normotension, the glomerular filtration rate (GFR), and preventing sodium wasting, which is evidence of a decline in renal function. Hypertension is a cardinal finding in PKD, and if a client is achieving the treatment goals, they will maintain regulated blood pressure.

The nurse is working the night shift in the ER when a patient is suddenly rushed in with burns on his legs and torso. The nurse notices that the wounds appear moist and pale white with a sluggish capillary refill. The nurse can classify the injury as which of the following? A. Deep-partial B. Full-thickness C. Superficial-partial D. Superficial

Choice A is correct. Wounds that appear moist and pale white with sluggish capillary refill are classified as deep-partial

Your client has a stat order for a cooling or hypothermia blanket. After you call the appropriate department, the cooling blanket is delivered to your nursing care unit. What is the first thing you should do concerning this stat order? A. Inspect and run the equipment prior to use. B. Immediately use the cooling blanket for the client because it is a stat order. C. Ask the engineering department to perform preventive maintenance on it. D. Inspect the blanket for any frayed cords before to protect against fire.

Choice A is correct. You must thoroughly inspect and run the equipment before use to ensure that it is appropriately functioning BEFORE it is used. This inspection should include an overall assessment for frayed electrical cords and documented evidence that the piece of equipment has had the mandated preventive maintenance and safety inspections according to the facility's policies and procedure.

The nurse is caring for a child admitted with congestive heart failure. Which of the following assessment findings would be expected? A. Pulse deficit B. Exercise intolerance C. Bradypnea D. Flattened neck veins

Choice B is correct. Exercise intolerance is common for a child with heart failure because the cardiac output cannot keep up with the demands of exercise. Fatigue may develop, as well as irritability from the child's inability to participate in exercise-related activities.

The nurse is counseling an adolescent who is pregnant and reports frequent eating at fast-food restaurants. The nurse should make which recommendation to help optimize her nutritional intake? A. Choose french fries over a baked potato B. Select a cheeseburger over a regular hamburger C. Pick sandwiches instead of wraps D. Breaded chicken is a better choice than broiled

Choice B is correct. Fast food is not desired during pregnancy because of the abundance of oils, dressings, and breading that supply a high degree of saturated fats, sodium, and calories. To optimize the client's nutritional intake, if the client insists on fast food, the nurse should recommend a cheeseburger because the cheese will add protein and calcium, both of which are essential during pregnancy

The nurse is caring for a client who has newly prescribed fondaparinux. The nurse understands that this medication is intended to treat which condition? A. Hemophilia B. Venous thromboembolism C. Sickle Cell Anemia D. Pernicious Anemia

Choice B is correct. Fondaparinux is a selective inhibitor of factor Xa, which is indicated for prophylaxis or treatment of DVT or PE. This medication is given subcutaneously once daily.

A nurse is caring for a client with multiple sclerosis (MS) undergoing plasmapheresis. The nurse understands that plasmapheresis controls symptoms of MS by removing which of the following from the blood? A. Catecholamines B. Antibodies C. Plasma proteins D. Lymphocytes

Choice B is correct. In clients with multiple sclerosis, an autoimmune reaction occurs. This autoimmune reaction causes immune cells and antibodies to attack and destroy the myelin sheath (a coating made of fat and proteins that protects nerves and helps transmit electrical signals) and the underlying nerve fibers in the brain, optic nerves, and spinal cord. During plasmapheresis, these antibodies are removed from the client's plasma, removing the cause of myelin sheath demyelination.

A 90-year-old woman has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility? A. A decrease in bone density B. Loss of short-term memory C. Atelectasis D. High serum calcium level

Choice B is correct. Loss of short-term memory is not an expected complication of prolonged immobility and warrants further assessment. Short-term memory loss may indicate medication effects, Alzheimer's dementia, or Lewy body dementia, etc.

A nurse prepares a client for computed tomography (CT) scan with intravenous (IV) iodinated contrast. The nurse should take which action? A. Ask the client if they are allergic to shellfish B. Insert a 20-gauge peripheral vascular access device C. Obtain capillary blood glucose (CBG) D. Instruct the client to decrease their fluids after the procedure

Choice B is correct. Patent vascular access of at least a 20-gauge catheter is necessary before the infusion of intravenous contrast. Extravasation of contrast media can be severe, and treatment involves stopping the infusion, removing the catheter, and elevating the extremity above the heart. This can be avoided by establishing IV patency before the infusion of contrast. Warm or cold compresses may also be helpful.

