Board Vitals Remediation 1st 200 Questions

The nurse received an order to administer metoclopramide 5 mg intramuscular twice a day 30 min after meals. The available dose is 10 mg per 2 mL. Calculate the required dose

correct answer: 1 mL

At a rate of 150 mL/hr, how many hours will it take 2.4 L of D5W to infuse? Round to the nearest whole number

correct answer: 16

You client has a deficiency of aldosterone. Which nursing diagnosis of risk is most appropriate for this client? a) at risk for hyperkalemia r/t an aldosterone deficiency b) at risk for hypokalemia r/t an aldosterone deficiency c) at risk for hypernatremia r/t an aldosterone deficiency d) at risk for HTN r/t an aldosterone deficiency

correct answer: A Rationale: A) is the most appropriate nursing diagnosis for a client who has a deficiency of aldosterone. Low aldosterone leads to the reabsorption of potassium and an increased excretion of sodium, therefore, leading to hyperkalemia and hyponatremia, respectively. Additionally, the client can be adversely affected with low BP rather then HTN, when the serum sodium is low.

Which of the following best describes the indications for performing an alpha-fetoprotein test? a) to identify fetal neural tube defects b) to test fetal heart rate c) to identify infection in the amniotic sac d) to determine whether the placenta is in the correct location

correct answer: A Rationale: an alpha-fetoprotein test is performed on a pregnant woman to identify certain abnormalities in the fetus, including neural tube defects, congenital nephrosis, abdominal wall defects, and fetal anemia. Neural tube defects include spina bifida and anencephaly. Alpha-fetoprotein is produced by the fetal yolk sac, GI tract, and liver

A nurse is caring for a postpartum client who is experiencing involution of the uterus. At which point during the postpartum period would the nurse expect to see this condition? a) immediately following delivery b) two weeks after delivery c) six weeks after delivery d) not at all; this is an abnormal condition

correct answer: A Rationale: involution of the uterus as a normal phenomenon immediately following delivery of the placenta. Uterine involution occurs as the uterus returns to its normal size after being stretched from carrying the fetus. During this process, the muscle fibers of the uterus contract and blood vessels tighten in the area where the placenta was attached. The lining of the uterus also sheds during involution, and it is expelled from the body in the form of lochia.

A nurse is admitting a child who has acetaminophen poisoning. Which of the following statements should the nurse plan to make to the parents? a) "your child will experience nausea and vomiting" b) "your childs liver function test will be decreased" c) "your child will have a fever" d) "your child will receive antibiotics for 24 hours"

correct answer: A Rationale: nausea, vomiting, and anorexia are the immediate manifestations of acetaminophen poisoning. These manifestations typically begin 2 to 4 hour after ingestion

A nurse is caring for a school age child who has a major burn and is experiencing severe pain. Which of the following actions should the nurse implement to manage this client's pain? a) administer morphine sulfate IV via continuous infusion b) administer meperidine IV around the clock as needed c) administer acetaminophen PO every 4 hr d) administer hydrocodone PO every 6 hr

correct answer: A Rationale: opioids administered IV via continuous infusion are recommended for clients who have major burns, regardless of age

A client who has remained in bed for most of the day develops pooling of blood in the lower extremities. This situation places the client at risk of developing which of the following conditions? a) DVT b) contractures c) urinary retention d) constipation

correct answer: A Rationale: pooling of blood in the lower extremities may occur with a lack of activity and ambulation. This excess blood increases the risk of blood clotting, which could result in a DVT if a clot forms in the veins of the lower legs

Two nurses are discussing a client's plan of care during hand-off report at the change of shift. They are following the SBAR technique to ensure accuracy of communication and to avoid missing pertinent date. The R in SBAR stands for: a) recommendations b) report c) risks d) rationales

correct answer: A Rationale: the SBAR system of hand-off communication is an effective tool that exchanges pertinent data in a comprehensive manner. The S stands for situation, the B stands for background, the A stands for assessment, and the R is for recommendations. During this type of report, after giving essential info about the client's background and the work done during the shift, the nurse should then provide recommendations for further client care during the next shift.

