ARCHER Tutor 12/22

The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports A. increased ability to focus. B. decreased muscle spasms. C. improved short-term memory D. sleeping without awakening at night.

B. decreased muscle spasms. Tizanidine is a muscle relaxant and is utilized in the treatment of multiple sclerosis. Other indications for a muscle relaxant include an injury such as a motor vehicle crash that may cause muscle spasms. Other medicines included in this class include baclofen, carisoprodol, cyclobenzaprine, and methocarbamol.

The occupational health nurse is conducting an in-service on reducing back injuries. It would be correct for the nurse to identify the most common location of the injury is the A. cervical spine. B. lumbar spine. C. thoracic spine. D. pelvis.

B. lumbar spine. The most common area injured during lifting is the lumbar spine. This is because it supports the lower back.

The nurse is caring for a client with schizophrenia, who is speaking words and phrases that are unrelated to one another. The nurse should document this communication pattern as A. pressure speech. B. word salad C. neologism. D. clang association.

B. word salad Word salad is a type of language and communication disturbance in which the client says words and phrases that are not indeed related to one another. Schizophrenia symptoms are divided into positive or negative symptoms. Positive symptoms include things that add something to the client. They include hallucinations. Negative symptoms are things that take something away from the client: anhedonia, avolition, apathy

A breastfeeding mother is struggling to care for her infant with lactose intolerance. Which of the following foods should the mother avoid? A. Leafy greens B. Red meats C. Yogurt D. Wheat rolls

C. Yougurt Yogurt is a dairy product and therefore contains lactose. Breastfeeding mothers with infants who are lactose intolerant should avoid dairy products such as cheese, milk, and yogurt.

When assessing for dehydration, the nurse should observe for which of the following? A. Headache and increased urinary output B. Weight gain and edema C. Hypertension and decreased urinary output D. Hypotension, headache, and dry mucous membranes

D. Hypotension, headache, and dry mucous membranes When there is an excessive loss of fluid within the body, dehydration can occur. Dehydration may be caused by acute illness or a chronic disease process. Common symptoms include dry mucous membranes, dark urine, decreased urinary output, confusion, low blood pressure, muscle cramps, and constipation.

Which of the following statements are true regarding growth and development during the preschool years? Select all that apply. A. Between ages 3 and 5, children grow 2 to 3 inches every year. B. Preschool-age children will be able to run, skip, and hop on one foot. C. Preschool-age children should gain at least 10 pounds each year. D. At age 5, children should be able to write in cursive.

A, B Preschool-age children should gain about 5 pounds each year Writing in cursive is a fine motor skill that will be developed in the school-age years, between the ages of 6 and 12.

You are completing a health history of a 4-year-old male at the primary care office. When checking with his mother about milestones in fine motor development. You would expect that the 4-year-old is able to do which of the following? Select all that apply. A. Complete a puzzle with 5 or more pieces B. Copy a triangle onto a piece of paper C. Dress himself D. Use a fork to eat dinner

A, B, C, D These are all fine motor skills that are expected in preschool-age children, who are 3 to 5 years old. Other fine motor developmental milestones include: pasting things onto paper, completing puzzles with 5 or more pieces, cutting out simple shapes with scissors, and brushing their teeth.

Which of the following educational points should the nurse reinforce with the parents of a toddler diagnosed with an imperforate anus? Select all that apply. A. "Toilet training will take longer for your child." B. "Normal bowel habits can be established for your toddler over time." C. "Do your best to have your child toilet trained before kindergarten starts." D. "Bowel irrigations may help your toddler achieve normal bowel function."

A, B, D

When caring for an Amish patient, what does the nurse know to be true? Select all that apply. A. They use traditional and alternative health care. B. Funerals are conducted in the home. C. The authority of women and men are equal. D. Many choose to live without health insurance. E. Health is believed to be a gift from God.

A, B, D, E Amish live a life that is generally strictly separate from society. While women are highly respected and valued, men hold the authority in the home. Traditional and alternative health care is appreciated, although many live without insurance. Health is believed to be a gift from God.

What is the nurse's priority when a fire occurs in a client's room? A. Rescue the patient B. Extinguish the fire C. Sound the alarm D. Run for help

A. Rescue the patient Rescue others immediate Alert - shout fire pull fire or dial 911 Contain - close all doors windows Extinguish/evacuate - extinguish small fires, evacuate clients. if appropiate

The nurse is caring for a client who has a prescribed regular insulin sliding scale. At 0800, the client's capillary blood glucose (CBG) was 258 mg/dl. At 1215 the CBG was 288 mg/dl. At 1730 the CBG was 254 mg/dl. The nurse should do which of the following at 1730? See the table below. Select all that apply. 151 - 200 mg/dl - Regular insulin 2 units 201 - 250 mg/dl - Regular insulin 4 units 251 - 300 mg/dl - Regular insulin 6 units 301- 350- mg/dl - Regular insulin 8 units Notify DM for 3 consecutives > CBGs than 250 mg/dl A. Administer 8 units of regular insulin B. Administer 6 units of regular insulin C. Notify the primary health care provider (PHCP) D. Withhold the prescribed insulin E. Modify the client's prescribed diet to low sodium

B, C The client's blood glucose has been above 250 mg/dL for three consecutive readings and the physician needs to be notified. In addition, the sliding scale prescribes six units of insulin based on the 17:30 CBG result.