The nurse is gathering evidence for a quality improvement committee focused on fall prevention. To provide the highest quality scholarly evidence, the nurse plans on gathering findings from A. expert opinions. B. randomized controlled trials (RCTs). C. quantitative studies. D. qualitative studies.

Choice B is correct. Randomized controlled trials (RCTs) are a high level of scholarly evidence. The only other scholarly evidence higher than an RCT is a systematic review. In an RCT, blinding may be used by the principal researcher to avoid bias between groups that receive a particular treatment/therapy. RCTs are the gold standard for a new medication or treatment modality undergoing a clinical trial.

The nurse is completing an assessment on a 6-year-old client with asthma. Which of the following assessment findings is of most concern to the nurse? A. Expiratory wheezing B. Silent chest C. Cough D. Head bobbing

Choice B is correct. Silent chest is the assessment finding of most concern. This refers to the inability to auscultate any lung sounds. There is complete obstruction of the patient's airway and therefore the inability to move air. When complete obstruction occurs, this is a medical emergency. This assessment finding is of most concern because the client has lost their airway.

A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10 g/dL(Male: 14-18 g/dL / Female: 12-16 g/dL) today. She tells the nurse that she is taking her iron supplements twice per day. Which response by the nurse would be most appropriate? A. "You're off to a great start! Tea has much less caffeine than coffee." B. "A little lemon would be a great addition to your cup of tea, as this will help the absorption of your iron pill." C. "Right now, your iron levels are low. Please eliminate all caffeine from your diet, including tea and coffee." D. "That's alright. Drinking coffee or tea will not affect the fetus."

Choice B is correct. Tannins are compounds found in coffees and teas, which often inhibit or decrease the body's absorption of iron. Specifically, concerning tea intake, research has shown that adding lemon juice (which is high in vitamin C) appears to cancel the inhibitory effect of tannins on iron absorption.

The nurse evaluating an oncology patient's chart notes that the patient has a tumor in his lung measuring about 4.3 cm in size and accompanying pneumonitis. His cancer does not invade the entire lung and has no metastasis or lymph node involvement. Using the TNM staging system, how would the nurse best classify this patient's tumor? A. T3 N3 M1 B. T2 N0 M0 C. T1 N1 M0 D. T2 N1 M0

Choice B is correct. The TNM tumor staging system explores tumor size (T), node involvement (N), and distant metastasis (M). This patient has a small tumor measuring 4.3 cm limited to one portion of the lung, giving it a T staging of T2. Without nodal involvement or metastasis, both N and M are 0. This question is intended to test the representation of N0 and M0 for negative lymph nodes and negative metastases, respectively. The nurse is not required to know "T" staging details.

The nurse is caring for a client with an exacerbation of congestive heart failure (CHF). The client has generalized edema, dyspnea, and jugular venous distention. The nurse should anticipate a prescription for which medication? A. Mannitol B. Furosemide C. Diltiazem D. Verapamil

Choice B is correct. The client's symptoms suggest fluid volume excess due to the client's congestive heart failure. A loop diuretic, such as furosemide, is highly effective in treating this exacerbation

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the RN notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority? A. Apply pressure to sites with sandbag B. Palpate pedal pulses C. Assess for signs of claudication D. Apply warm compress to incision sites

Choice B is correct. The most significant complications this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain.

The nurse is teaching a caregiver how to administer an injection of enoxaparin. Which statement, if made by the caregiver, would require further teaching? A. "I will give this injection in the abdomen." B. "I should expel the air bubble before administering." C. "Green leafy vegetables are allowed while taking this medication." D. "This medication may increase the risk for bleeding."

Choice B is correct. This statement is incorrect and requires follow-up. Enoxaparin comes in prefilled syringes that are administered to the client subcutaneously. Since this medication comes in prefilled syringes, the air bubble should not be expelled. This is designed to remain next to the plunger to ensure the full dose is administered.