A nurse is counseling first-time parents who ask when they should take their child to the dentist. How should the nurse respond? a) within 6 months after the first tooth appears b) after the child is 1 year old c) after beginning preschool d) when all of the child's baby teeth have erupted

correct answer: A Rationale: the american academy of pediatrics and the american association recommend an initial dental visit for children within 6 months after the eruption of the first tooth, which usually appears by the age of 6 months or by the first birthday. At this time, the dentist can assess the child's risk of dental disease and provide anticipatory guidance about diet, fluoride, non-nutritive sucking, and dental hygiene. Dental care is also provided, including treatment of dental caries if necessary. The initial visit is an opportunity to establish care with a dentist and plan future visits. The child will begin to get accustomed to the dental office and the routine of the dental exam and care

A nurse is caring for an older adult client who has injuries resulting from intimate partner violence. Which of the following actions is the nurse's highest priority? a) inform the client about the location of shelters or safe houses b) encourage the client to participate in a support group c) coordinate with case management to provide community and social services d) allow the client to discuss feeling r/t the abuse

correct answer: A Rationale: the greatest risk to this client is injury from intimate partner violence; therefore, the priority action the nurse should take is to assist the client with the development of a safety plan that includes the identification of sage places to live

A nurse is assessing a client who has hypothyroidism and is receiving thyroid hormone replacement therapy. Which of the following findings should indicate to the nurse the need for a decrease in the medication dosage? a) hand tremors b) bradycardia c) pale skin d) slow speech

correct answer: A Rationale: the nurse should identify that hand tremors is a manifestations of hyperthyroidism that can result from thyroid hormone replacement therapy. The nurse should report this finding to the provider due to the possible need for a decrease in the dosage of medication

Which of the following tasks can the nurse assign to a LPN? (Select all that apply) a) administer acetaminophen PO to a client b) recheck the temp of a febrile 6 year old c) complete discharge teaching with a client following an uncomplicated appendectomy d) assess breath sounds in an 83 year old bed bound client e) start the admission assessment of a client who just arrived on the floor

correct answer: A, B, & D Rationale: delegation and assignment require clinical judgment by the nurse, who retains accountability for client care when delegating a task. Assignment refers to giving someone as task within their own scope of practice. Assignment is based on job descriptions and policies within the healthcare organization. Delegations refers to giving someone a task within the delegator's scope of practice. The person to whom the task is delegated would otherwise not be able to perform the task. The nurse should ensure that the LPN is qualified to perform the delegated task. Administration of medication and taking VS in stable clients are within the LPNs scope of practice and can be assigned to the LPN. The LPN can perform client assessment. However, the initial triage or admission assessment must be completed by the RN. The LPN must work under the supervision of the physician or RN. The scope of practice of the LPN is governed by the nurse practice act in the state, and can vary greatly across the country.

A nurse in an outpatient clinic is assessing a client who report night sweats, fatigue, cough, nausea, and diarrhea. The client asks the nurse if it is possible he has HIV. Which of the following actions should the nurse take initially? (Select all that apply) a) perform a physical assessment b) determine when manifestations began c) provide education about HIV transmission d) draw blood for HIV testing e) obtain a sexual history from the client

correct answer: A, B, & E

The nurse has been assigned the following tasks. Order the tasks from highest priority to lowest: a) suction a client who has a new tracheal tube and has a decreased O2 sat level b) hold pressure at the site of insertion for a client who is experiencing a hematoma following cardiac cath c) provide pain medication for a client who is experiencing post surgical incision pain d) ambulate a client in the hallway, who had surgery two days ago e) help a client explore the meaning of their recent terminal diagnosis

correct answer: A, B, C, D, & E Rationale: the nurse should approach the tasks considering Maslow's hierarchy of needs as they prioritize them. Airway care is first, followed by circulatory needs. In this question, that means controlling bleeding. Next, the nurse should treat the client's pain. Then ensure client safety when ambulating a client. Finally, the nurse can help the client with a terminal diagnosis self-actualize by exploring meaning

A nurse is performing an indirect fist percussion on the back of a client. Put the following steps of this process in order: a) assist the client to a sitting position b) expose the client's back c) draw the dominant hand into a closed fist d) place the palm of the non-dominant hand over the area to examine e) hit the back of the flat hand using the ulnar aspect of the fist f) check with the client for the result

correct answer: A, B, D, C, E, & F Rationale: Percussion, an assessment technique, can be direct or indirect. Indirect percussion is performed using the fist to assess for pain and tenderness. Use of indirect fist percussion reduces the risk of client harm. Use of indirect fist percussion is appropriate for assessment of pain or tenderness in the region of the kidneys. Anteriorly, it is used for assessment of right upper quadrant pain in clients with liver or gallbladder disease. Percussion of the back is also used to provide info about the lung fields. Indirect percussion in exam of the lungs is performed by placing the middle finger of the nondominant hand over area of assessment and tapping rapidly at the distal phalanx or distal interphalangeal joint with the middle finger of the dominant hand using a relaxed wrist motion. Direct percussion is performed by tapping directly on the skin surface using one or two fingers. Deviations from the expected sound should prompt further evaluation. A tympanic or hollow sound is expected in the lung fields. If the sound is dull, it may indicate congestion of the lungs from fluid, a pulmonary effusion or abscess, a lung mass, or other causes of consolidation