Seizure precautions have been ordered for a patient admitted to the psychiatric unit. Which of the following nursing interventions is not appropriate when initiating seizure precautions? Select all that apply. A. Pad the side rails of the bed B. Lower side rails while the patient sleeps C. Remove hard or sharp objects from the bed D. Use four point restraints to prevent injury E. Adhere a fall risk bracelet to the seizure prone patient

B, D Lowering the side rails and using four point restraints are not appropriate actions while deploying seizure precautions. Padded bed rails should remain up while the patient sleeps. Patients should be provided with a call light so that they may call for help if needed. Four-point restraints are not appropriate for the seizing patient and could result in injury.

The nurse is teaching a client about the newly prescribed medication, sevelamer. Which statement, if made by the client, would indicate a correct understanding of the teaching? A. "This medication will help lower my calcium level." B. "I should take this medication with my meal." C. "I may experience bad diarrhea with this medication." D. "My blood pressure may increase while I take this medication."

B. "I should take this medication with my meal." Sevelamer is a phosphate binder that is indicated for individuals with chronic kidney disease (CKD). This medication inhibits phosphorus absorption, thereby increasing the calcium level.

The nurse is counseling a client with congestive heart failure (CHF) about newly prescribed bumetanide. The nurse determines that the teaching has been effective when the client plans to A. increase their daily intake of protein. B. record their daily urinary output. C. weigh themselves daily. D. take their blood pressure and pulse daily.

C. weigh themselves daily. For a client with congestive heart failure prescribed bumetanide, a loop diuretic, the client should verbalize the importance of weighing themselves daily. Their daily weight should be obtained in the morning after the first. Examples of loop diuretics include - bumetanide, ethacrynic acid, furosemide, and torsemide.

A client with a history of confusion has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A. "Good morning. Do you remember where you are?" B. "Hello, my name is Susan Jones and I am your nurse for today." C. "How are you today? Remember, you're in the hospital." D. "Good morning. You're in the hospital. I am your nurse, Susan Jones."

D. "Good morning. You're in the hospital. I am your nurse, Susan Jones." This option gives the patient information about where he is and who is caring for him. It does not require him to answer questions or risk increasing his agitation if he does not know the answers. When a client is experiencing confusion, the nurse needs to provide a calm, predictable environment. Greeting the patient and stating where he is, who you are, and any pertinent information (without overwhelming him) will help prevent increased anxiety, which could lead to worsening confusion.

Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic? A. "Autologous donations require a health care provider's (HCP) order." B. "There is no age limitation for autologous blood donations." C. "I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery." D. "My autologous blood donation will be screened for infectious diseases."

D. "My autologous blood donation will be screened for infectious diseases." Autologous donations are not screened for infectious diseases. According to the Food and Drug Administration (FDA), autologous donations are not screened because autologous donors are not exposed to new transfusion-transmitted infections in receiving their own blood.

The emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below. Pulse: 108 R: 28 min BP: 164/93 T: 95.5 F (37.5 C) SO2: 87% A. Pulmonary embolism B. Hypovolemic shock C. Disseminated intravascular coagulation (DIC) D. Pulmonary edema

D. Pulmonary edema The client's history of congestive heart failure significantly increases the risk for pulmonary edema. The vital signs show respiratory distress (tachypnea, hypoxia, and tachycardia), which supports the complication of pulmonary edema.

You are working in the emergency department when a 23-year-old woman comes in after being bitten by multiple fire ants. You examine her and notice that there are many fluid-filled bites on her legs and ankles. She is complaining of numbness in her face and you notice swelling around her lips. She complains of shortness of breath and her respiratory rate is 28 breaths per minute. You hear wheezing when you auscultate her lungs. Her heart rate is 110/minute and her blood pressure is 82/40 mmHg. You have the following orders for this patient: Administer epinephrine Ensure a patent airway Administer an antihistamine Place on a cardiac monitor to analyze the heart rhythm As you work to prioritize these tasks, you know that the best sequence for doing them is:

Ensure a patent airway Administer epinephrine Administer an antihistamine Place on a cardiac monitor to analyze the heart rhythm

Before administering a nasogastric feeding to a preterm infant, the nurse prepares to aspirate the residual fluid from the stomach. Please place the following nursing actions in sequential order. Begin the prescribed nasogastric feeding Position the patient with the head slightly elevated Aspirate gastric contents Measure the aspirate Return the aspirate

Position the patient with the head slightly elevated Aspirate gastric contents Measure the aspirate Return the aspirate Begin the prescribed nasogastric feeding

The registered nurse (RN) observes licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply. A. Irrigates an indwelling catheter with warm tap water. B. Administers glargine insulin for a client with nothing by mouth (NPO) C. Obtains a 12-lead electrocardiogram for a client with hyperkalemia. D. Clamps a chest tube while the client ambulates. E. Repositions a client who requires log rolling by using a gait belt.

A, D, E An indwelling catheter is irrigated with sterile water or sterile normal saline. Irrigating an indwelling catheter with tap water would introduce pathogens into the bladder. A chest tube should never be clamped as it will cause a rapid increase in intrathoracic pressure, which may cause a tension pneumothorax. A client requiring log rolling should be repositioned with more than one staff member and with a transfer sheet. A gait belt is used when a patient is ambulating.

The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN? Select all that apply. A client A. receiving antibiotics for lower extremity cellulitis. B. newly admitted with an exacerbation of myasthenia gravis. C. with a chest tube and receiving mechanical ventilation. D. requiring a referral to an outpatient support group. E. needing to receive intramuscular RhoGAM. F. needing scheduled tube feedings and colostomy irrigations.