The nurse is caring for a client with Addison's disease. Which statement, if made by the client, would require follow-up? A. "I started using table salt instead of salt substitutes." B. "I joined a gym to train for an upcoming marathon." C. "I recently started wearing a MedicAlert bracelet." D. "If I start to feel ill, I should call my doctor right away."

Choice B is correct. Vigorous exercise requires additional dosing of the client's steroid to prevent an adrenal crisis. Training for a marathon is strenuous and should alert the nurse that follow-up is needed to ensure that adequate dosing of the client's prescribed corticosteroid is sufficient. When engaging in vigorous exercise, the body demands more steroid production, and the hallmark of adrenal insufficiency is the inability of the body to meet that demand.

The nurse is conducting patient teaching to a client with a level T4 spinal cord injury to transfer from the bed to the wheelchair independently. The nurse should emphasize to the client to move: A. His upper and lower body should move together into the wheelchair. B. His upper body moves into the wheelchair first. C. His lower body into the wheelchair first, placing his feet on the pedals, and then his hands to the wheelchair arms. D. His buttocks to the wheelchair first and then place his feet to the floor.

Choice B is correct. When transferring a patient with paralysis of the lower extremities from a bed to a wheelchair, move the big part of the body (upper) to the chair first. This is the proper technique and the safest. The client should move his upper body to the wheelchair first, then his legs from the bed to the wheelchair.

You have offered one of your newly admitted clients a partial bed bath. The client states, "I took a bath at home three days ago. I do not need a bath for another 3 or 4 days." How should you respond to this client? You should respond by saying: A. "Would it be okay with you if I teach you about the benefits of and the need for daily bathing?" B. "That is fine. At what time of the day do you prefer to bathe and do you prefer a shower or tub bath?" C. "A once a week bath is not good. You have to bathe at least every other day to protect against infection." D. I am sorry but we have rules here. All clients must be bathed at least every other day. Let's start the bath."

Choice B is correct. You would respond with, "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" when one of your newly admitted clients refuses a partial bed bath by stating, "I took a bath at home three days ago. I do not need a bath for another 3 or 4 days." This response acknowledges the fact that the frequency of bathing, bathing routines, and practices vary among individuals and cultures. Clients should be assessed for their bathing needs in preferences of their type of bathing and time of bathing. Additionally, a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic.

You are the nurse manager of the surgical acute care unit. You have noticed that several clients have almost been sent to the preoperative suite when they are not scheduled for a planned surgical procedure. Fortunately, no clients have gotten a "wrong surgery" because this possible error was caught in time. What is your priority action as the nurse manager? A. Praise the staff for catching these near misses before a surgical error occurs. B. Investigate and explore this near miss. C. Investigate and explore this medical error. D. Report the nature and frequency of these medical errors to the State Department of Health.

Choice B is correct. You, as the nurse manager of this surgical unit, should investigate and explore this near miss to prevent further medical errors in the future. This is your priority action. It's important to conduct near-miss investigations within 24 to 48 hours of the incident while memories are fresh about what happened and how the incident could have been prevented.

The nurse is reviewing Freud's Psychosexual Stages of Development with a student. It would be correct for the student to state that the milestone within the anal stage is A. seeing itsself as separate from the caregiver. B. the onset of puberty. C. toilet training. D. developing emotional relationships.

Choice C is correct. According to Freud's developmental stages, toilet training usually occurs during the anal phase. This development theory believes that children in this stage derive pleasure from eliminating body waste.

A client presents to the emergency department (ED) with a suspected ectopic pregnancy. The nurse anticipates which diagnostic test will confirm this finding? A. Nonstress testing B. Abdominal radiograph (x-ray) C. Transvaginal ultrasound D. Doppler transducer

Choice C is correct. An ectopic pregnancy (EP) is a medical emergency. The imaging of choice is a transvaginal ultrasound, as this type of ultrasound may visualize an extrauterine gestational sac with a yolk sac or embryo (with or without a heartbeat)

The nurse working on a medical-surgical unit has just received a change-of-shift report. The nurse should initially assess the client who is A. receiving treatment for chronic pulmonary emphysema with PaCO2 of 50 mm Hg. B. admitted with pulmonary tuberculosis (TB) and refuses their prescribed isoniazid. C. infected with Clostridium difficile, and is reporting dizziness. D. being treated for acute pyelonephritis and has a temperature of 101.8⁰ F (38.7⁰ C).