A 28-year-old male client is undergoing tests to confirm the diagnosis of Hodgkin's lymphoma. The client and his wife are worried that he may have cancer. The wife states, "dont you think that it is unlikely for someone like my husband to have cancer?" The nurse's response is based on the info that Hodgkin's lymphoma is: a) more likely to affect women than men b) often diagnosed during adolescence and young adulthood c) usually occurs frequently among populations as Asian heritage d) typically a disease of the elderly rather than younger adults

correct answer: B Rationale: Hodgkin's lymphoma occurs most often between the ages 15 to 35 and between 50 to 60 years of age

A charge nurse is admitting a client who has bipolar disorder and is experiencing a manic episode. Which of the following client room assignments should the nurse make? a) a semi-private room across from the dayroom b) a private room across from the linen room c) a private room across from the exercise room d) a semi-private room across from the nurses' station

correct answer: B Rationale: The nurse should work to maintain a safe environment for the client and minimize distractions and other environmental stimuli. Assigning the client to a private room in a quiet area of the unit decreases stimuli for the client, thus reducing client anxiety. The area around the linen room should be low-traffic area, which will help decrease the client's anxiety and manic activities.

When caring for a client whose upper and lower teeth were wired together after a fracture of the mandible, which of the following nursing actions is most appropriate if the client begins to choke? a) call the healthcare provider b) suction the airway c) cut the wires d) elevate the head of the bed

correct answer: B Rationale: The upper and lower jaw may be wired together in simple mandibular fractures when there is no loss of teeth, with wiring placed around the teeth and cross-wires or rubber bands used to hold the upper and lower jaw tightly together. There may be arch bars on the maxillary and mandibular arches of the teeth with vertical wires between the arch bars to hold the jaws together. Maintenance of a patent airway is a priority for any client with teeth wired together after a mandibular fracture. The client should be placed on the side with the head slightly elevated immediately postop. Scissors or a wire cutter should be taped to the head of the bed and sent with the client on transplant for appointments. They are used to cut wires or rubber bands if the client is in respiratory distress or cardiac arrest. The surgeon should provide instructions for cutting the wire of wires and these instructions should be part of the client's care plan. Tracheostomy and endotracheal tray should be available. If the client is choking, the nurse should clear the airway with suction, using the nasopharyngeal or oropharyngeal route. An NG tube can be used to decompress the stomach to prevent vomiting and aspiration. An NG tube can be used later for feeding

A nurse is caring for a client in preterm labor who is scheduled to undergo amniocentesis to evaluate fetal well-being and lung maturity. Which of the following test does the nurse understand will be used to assess fetal lung maturity? a) alpha-fetoprotein (AFP) test b) lecithin/sphingomyelin (L/S) ratio test c) kleihauer-betke test d) chorionic villus sample test

correct answer: B Rationale: a test of the L/S ration is determines by amniocentesis. The test is used to determine fetal lung maturity. A sample of the amniotic fluid is analyzed to identify presence of surfactant. Surfactant is needed by the fetal lungs to keep the alveoli from collapsing and the promote gas exchange.

A nurse is providing care to a client who is to be maintained on strict bed rest for three weeks. In order to help prevent atelectasis, the nurse teaches the client to: a) perform ROM exercises several times a day b) deep breathing and coughing several times a day c) wear anti-embolism stockings daily as ordered d) flex and extend her feet every two hours

correct answer: B Rationale: deep breathing and coughing will help to expand the lungs and prevent atectasis

A nurse is assigned to care for a client admitted for treatment of cholecystitis. The nurse would expect the client's history to include intolerance to which of the following? a) carbohydrates b) fatty foods c) protein d) vit C

correct answer: B Rationale: inflammation of the gallbladder (cholecystitis) and/or the presence of gallstones (cholelithiasis) interfere with movement of the bile from the liver or gallbladder into the small intestine. Bile is secreted from the gallbladder into the small intestine to facilitate the breakdown of fats into fatty acids in the digestive process