A, F When making client assignments, the LPN should be assigned to a stable client with a predictable outcome. A client receiving antibiotics for lower extremity cellulitis is a low acuity illness and may be cared for by the LPN. Scheduled tube feedings and colostomy irrigations are within the scope of an LPN, and this can be delegated.

The nurse is caring for an infant with developmental dysplasia of the hip (DDH). Which of the following prescriptions would the nurse anticipate from the primary healthcare provider (PHCP)? A. Pavlik harness B. Compression hose C. Knee immobilizer D. Continuous passive motion

A. Pavlik harness The Pavlik harness is utilized for the treatment of DDH. The goal of the therapy is to keep the hips abducted as much as possible. * The harness may be maintained for eight to twelve weeks. * Frequent follow-up appointments are recommended because the straps will need to be adjusted. * The parents should be taught to frequently inspect the infant's skin for any breakdown. * Lotions, creams, and powders should be avoided under the straps. * The diaper should be placed under the straps.

A 38-week pregnant woman comes into the emergency department complaining of vaginal bleeding. The client is not in obvious distress or pain. Which statement by the client would lead the nurse to suspect placenta previa? A. "I don't feel any pain at all. It's just the bleeding that concerns me." B. "I feel like I'm about to go into labor. My tummy is starting to contract." C. "I started bleeding when I picked up my 3-year-old son, who weighs 32 pounds." D. "I feel like I'm about to vomit."

A. "I don't feel any pain at all. It's just the bleeding that concerns me." Placenta previa typically manifests as painless vaginal bleeding after 20 weeks gestation. Placenta previa occurs when the placenta implants over or near the internal os of the cervix. In clients with placenta previa, the source of bleeding is maternal. Diagnosis is performed by ultrasonography. Treatment is modified activity if minor vaginal bleeding occurs before 36 weeks gestation, with cesarean delivery at 36 to 37 weeks, 6 days. Immediate cesarean delivery is indicated if the bleeding is severe or refractory or if the fetal status is nonreassuring.

The registered nurse is on a shift in the emergency department of a pediatric hospital. There are four patients in the ED; which patient would the nurse see first? A. A 1-month-old infant that is crying with retractions during inspiration. B. A 5-year-old with pneumonia with 95% pulse oxygen saturation. C. A 10-year-old with diarrhea and vomiting with a potassium level of 3.6 mEq/L. D. A 15-year-old diabetic with a blood glucose level of 190 mg/dL.

A. A 1-month-old infant that is crying with retractions during inspiration. The child with inspiratory retractions indicates respiratory distress in the child and should be assessed first.

Which of the following foods can the nurse recommend to parents of toddlers who have constipation? SATA A. Mac and cheese B. Whole grains C. Whole milk D. Black beans

B. Whole grains D. Black beans Whole grains are rich in fiber and an excellent choice for toddlers who have constipation (Choice B). Black beans are high in fiber and are an excellent choice for toddlers who have constipation (Choice D).

What is the priority nursing assessment for a 76-year-old patient with pneumonia? A. Airway patency B. Percussion sounds C. Breath sounds D. Respiratory rate

A. Airway patency Impaired mobility in older adults creates a risk for airway collapse, reduced air exchange, hypoxia, hypercapnia, and acidosis. Reduced gag and cough reflexes can place older people at risk for aspiration of secretions and, potentially, aspiration pneumonia. There is a possibility of postoperative respiratory complications because of impaired cough reflex, weaker muscles, and decreased inspiratory capacity. Older adults are at increased risk of respiratory complications due to stress. The nurse should pay attention to maintaining adequate ventilation, keeping lung volumes high, clearing secretions, and positioning to prevent aspiration.

A patient with a crush injury to her left arm calls the nurse's station and requests pain medication an hour after initial administration. The patient is still complaining of intense pain. What is the next nursing action? A. Ask the patient to describe the pain in quality and intensity. B. Offer the patient a distraction, such as a book or television. C. Tell the patient she can have more medication in three hours. D. Tell the patient that crush injury victims should expect intense pain.

A. Ask the patient to describe the pain in quality and intensity. A crush wound is a wound caused by force, which leads to compression or disruption of tissues. It is often associated with fractures. Usually, there is minimal to no break in the skin. While other external symptoms, such as bruising or edema, may be visible, nurses should also rely on subjective symptoms reported by the patient. Unrelieved pain is an indication of a complication. Patients who experience a crush injury are at risk for developing compartment syndrome. Therefore, asking the patient to be specific about the quality and intensity of pain will help the nurse re-evaluate her status.

The nurse is providing teaching to a student nurse about the immune system. Which of the following is the best example of natural adaptive immunity? A. Cell-mediated response B. Lymphocyte creation C. Inflammatory response D. The flu vaccine

A. Cell-mediated response Cell-mediated immunity is the best illustration of natural adaptive immunity. This immunity is spurred by cytokines and T-lymphocytes and doesn't include antibodies.

The nurse is reviewing the client's laboratory data. Which current prescription should the nurse clarify with the primary healthcare provider (PHCP)? See the image below. Laboratory Result Sodium 129 Potassium 3.7 Calcium 9.4 BUN 12 Creatinine 1.0 A. Dextrose 5% in water (D5W) B. Dexamethasone C. Digoxin D. Vitamin D

A. Dextrose 5% in water (D5W) This client has hyponatremia, and infusing more water into the client (D5W) would drive down the sodium further. D5W is a hypotonic solution (although it goes in isotonic, it then becomes hypotonic) and raises blood glucose while restoring intracellular volume. D5W provides an individual with water and some calories. Prolonged use of this fluid may cause hyperglycemia and hyponatremia.