Choice C is correct. Dizziness is not expected with a C. diff infection. This could be regarded as a complication because the dizziness is likely associated with severe dehydration caused by diarrhea. The nurse needs to follow up with this client because of the potential for further clinical deterioration.

The nurse is performing a head-to-toe assessment for an older adult. Which finding from the integumentary assessment does the nurse recognize as a normal age-related change? A. Moist skin B. Increased nail growth C. Dry, itchy skin D. Increased skin pigmentation

Choice C is correct. Dry, itchy skin is a normal process of aging. Decreased eccrine and apocrine gland activity causes the older adult to have dry skin.

The nurse has instructed a client with type 1 diabetes mellitus about proper exercise. Which of the following client statements indicates a correct understanding of the teaching? A. "I should carry a snack rich in protein just in case I feel shaky." B. "I will not take my prescribed daily glargine insulin if I plan on exercising." C. "I can initially expect my glucose level to rise with vigorous exercise." D. "I should start my exercise near the time that my insulin peaks."

Choice C is correct. For the client with type 1 diabetes mellitus, glucose levels will initially rise with exercise. The epinephrine released from the adrenal gland will cause the liver to discharge more glucose into the body. Prolonged exercise is likely to cause hypoglycemia because of the uptake of glucose from the muscles.

The nurse is performing a home safety assessment for an older adult. Which of the following client statements would require follow-up by the nurse? A. "I will have grab bars installed in the bathroom." B. "I placed a nonskid mat in my shower." C. "My furniture is arranged so I can hold onto something if I need it." D. "I secured my electrical cords against the wall behind furniture."

Choice C is correct. Furniture should be arranged so that there are clear paths, free of rugs, cords, or other obstacles. It is unsafe for the client to use furniture for support during walking. The nurse should discuss the risks associated with this action and evaluate the client's need for a mobility aid such as a walker or cane.

Following a diagnosis of cystitis, a client was instructed to drink cranberry juice. Changes in which of the following assessment parameters would indicate to the nurse that this recommendation has been effective? A. Urine specific gravity B. Leukocyte count C. Urine pH D. Protein level

Choice C is correct. Here, the client is being instructed to consume cranberry juice to alter the pH of the urine as part of the acid-ash diet. The acid-ash diet is based on the concept that by altering the composition of one's diet, one can change the pH of their urine. Here, the goal is to make the client's urine more acidic, which may help reduce some symptoms of cystitis that the client is experiencing. Therefore, the nurse would utilize the client's urine pH as an assessment parameter to indicate whether this recommendation has been effective.

The fertility nurse is providing education to a woman hoping to become pregnant. This nurse would be most correct in stating that which of the following hormones is chiefly responsible for the release of an ovum from a woman's ovary? A. Estrogen B. Testosterone C. Luteinizing hormone D. Human chorionic gonadotropin

Choice C is correct. Luteinizing hormone is the hormone chiefly responsible for the release of an ovum from a woman's ovary.

The nurse is discussing infection control guidelines with a coworker. It would be correct for the nurse to state that A. "The nurse should wear a surgical mask when transporting a client with active pulmonary tuberculosis (TB)." B. "Disposable utensils must be provided for a client infected with hepatitis B." C. "A surgical mask should be worn when working within three feet of the client infected with Neisseria meningitidis." D. "A surgical gown should be applied when entering a client's room with bacterial pneumonia."

Choice C is correct. Neisseria meningitidis is spread by infected droplets, and the nurse should wear a surgical mask while working within three feet of the client. Three feet is the distance for droplets to spread to another individual. If the client with Neisseria meningitidis should leave the room, they should wear a surgical mask

Which of the following interventions is helpful in reducing the effects of GERD? A. Lie down after eating. B. Wear a girdle. C. Elevate the head of the bed on 4-6 inch blocks. D. Increase fluid intake just before bedtime.

Choice C is correct. Patients should be encouraged to elevate the head of the bed to allow food to move out of the stomach before lying flat. GERD occurs when stomach acid slips into the esophagus. Any position that hinders or slows the movement of food from the stomach should be avoided.