Which pediatric presentation is most concerning for child abuse when evaluating clients in the emergency department? a) a 3 year old child who has splattered boiling water over the arms after allegedly pulling a pot from the stove b) a 3 month old infant who is lethargic after allegedly rolling off a changing table c) a 2 year old with a bruise on the forehead that the mother say occurred when the child ran directly into the kitchen table d) a 2 month old infant who has a flat purple discoloration on the back that the mother says has been present since birth

correct answer: B Rationale: injury suspected in this case because infants do not roll until 4 months of age. They typically begin rolling from front to back. The childs development stage is inconsistent with the mechanism explained by the mother. The nurse should be concerned about possible abuse when a child's injury is not consistent with the reported mechanism. Lethargy suggests a head injury. Injuries suspicious for child abuse include fractures of the humerus or femur, linear immersion burns, retinal hemorrhages, frenulum and gingival lesions, epidural and subdural hematomas.

An unvaccinated health care worker has been exposed to Hep B through a needle stick. Which of the following should the nurse anticipate administering as post-exposure prophylaxis? a) Hep B immune globulin b) Hep B vaccine and Hep B immune globulin c) Hep B surface antigen d) amphotericin B

correct answer: B Rationale: post exposure prophylaxis is recommended for all unvaccinated individuals who are exposed to blood or infectious secretions. The first dose of vaccine should be given as early as possible and within 12 hours of exposure. If the source is known to be HBsAg positive, one dose of HBIG should be administered at the same time at another site

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? a) heat the solution using a microwave before cleaning the wound b) reposition the client at least Q2H c) clean the wound with hydrogen peroxide solution d) massage reddened areas during dressing changes

correct answer: B Rationale: the nurse should plan to reposition the client at least Q2H and make a schedule to record position changes in the client's medical record

A nurse notices during shift change that another nurse mistakenly started an insulin infusion 15 min ago at a rate of 200 units/hr when the order was 20 "U" per hour. Which of the following is the initial priority action by the nurse? a) alert the nursing supervisor and fill out an incident report b) assess the client after slopping the infusion c) notify the healthcare provider to obtain further orders for the client d) turn down the infusion pump to the correct rate and assess the client's VS

correct answer: B Rationale: the nurse's priority is client safety. When a medication error is discovered, the nurse should assess the client and intervene as necessary to prevent injury. In this case, the insulin infusion should be discontinued immediately before the nurse assesses the client to determine if further intervention is necessary for stabilization. "U" is an unacceptable abbreviation in medical documentation, since it can easily be mistaken for a zero.

A nurse is assessing an infant who has heart failure. Which of the following manifestations should the nurse expect? (Select all that apply) a) increased pulmonary blood flow b) volume overload c) pressure overload d) increased cardiac output e) decreased cardiac blood flow

correct answer: B & C Rationale: Volume overload and pressure overload is a manifestation of heart failure

A nurse is caring for a client who has peptic ulcer disease (PUD). Which of the following interventions should be included in the plan of care? (Select all that apply) a) instructing the client not to eat for at least 30 min before bedtime b) encouraging smaller meals during the day c) limiting the use of red and black pepper d) providing info on a smoking cessation plan e) advising the client to eat less frequent meals during the day

correct answer: B, C, & D Rationale; Clients who have PUD should eat smaller, more frequent meals during the day. Red and black pepper, as well as chili pepper, may create discomfort when consumed by the client who has PUD. Smoking aggravates PUD, and the client who smokes should be encouraged to stop

A nurse is checking for cyanosis in a client who has COPD and has dark skin. Which of the following sites should the nurse assess to identify cyanosis in this client? a) pinnae of the ears b) dorsal surface of the hand c) palpebral conjuctivae d) facial skin

correct answer: C Rationale: Assess skin-color changes in clients who have dark skin, the nurse should examine the sclerae, the soles of the feet, the palms of the hands, the palpebral conjunctivae (inside the eyelids), and the mucous membranes

A nurse is caring for a client who is in labor. The anesthesiologist has just administered a pudendal block. Which of the following is correct regarding a pudendal block? a) a pudendal block may cause side effects of respiratory depression and hypotension b) a pudendal block is on of the first drugs administered for pain control during labor c) a pudendal block anesthetizes the perineum, vulva, and rectum d) a pudendal block is only used in emergency situations

correct answer: C Rationale: a pudendal block is a type of anesthetic block used for pain control during labor. It is given during the time that the mother is in labor but shortly before the baby is born to help the mother remain comfortable. A pudendal block anesthetizes the perineum, vulva, and rectum before the infant is delivered.