The nurse is performing a physical assessment on a child admitted with erythema infectiosum (Fifth disease). Which of the following would be an expected finding? Select all that apply. A. Erythema on face B. Headache C. Nuchal rigidity D. Hepatosplenomegaly E. Photophobia

A. Erythema on face B. Headache Erythema infectiosum (Fifth disease) characteristically causes a child to develop erythema on the face (slapped face appearance). It also causes the appearance of maculopapular red spots distributed on the upper and lower extremities. Finally, the client will have mild flu-like symptoms such as a fever, headache, and malaise.

The nurse just finished a shift in the emergency department during winter when she notices a homeless man outside with frostbite on his hands. The nurse brings the man into triage and starts to treat the frostbitten area by rewarming it. Which action by the nurse is most appropriate? A. Immerse the affected area in heated water at 40-46°C. B. Immerse the affected area in heated water at 80-90°C. C. Remove the blood-filled blisters. D. Apply snug, sterile dressings.

A. Immerse the affected area in heated water at 40-46°C. The nurse should immerse the frostbitten area in heated water at 40.6 - 46.1°C to rewarm the area.

The nurse is caring for a 5-year-old girl diagnosed with hemophilia with a recurrent episode of hemarthrosis. Which of the following would the nurse expect on their assessment? Select all that apply. A. Joint pain and swelling B. Decreased level of consciousness C. Bruising D. Melena

A. Joint pain and swelling C. Bruising Hemarthrosis is defined as bleeding into a joint cavity. Most commonly affected joints include knees, ankles, and elbows. Hemarthrosis is a frequent complication of hemophilia because of the deficiency of clotting factors and prolonged clotting times. When the nurse has a patient with hemarthrosis, she can expect joint pain and swelling, and external bruising in the hemarthrosis area due to the accumulation of blood in that joint cavity.

The nurse is caring for a client who is receiving prescribed isotretinoin. Which laboratory data is essential prior to the initiation of this therapy? A. Lipid panel B. C-Reactive Protein C. Hemoglobin A1C D. International normalized ratio (INR)

A. Lipid panel Isotretinoin is indicated in the treatment of moderate to severe acne vulgaris. This medication may raise triglyceride levels, and thus a baseline lipid panel is necessary along with periodic monitoring.

The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply. A. The client reports feeling nauseated. B. The client's lower extremities are swollen. C. The client expresses nervousness about test results. D. The client reports that their leg is itching. E. The client rates pain at a 6 on a scale of 1 to 10. F. The client vomits twice after eating dinner.

A, C, D, E Subjective data is information that is perceived only by the person affected. This data cannot be seen or verified by another person. Feeling nauseous or nervous, itchiness, and pain are all examples of subjective data.

Which of the following nursing actions can an LPN/LVN perform on a patient who has a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA)? A. Obtain wound cultures during dressing changes. B. Plan ways to improve the client's oral protein intake. C. Assess the risk for further skin breakdown. D. Educate the client about home care of the leg ulcer.

A. Obtain wound cultures during dressing changes. LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound cultures.

You are providing education to a group of parents about nutrition for their toddler age children. Which of the following educational points should you include? Select all that apply. A. Offer whole milk instead of skim or 2% milk. B. Using food as a reward can be a positive incentive. C. Good iron-rich choices include whole grain bread and cheese. D. Iron deficiency anemia is common in toddlers.

A. Offer whole milk instead of skim or 2% milk. D. Iron deficiency anemia is common in toddlers.

The nurse is teaching a client about newly prescribed insulin glargine. The nurse recognizes the need for further instruction when the client makes the following statement? Select all that apply. A. "I will take this insulin right before my meals." B. "I should roll this vial of insulin before removing it with the syringe." C. "This insulin will help control my glucose for 24 hours." D. "I can only inject this insulin into my abdomen." E. "I'm glad to know I can mix this with my regular insulin."

A, B, D, E These statements are incorrect and require follow-up. Insulin glargine is a long-acting insulin that has no peak effect. Thus, it is not taken with meals. It is dosed once a day to provide glucose control for 24 hours. Insulin glargine is not a suspension; thus, it does not need to be rolled like NPH. This insulin is not mixed with any other insulin. Insulin glargine does not have to only be injected into the abdomen.

Which statements about therapeutic communication are accurate? SATA A. Therapeutic communication is goal-oriented, purposeful, caring, and compassionate. B. Therapeutic communication occurs after trust is established in the nurse-client relationship. C. Therapeutic communication occurs between the nurse and other members of the nursing team. D. Therapeutic communication consists of only oral communication that is understandable. E. Therapeutic communication must be modified and altered according to the client's culture. F. Therapeutic communication is fully mindful of any nonverbal messages that are sent by the nurse.

A, B, E, F

When interpreting results from a direct Coombs test, you know that a positive result indicates which of the following? Select all that apply. A. Maternal antibodies are present on the infant's red blood cells. B. Antibodies are present in the maternal serum. C. The infant is at risk for erythroblastosis fetalis. D. The mother is at risk for Rh immunization.