The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching? A. "Egg allergy is a contraindication to giving this vaccine." B. "This is a three-series vaccine that should be started at birth." C. "It is safe for breastfeeding women to receive the MMR vaccine." D. "This vaccine is safe if the client is pregnant."

Choice C is correct. The MMR vaccine is safe to administer to a client who is breastfeeding. No evidence exists of this vaccine being weakened by breastfeeding. Further, breastfeeding does not interfere with the response to the MMR vaccine.

The nurse is teaching a client about ambulating with a cane. It would indicate effective teaching if the nurse observes the client A. position the cane on their weaker side. B. advances their weaker leg first, then the cane. C. measures the height of the cane from their wrist crease. D. advances the cane 12-16 inches with each step.

Choice C is correct. This observation is correct and reflects effective teaching. The nurse should instruct the client that the height of the cane should be measured with the client facing forward, wearing their shoes, and either from their wrist crease or greater trochanter.

The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question? A. Furosemide for a client with hyperparathyroidism B. Methimazole for a client with hyperthyroidism C. Hydrocortisone for a client with diabetes insipidus D. Prazosin for a client with pheochromocytoma

Choice C is correct. Treatment for diabetes insipidus includes medications such as desmopressin, thiazide diuretics, and anti-inflammatories. Hydrocortisone is a short-acting corticosteroid and is indicated in the treatment of adrenal insufficiency. This requires follow-up because DI is not treated with hydrocortisone.

The nurse is preparing to administer ear drops to a client who is six years old. The nurse should perform which action? A. Pull the ear pinna down and back B. Position the client on their side with the ear to be treated against a pillow C. Pull the ear pinna up and back D. Place cotton directly into the ear canal after ear drop administration

Choice C is correct. When administering ear drops to this client, the nurse should have the client positioned on the side with the ear to be treated facing up, or the client may sit in a chair or at the bedside. Once the client is in an appropriate position, the nurse should straighten the ear canal by pulling the pinna up and back to the 10 o'clock position.

A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client A. withdrawing from alcohol and is malnourished. B. receiving methylprednisolone for an asthma exacerbation. C. has an external urinary catheter device for urinary incontinence. D. receiving total parenteral nutrition (TPN) via a central line.

Choice D is correct. A central line is a significant risk factor for a client to develop a central line-associated bloodstream infection (CLABSI). This occurs because of suboptimal sterile technique during insertion and/or inappropriate dressing changes. Additionally, TPN is a risk factor as the high glucose content makes the client more likely to develop a bacterial or fungal infection. TPN increases the risk for a CLABSI compared to solutions such as 0.9% saline.

The nurse is caring for a group of clients. It is a priority to follow up on which client situation? A. A client admitted with an asthma exacerbation that is wheezing while receiving albuterol via nebulizer. B. A client admitted with pulmonary emphysema who puts on their nasal cannula oxygen before eating. C. A client with pneumonia is ambulating around the nursing unit while wearing a surgical mask. D. A client receiving oxygen via nonrebreather and has an oxygen saturation of 92%.

Choice D is correct. A client receiving oxygen via non-rebreather is receiving approximately 80%-95% Fio2. If the best oxygen saturation is 92%, this is concerning and may warrant more aggressive measures to improve oxygen saturation.

The nurse is caring for a newborn immediately after delivery. Which of the following actions would be appropriate? A. Perform APGAR assessment at five and ten minutes B. Suctions the nose then the mouth C. Administer RhoGAM intramuscularly D. Place the infant skin to skin with a parent

Choice D is correct. A newborn is at risk of cold stress during the first few hours of post-intrauterine life. The nurse should dry the newborn thoroughly and place the newborn skin-to-skin with a parent

When the nurse notes an irregular radial pulse in a client, further evaluation should include assessing for which of the following? A. The carotid pulse B. Diminished peripheral circulation C. The brachial pulse D. A pulse deficit

Choice D is correct. Assessing for a pulse deficit provides an indirect evaluation of the heart's ability to eject enough blood to produce a peripheral pulse. When a pulse deficit is present, the radial pulse is less than the apical pulse.

The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding? A. Decreased pulse oximetry (SpO2) B. Hyperarousal C. Bradycardia D. Headache

Choice D is correct. CO poisoning is odorless, colorless, and tasteless. This potentially lethal poison initially causes clients to develop symptoms such as headache, reduced visual acuity, and slight breathlessness. As the CO level increases, it causes hypotension, confusion, and vertigo and then progresses to death.

The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take? A. Place a box of disposable respirators inside the client's room B. Remove alcohol-based sanitizers from the client's room C. Assign the client to a private room with a positive airflow D. Remove the portable fan from the client's bedside table

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. Pulmonary tuberculosis requires airborne precautions.

The Registered Nurse is preparing a patient for a pneumonectomy. What teaching should the nurse discuss with the patient? A. Instruct patient to lie on the non-operative side following the procedure. B. Expect the remaining lung to return to normal function within 2-6 hours. C. Advise the patient to avoid coughing and make sure the nurse will use wall suction to clear secretions. D. Keep head of bed elevated at 30-45 degree angle post-procedure.

Choice D is correct. Keeping the head of the bed between 30-45 degrees will minimize respiratory efforts and facilitate recovery post-pneumonectomy. This intervention will also prevent post-pneumonectomy pulmonary edema. The patient should lie on the operative side and should have the head of the bed raised to 45 degrees as soon as awake. These positions minimize the gravitational effect on capillary pressure in the remaining lung.

The nurse is about to change a dressing on an older man with a stage 3 pressure ulcer. What should be the nurse's first action? A. Gather all the necessary equipment. B. Use non-sterile gloves to remove the old dressing. C. Explain the procedure to the client immediately before dressing change. D. Check the medication record to see if pain medications were administered.

Choice D is correct. Pain associated with pressure ulcers should be appropriately addressed, specifically with dressing changes.

The nurse reviews a client's medical history and identifies a diagnosis of presbycusis. The nurse should integrate which intervention in the care plan? A. Have educational materials in large print B. Provide an eye patch to the affected eye C. Request food be seasoned with herbs D. Move closer to the better-hearing ear

Choice D is correct. Presbycusis is a type of sensorineural hearing loss associated with aging. Sensorineural hearing loss is often permanent. Interventions for a client with this type of hearing loss include speaking in the ear less affected, speak clearly and slowly, avoid shouting, and ensure that the environment is well lit while conversing.

Which of these is the best example of an ethical principle in nursing? A. Fidelity: the nurse should maintain honesty with patients during any education and care. B. Veracity: the nurse followed through with any promises made to the patient during his or her care. C. Beneficence: the nurse encourages the patient to be involved in his or her care. D. Nonmaleficence: the nurse did not cause harm to the patient.

Choice D is correct. The nurse did not cause harm to the patient, which is known as nonmaleficence. The ethical principles that nurses must adhere to are the principles of justice, beneficence, nonmaleficence, accountability, fidelity, autonomy, and veracity.

The nurse is caring for a client with a newly applied plaster cast. The nurse should A. use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable. B. expedite drying by using a hot blow dryer on the cast. C. let the cast hang below the heart to promote blood flow. D. handle the cast with the palms of the hands.

Choice D is correct. The plaster cast should be handled with the palms rather than the fingertips. Using the palms reduces the risk of the cast having indentation

The nurse is caring for a 26-year-old patient who cannot meet their nutritional needs by mouth. The interdisciplinary team decided inserting an NG tube for enteral feedings would be best. After inserting the tube, the nurse knows which of the following is the most accurate way to verify the placement of the tube? A. Aspiration of stomach contents B. pH verification of the aspirate C. Injecting air into the tube and then auscultating the left upper quadrant (LUQ) D. Visualization on an X-ray

Choice D is correct. Visualization on an X-ray is the gold standard for verification of nasogastric tube placement. This allows the radiologist to visualize the tip of the tube in the stomach and recommend any changes in placement that may be needed, such as pulling the tube back or advancing further.