A, C A direct Coombs test measures maternal antibodies, specifically IgG, that are present on the infant's red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis (Choice C).

Which of the following are required for a nonstress test to be considered reactive? Select all that apply. A. Two increases in the fetal heart rate of 15 beats per minute. B. Two decreases in the fetal heart rate of 15 beats per minute. C. Two increases in the fetal heart rate for 15 seconds. D. Two decreases in the fetal heart rate for 15 seconds.

A, C For a nonstress test to be reactive, there must be two accelerations. Acceleration is defined as an increase in fetal heart rate by 15 beats per minute for at least 15 seconds with movement (Choice A). For a nonstress test to be reactive, there must be two accelerations. Acceleration is defined as an increase in fetal heart rate by 15 beats per minute for at least 15 seconds with movement (Choice C).

The patient is diagnosed with acute pancreatitis. Which preventative intervention should the nurse implement to reduce the patient's risk of developing a respiratory infection? Select all that apply. A. Assist the patient to turn and reposition frequently. B. Document the respiratory rate and oxygen saturation. C. Place the patient in a semi-fowlers position. D. Encourage deep breathing and coughing.

A, C, D Respiratory infections are common in acute pancreatitis due to retroperitoneal fluid pushing the diaphragm upwards and causing the patient to take shallow abdominal breaths. Assisting the patient to change positions frequently, encouraging deep breathing as well as coughing exercises, and positioning patients for maximum chest expansion would all be preventative interventions to reduce the risk of respiratory infection.

The nurse is caring for an elderly patient who has become comatose. The patient's living will specifies that no life-extending procedures are to be done. However, the patient's adult children are troubled and strongly object to this. How would the nurse effectively advocate for the patient in this situation? A. Remind colleagues about the contents of the patient's advance directives. B. Document the wishes of the patient's adult children. C. Plan to respond slowly or incompletely should the patient experience cardiac arrest. D. Develop a plan of care based on the preferences of the patient's children.

A. Remind colleagues about the contents of the patient's advance directives. The 'living will' is a legal document expressing the patient's preferences regarding life-extending medical procedures. It is the nurse's responsibility to support the patient's right to autonomy and self-determination, as shown in that document. One strategy to do so is to communicate the patient's wishes to the health care team involved with the patient.

A nurse is preparing a client's intravenous (IV) infusion. As the nurse was preparing to attach the distal end of the IV tubing to the client's needleless access device, the exposed tubing slipped and hit the top of the client's bedside table. Which of the following is the most appropriate action by the nurse? A. Replace the IV tubing with new tubing B. Discard the client's current needleless access device and replace it with a new one C. Wipe the distal end of the tubing with povidone-iodine to render it sterile D. Clean the needleless access device with an alcohol swab

A. Replace the IV tubing with new tubing The nurse should replace the IV tubing as the existing tubing has now been contaminated and places the client at increased risk for systemic infection due to direct infusion into the bloodstream.

A woman is in the labor and delivery suite at 37 weeks gestation. She has been under her obstetrician's care for preeclampsia. The labor nurse notices that the fetus is experiencing heart rate decelerations. You are part of the neonatal resuscitation team that responds to the call from the labor room nurse. The infant is born but does not respond to tactile stimulation. The group moves the infant to the warmer. You evaluate the infant and confirm he is still not breathing. You begin positive pressure blowing with room air. Another team member notes that the heart rate is 72 bpm and the newborn's chest is not moving with PPV on room air. The next appropriate action is to: A. Reposition the infant to open the airway B. Begin CPR C. Suction the infant with a bulb syringe D. Increase the oxygen concentration

A. Reposition the infant to open the airway Reposition the infant to open the airway while ensuring that you have a good seal with the mask on the newborn's face. Following that action, a team member should suction the infant's mouth and nose. Until the team establishes sufficient ventilation, there is no indication to increase oxygen concentration or begin CPR. The AHA and AAP focus on positive-pressure ventilation as the single most crucial step in the resuscitation of the newborn.

You are taking care of a 10-year-old with a gastro-jejunostomy (GJ) tube. Which electrolyte deficit is this patient at risk for? A. Sodium B. Potassium C. Chloride D. Calcium

A. Sodium There is a large amount of extracellular fluid in the peritoneal cavity, which contains a high amount of sodium. If this fluid is lost through the GJ tube, there will be a sodium deficit.

Intravenous therapies often consist of electrolyte replacement therapies. Select the electrolyte that is accurately paired with one of its functions. A. Sodium: The control and management of circulating blood volume. B. Bicarbonate: The regulation of extracellular fluid. C. Chloride: The regulation of plasma protein. D. Calcium: The metabolism of fats, carbohydrates, and proteins.

A. Sodium: The control and management of circulating blood volume. In addition to other functions, sodium controls and manages circulating blood volume, it maintains circulating blood volume, and it also is necessary for the transmission of nerve impulses.

The nurse is caring for a client who has developed dystonia following the administration of fluphenazine. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe? A. diphenhydramine B. mannitol C. thiamine D. haloperidol

A. diphenhydramine Diphenhydramine is an anticholinergic and is utilized for dystonic reactions associated with antipsychotic use (such as fluphenazine, a typical antipsychotic). Dystonia is one of the earliest adverse effects and should be promptly reported to the prescriber. Mannitol is an osmotic diuretic indicated for increased intracranial pressure. Thiamin is a B-vitamin and can be helpful for alcohol withdrawal. Haloperidol is a typical antipsychotic and would be detrimental in treating dystonia. Medications like fluphenazine include haloperidol which would worsen the effect.