The nurse is assessing a client for bacterial meningitis. Which of the following assessments should the nurse perform? Oral temperature Patellar reflexes Weber and Rinne tests Glasgow Coma Scale Orthostatic blood pressure

Choices A and D are correct. Bacterial meningitis manifests as a stiff neck, photophobia, fever, altered mental status, and malaise. The nurse would need to perform an oral temperature and the Glasgow Coma Scale to discern the client's current mental status.

Which imbalance would the nurse monitor for a client with fluid imbalance related to the development of ascites? Select all that apply. Effective extracellular fluid volume deficit Protein deficit Metabolic alkalosis Sodium deficit Plasma-to-interstitial fluid shift Metabolic acidosis

Choices A, B, D, and E are correct. Ascites indicates fluid accumulation in the peritoneal cavity. these clients are prone to hypotension due to circulatory volume deficit.

Which of the following patients would be the best candidates for total parenteral nutrition (TPN)? A patient with inflammatory bowel disease who has intractable diarrhea. A patient with celiac disease who is not absorbing nutrients. A patient who is underweight and needs short-term nutritional support. A patient who is comatose and needs long-term nutritional support. A patient who has anorexia and refuses to take foods via the oral route. A patient with burns who has not been able to eat adequately for 6 days.

Choices A, B, and F are correct. The assessment criteria used to determine the need for total parenteral nutrition (TPN) include an inability to achieve or maintain enteral access. Examples include motility disorders, intractable diarrhea (Choice A), impaired absorption of nutrients from the gastrointestinal tract (Choice B), and when oral intake has been inadequate for a period over seven days. TPN promotes tissue healing and is an excellent choice for a patient with burns who has an improper diet. Please note that oral intake is the best feeding method; the second best method is via the enteral route. Total parenteral nutrition (TPN) is indicated only in specific cases. TPN provides calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. TPN can also promote tissue and wound healing and healthy metabolic function. TPN may be used to improve a patient's response to surgery. TPN is a highly concentrated, hypertonic nutrient solution. Hence, it is given intravenously through a central venous access device, such as a multi-lumen, tunneled catheter into the subclavian vein, or a peripherally inserted central catheter (PICC). Strict surgical asepsis should be followed due to the risk of infections.

The nurse is providing education to a group of nursing students regarding the causes of hypercalcemia. Which of the following information should be included? Select all that apply. hypoparathyroidism. thiazide diuretics. malignancy. end-stage kidney disease. crohn's disease.

Choices B and C are correct. Thiazide diuretics cause calcium retention, making their administration a potential cause of hypercalcemia. Malignancy, especially malignancies with metastasis involving the bones, may induce hypercalcemia from the breakdown of the bone. This causes the calcium to transition into the bloodstream.

The nurse is caring for a 14-year-old scheduled for an appendectomy. What is the nurse's role in obtaining informed consent before surgery? Select all that apply. Informing the parents that only the surgeon may withdraw the surgical consent Review the risks and benefits of the surgery with the parents Validate that the parents are competent to provide consent for the client Witness the signature on the informed consent Make sure that the consent is witnessed by two healthcare professionals

Choices C and D are correct. Since the client is 14, they are a minor, and their parents will be responsible for signing informed consent. The nurse is accountable for validating that the parents are competent to provide consent for the client (Choice C). The nurse will serve as the witness for the informed consent. This is one of the primary responsibilities of the nurse when a client is getting a procedure and signing a consent. The other primary responsibility will be to serve as the client's advocate and ensure that the parents have received sufficient information to make an informed decision. If they have not, the nurse must call the surgeon to return and speak further with the parents (Choice D).

The nurse is reviewing test results for an antepartum client. Which of the following antepartum test results indicate a need to further follow up? Contraction stress test - negative Nonstress test - reactive Contraction stress test - positive Nonstress test - nonreactive Rh-negative blood type

Choices C, D, and E are correct. A positive contraction stress test means the baby had decelerations in response to contractions and therefore, may not tolerate labor. Therefore, follow-up is needed (Choice C). A nonreactive nonstress test means that the baby did not have two or more 15 by 15 accelerations during the 20 minute test period and is not responding appropriately to movement. Follow-up would be needed for this test result, most likely with a contraction stress test (Choice D). If the mother has Rh-negative blood and the father has Rh-positive blood, further testing and treatment may be needed to prevent complications related to Rh incompatibility. (Choice E)