The nurse is assessing an infant with dark skin for jaundice. The nurse plans on assessing this client's A. hard palate of the mouth. B. lower back and sacrum. C. lower legs right below the knee. D. nail beds.

A. hard palate of the mouth. The correct technique when assessing an infant (or an adult) with dark skin for jaundice would be to examine the mucous membranes in the mouth, the hard palate, or the sclera.

The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with A. heart failure receiving diuretics B. bacterial meningitis receiving antibiotics C. prostate cancer receiving brachytherapy D. varicella prescribed antivirals

A. heart failure receiving diuretics Although hepatitis B needs to be reported to the public health department, a client with hepatitis B does not need to be isolated. An appropriate client to room with would be an individual receiving intravenous diuretics for heart failure as this client does not have any transmissible pathogens. A client with bacterial meningitis requires droplet precautions, a client receiving brachytherapy requires a private room, and airborne isolation must be initiated for an individual with varicella.

The nursing diagnosis "[a]t risk for insufficient vascular perfusion" would most apply to which of the following clients? A. An adolescent client undergoing an expected maturational growth spurt B. A 6-year-old pediatric client with a leg recently placed in a cast following a greenstick fracture C. A 76-year-old female client with urinary and fecal incontinence D. A 42-year-old male client who recently sprained his ankle while playing basketball and wrapped the affected ankle in an elastic bandage

B. A 6-year-old pediatric client with a leg recently placed in a cast following a greenstick fracture The nursing diagnosis "[a]t risk for an alteration in vascular perfusion" is most applicable to this client, as the recently casted extremity following the greenstick fracture places this client at risk for decreased tissue and vascular perfusion, primarily compartment syndrome. Compartment syndrome is always a concern for a client with a newly placed cast. In compartment syndrome, tissue pressure (often due to swelling) occurs within a confined space (i.e., within the cast), leading to restricted blood flow and eventually ischemia. Compartment syndrome is always considered a medical emergency and requires prompt medical intervention. Failure to intervene quickly can result in ischemia, possibly leading to irreversible damage to the tissue(s).

Which of the following statements about security in healthcare environments is accurate? A. Healthcare facilities must have egress alarms on all doors, except client doors, to maintain security within the facility. B. All members of the healthcare facility must have education and training relating to security in the facility. C. Members of the healthcare facility who do not have clinical access do not need education and training relating to security in the facility. D. Members of the healthcare facility who have only clerical roles do not need education and training relating to security in the facility.

B. All members of the healthcare facility must have education and training relating to security in the facility. All healthcare facility members must have education and training relating to security in the facility.

What health issues might you expect to find in a client that is a victim of domestic violence? SATA A. Upper respiratory infections B. Bruises and broken bones C. Unintended pregnancies D. Repetitive strain injuries E. Alcoholism F. Depression

B. C, E, F Domestic violence (including physical, emotional, and sexual abuse) occurs throughout society. It is present among all racial, social, and economic groups. Health issues related to domestic violence include physical injury from the assault and chronic health problems that may emerge, either as a complication of traumatic injury or as a physical response to ongoing stress from violence or neglect. Health issues related to domestic violence include physical injury from the assault itself, such as bruises and broken bones (Choice B). Families experiencing domestic violence/ physical abuse have more unintended pregnancies, miscarriages, abortions, and low-birth-weight babies (Choice C). Families experiencing domestic violence have higher rates of substance abuse and depression (Choices E and F).

The nurse is caring for a child with nocturnal enuresis that was not responsive to non-pharmacological modifications. The nurse anticipates the primary healthcare provider (PHCP) to provide which medication? A. Urecholine B. Desmopressin C. Prazosin D. Finasteride

B. Desmopressin Desmopressin is indicated for the treatment of diabetes insipidus and nocturnal enuresis. This medication is a synthetic form of antidiuretic hormone. Urecholine is a cholinergic medication that promotes urinary output and is unhelpful in managing nocturnal enuresis. Prazosin is a medication approved to treat benign prostate hyperplasia (BPH). Finasteride is an antagonist of the peripheral form of testosterone, DHT. Thus, this medication is approved to treat BPH.

A client with bowel perforation is scheduled for surgery and has just been given his pre-operative medication, diazepam. However, the new resident physician forgot to get the client to sign the consent form. He hurriedly tries to make the patient sign the consent and asks the nurse to witness the signing. Which intervention by the nurse is most appropriate? A. Witness the consent form. B. Have the wife sign the consent for the patient and witness the signature. C. Reschedule the surgery. D. Report the physician to the nurse manager.

B. Have the wife sign the consent for the patient and witness the signature. Informed consent must always be obtained before pre-medication/sedation. Unfortunately, in this case, it was missed. If the surgery is urgent, and a client is declared mentally or emotionally incompetent, the next of kin has the legal authority to give consent. In this case, the surgery is urgent (bowel perforation) and cannot be deferred, the patient is temporarily disabled, and therefore, the wife has the authority to sign the consent.

The nurse is performing a verbal hand-off report for a client. Which essential information should the nurse include in the report? A. Current medication list B. Involuntary admission status C. Food and mealtime preferences D. The presence of family at the bedside

B. Involuntary admission status Admission status is essential information provided in the hand-off report because involuntary admission requires the client to stay in the healthcare facility. This status is typically required when a client may pose a threat to themselves or others. This type of involuntary admission status also may raise the risk of the patient eloping. This should be communicated because if a client is involuntarily admitted, they may not have a rational thought process which may raise the risk of self-injury if they do successfully elope.

The nurse cares for a client at 30 weeks gestation at risk of delivering preterm. Which of the following medication would the nurse anticipate the primary healthcare provider (PHCP) to prescribe? A. Penicillin G B. Nifedipine C. Oxytocin D. Misoprostol

B. Nifedipine Nifedipine is a calcium channel blocker indicated as a tocolytic in preterm labor. This medication relaxes smooth muscle and reduces uterine contractions.

The nurse is providing education to the mother of an 8-year-old boy scheduled to receive a scratch skin test to assess for the presence of allergies. The nurse would be correct in encouraging the mother to do which of the following actions to prepare for the test? A. Administer a single dose of anti-histamine medication one day before the test to prepare for any discomfort. B. Refrain from administering systemic steroids to the child in the 5 days preceding the exam. C. Scrub the child's skin vigorously before the exam. D. Maintain NPO status for twelve hours before the test.

B. Refrain from administering systemic steroids to the child in the 5 days preceding the exam. The nurse providing education to this mother would be most accurate in reminding the mother to refrain from administering systemic steroids to the child in the five days prior to the exam. Systemic corticosteroids, as well as anti-histamine medications, may interfere with the test results by reducing reactions and giving false-negative results.

The nurse is observing a newly hired nurse apply bilateral wrist restraints to a client. Which action by the newly hired nurse requires follow-up? A. Secures the restraint to the frame of the bed. B. Repositions the client from semi-Fowlers to prone. C. Provides easy access to the quick release buckle. D. Assesses the radial pulse every two hours.

B. Repositions the client from semi-Fowlers to prone. This action is not appropriate and requires follow-up. A client in physical restraints should not be positioned prone, which may lead to suffocation. Additionally, a client should not be positioned supine because this makes the client feel vulnerable.

What does the area labeled 13 in the picture below represent? A. The anterior horn B. The dorsal root ganglion C. The anterior root D. The posterior root

B. The dorsal root ganglion he dorsal root ganglion is labeled 13 in the picture. A ganglion is a collection of cell bodies of the neurons outside the central nervous system. This cluster of cell bodies in the dorsal root ganglion gives rise to all the fibers present in the spinal nerve's dorsal root, which carries afferent ( sensory) information to the spinal cord. The dorsal/ posterior root nerve fibers sense painful and noxious stimuli that can be chemical or thermal.

The nurse has provided medication instruction to a client who has been prescribed formoterol. Which of the following statements would indicate a correct understanding of the teaching? A. "I will take this medication if I experience shortness of breath." B. "I will need to rinse my mouth out after using this medication." C. "This medication may make it hard for me to fall asleep." D. "I should take this medication two hours before I go exercise."

C. "This medication may make it hard for me to fall asleep." Beta-adrenergic agonists may cause a client to develop insomnia because the medication has the propensity to activate the client and their adrenergic receptors. Drugs in this class (albuterol, salmeterol) share the same effect, insomnia.

A 30-year old female on a cardiac unit states to the nurse, "I'm just not sure my incision is ever going to look right. I don't want to look like a freak." What should the nurse say to comfort her? A. "It will heal fine." B. "Why are you worrying?" C. "What do you think you will look like?" D. "Tell me more."

C. "What do you think you will look like?" This encourages the patient to explain what they think they will look like, which in turn leads to open conversation.

The nurse caring for a client with lung cancer who is scheduled for a wedge resection the following day. What part of the lung will be removed? A. One lobe of the lung B. An entire lung C. A small, localized slice near the superficial surface of the lung D. One portion of the lung with all bronchioles and alveoli

C. A small, localized slice near the superficial surface of the lung A small, localized portion of the lung will be removed during a wedge resection. This section is generally near the surface of the lung. Wedge resection is usually performed to remove a suspicious pulmonary module or a cancerous lung lesion. In addition to the suspected area, a small portion of healthy tissue is removed to ensure the lesion is completely removed with negative margins.

The nurse manager receives a complaint from a client's family member regarding the client's care provided by a specific nurse. Which initial action should the nurse manager take? A. Tell the night charge nurse to ensure the night shift nurse performs the assigned duties appropriately B. Speak with the night shift nurse regarding the complaint and discuss the care provided C. Contact the client's family member who made the complaint to discuss the situation D. Take note of the complaint and place it in the applicable employee's file

C. Contact the client's family member who made the complaint to discuss the situation Assuming the family member rendering the complaint is listed on the client's HIPAA release form, the nurse manager's initial action should be to contact this individual to let them know they have been heard. Additionally, this point of contact allows the nurse manager to ask additional questions regarding the complaint to ultimately help in determining whether the complaint holds merit. Once the manager has determined how reliable the information from the client's family member is, the nurse manager may speak with the client (if the client is capable) before speaking with the nurse in question.

Which part of the laryngeal cartilage is a full circular ring and is the narrowest part of the airway in young children? A. Hyoid B. Arytenoid C. Cricoid D. Thyroid

C. Cricoid The cricoid appears as a full circular ring and is the most narrow part of the airway. While intubating, it can be useful to place pressure on the cricoid to make the airway more comfortable to access.

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? A. Alginate B. Dry gauze C. Hydrocolloid D. No dressing is indicated

C. Hydrocolloid Hydrocolloid dressings protect shallow ulcers and promote an appropriate healing environment. Several factors contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of certain chronic conditions. The stage of breakdown will determine treatment. Nurses should review standing orders from their facility and any additional physician's orders for pressure ulcer care.

The nurse caring for a patient with Guillain-Barre syndrome is gathering supplies to keep near the patient's bedside. The patient is experiencing paralysis up to his waist. Which of the following instruments is of the highest priority? A. Blood pressure cuff B. Pulse oximeter C. Intubation tray D. Stethoscope

C. Intubation tray Ascending paralysis is an attribute of Guillain-Barre syndrome; therefore, these patients are at risk for respiratory failure. An intubation tray should be kept near the patient's bedside.

The nurse is caring for a client who is severely hypernatremic. Based on the complications from this electrolyte imbalance, the nurse knows that the priority assessment is which of the following? A. Cardiovascular status B. Genitourinary status C. Neurological status D. Gastrointestinal status

C. Neurological status When a client is suffering from severe hypernatremia, monitoring neurological status is the nurse's priority. Neurological complications of hypernatremia range from a restless, agitated client, to a comatose state. Sodium plays a major role in the brain and nervous system, so any imbalances can cause serious neurological symptoms.

A patient recovering from a transient ischemic attack can walk but is having difficulty going upstairs. What professional should visit them to help work through this issue? A. Case manager B. Nurse practitioner C. Occupational therapist D. Respiratory therapist

C. Occupational therapist Occupational therapists are excellent resources for helping patients suffering from gait and movement problems. Occupational therapists help patients transition from their hospital life to their homes. While physical therapists are mostly involved in specific gait related issues, occupational therapists also assist to help improve functional mobility so that the patients can perform their activities of daily life ( ADL).

You are working as a school nurse in a local high school. One of the students frequently presents to your office with a fever, runny nose, nausea, vomiting, and dilated pupils. What do you suspect is most likely happening with this high school student? A. Inhalant abuse B. Barbiturate abuse C. Oxycodone abuse D. Viral infection

C. Oxycodone abuse You most likely suspect that this high school student is abusing an opioid drug such as oxycodone. Fever, runny nose, excessive yawning, nausea, vomiting, and dilated pupils are some of the signs associated with opiate withdrawal. Based on the presentation, it appears like the student is abusing opioids potentially after school and now showing early withdrawal signs. Withdrawal symptoms may present just after 8 to 12 hours in clients with a history of chronic opioid abuse. Opioids are Morphine, Oxycodone, Heroin, Methadone.

The patient has been diagnosed with scleroderma. Which of the following will the nurse expect to be the management? A. Maintain a warm atmosphere during the day and a cool room during the night. B. Keep the client supine for 1 hour after meals. C. Initiate strict bed rest. D. Administer prescribed corticosteroids.

D. Administer prescribed corticosteroids. Scleroderma is a medical condition in which connective tissue and skin harden. The surest way to manage this disease is to administer prescribed corticosteroids.

A 30-year-old man was involved in a head-on collision and was unconscious for two minutes prior to EMS arrival. Five minutes before arriving to the hospital, the paramedic notices clear fluid draining from the patient's nose. Having seen this before, the paramedic places a drop from the patient's nose onto a piece of gauze. The nurse is looking for a clinical finding that is called the halo's sign. What type of fracture does the paramedic suspect the patient has? A. Depressed skull fracture B. Traumatic linear skull fracture C. Subarachnoid hemorrhage D. Basilar skull fracture

D. Basilar skull fracture Halo's sign is an indication of a basilar skull fracture. Rhinorrhea can occur from a basilar skull fracture. When this finding is assessed, the provider can place a drop from the nose onto a piece of gauze. The CSF will form a ring around the outside of the drop. This is halo's sign.

Which of the following lab values would be most significant in determining renal function in a client with a history of polycystic kidney disease? A. BUN 90 mg/dL B. Serum potassium 7.0 MEq/L C. Uric acid 7.5 D. Creatinine 8.7 mg/dL

D. Creatinine 8.7 mg/dL Creatinine is a specific indicator of renal function/failure. Polycystic kidney disease is a genetic disorder that causes fluid-filled cysts to grow inside the kidneys. Unlike simple kidney cysts that may develop later in life, PKD cysts can change the shape of organs and alter the functioning of organs. Several tests can evaluate renal functioning.

The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include? A. Sterile gloves should be used to perform urinary catheter care. B. Urinary specimens may be collected from a catheter bag. C. You may irrigate a catheter with warm water for poor outflow. D. Daily use of soap and water should be used around the urinary meatus.

D. Daily use of soap and water should be used around the urinary meatus. Daily cleaning of the urinary meatus with soap and water is recommended for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus.

Which of the following members of the intradisciplinary team should be consulted for an infant suspected of having Celiac disease? A. Pharmacist B. Pulmonologist C. Occupational therapist D. Dietician

D. Dietician Consulting with a dietician is of the utmost importance for the patient who is suspected of having Celiac disease. The dietician is the expert in this area and will provide support, education, and a dietary plan for this patient. Learning to avoid gluten can be difficult for the family, so the dietician is the best resource to help them navigate this.

What is the correct documentation of the patient's peripheral pulse when the finding is that the posterior tibial pulse is weak and thready? A. Grade C posterior tibial pulse B. Posterior tibial pulse is Grade B C. The client's posterior tibial is 2 D. Posterior tibial pulse is 1

D. Posterior tibial pulse is 1 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