Most medical errors are primary due to: a) inadequate staffing levels b) errors of omission c) communication issues d) noncompliance of clients

correct answer: C Rationale: poor communication and poor transfer of information are the root cause of most medical errors. Procedures for hand-off communications have been instituted widely to reduce these errors. SBAR is one reporting framework commonly used to reduce errors due to communication issues during transfer of care. The acronym refers to: -Situation -Background -Assessment -Recommendation

A nurse on a general surgical unit is caring for a client monitored through telemetry from a central location in the hospital. Which action must the nurse implement when the client is transported to the radiology department for a chest x-ray? a) call the radiology department to see if they can perform the x-ray at the bedside b) ask the physician to postpone the x-ray for a day c) notify the central monitoring center that the patient will be going to radiology d) call the client's family to determine whether it is safe for the client to be exposed to radiation

correct answer: C Rationale: telemetry monitors may be monitored locally or at a central location in the facility, such as the ICU or cardiac care unit. If a client on telemetry monitoring needs to go to another location within the facility, the nurse should notify the central monitoring station of the change. The telemetry monitoring location will notify the nurse if the client foes out of monitoring range

A client tells a nurse that her pain is nagging, dull, and intense. The client is describing which characteristic of pain? a) measure b) associated manifestations c) quality d) severity

correct answer: C Rationale: the client is describing the quality of pain, which refers to how the pain feels to the client. There are many different ways to describe the feeling of pain, and some of the more common expressions are typical of certain types of pain, such as the burning or "pin and needle" sensation associated with neuropathic pain. When asking a client about the quality of their pain, the nurse should give several examples when asking what the pain feels like. Those examples include words like throbbing, sharp, and heavy. A complete and accurate pain assessment should be performed and documented by the nurse. The acronym "PQRST" can be helpful to ensure thorough assessment and documentation. P: provocative and palliative factors Q: quality of pain R: region and radiation S: severity T: timing: onset, duration, and frequency

A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which of the following statements by the client indicates an understanding of the teaching? a) "I will chew the gum for no more than 10 min" b) "I will keep the gum in the refrigerator when I am at home" c) "I will avoid eating for 15 min prior to chewing the gum" d) "I mist stop using the gum after 90 days"

correct answer: C Rationale: the client should avoid eating or drinking for 15 min prior to and while chewing the gum

A nurse is assessing a client's hearing by conducting a Rinne test using a tuning fork. Which of the following actions should the nurse take? a) place the base of the vibrating tuning fork in the center of the client's forehead b) place the stem of the vibrating tuning fork on the scalp above the client's ear c) with the tuning fork still vibrating, move it to 1 to 2 cm (0.4 in to 0.8 in) from the client's ear canal d) determine the results by combining the number of seconds for loss of sound from each of the two fork positions

correct answer: C Rationale: the nurse should quickly move the vibrating tuning fork from the mastoid process to the ear canal. The nurse should count the seconds it takes until the client no longer hears sound

A client complains of feeling "lightheaded" after radiofrequency catheter ablation. His cardiac monitor reveals dissociation of P waves and QRS complexes. Which of the following is the most appropriate first nursing intervention? a) call the rapid response team for cardioversion b) notify the healthcare provider and prepare to administer atropine c) notify the cardiologist and prepare for transcutaneous or transvenous pacing d) document the rhythm and assessment in the client's chart and monitor for further changes

correct answer: C Rationale: whatever the cause, the nurse should recognize a complete heart block. The rhythm shown is third-degree heart block, which is complete dissociation of atrial and ventricular arrhythmia caused by failure of the conduction system. This can occur after radiofrequency ablation, which is ablation of electrical pathways that case tachyarrhythmia. Third-degree heart block can result in pre-syncope (lightheadedness), dizziness, fainting, confusion, hypotension, bradycardia, or heart failure. The ECG will demonstrate a regular rate and rhythm, but the P waves and Q waves have no relationship to one another. Third-degree heart block requires temporary or permanent pacing and is a life-threatening condition.

A nurse is providing foot care instructions to a client who has DM. Which of the following instructions should the nurse include? (Select all that apply) a) remove calluses using over-the-counter remedies b) apply moisturizer between toes c) perform nail care after bathing d) trim toenails straight across e) wear closed-toe shoes

correct answer: C, D, & E Rationale: the client should perform nail care after bathing because the toenails are soft and easier to trim the client should trim toenails straight across to prevent injury to soft tissue of the toes the client should wear closed-toe shoes to prevent injury to soft tissue of the toes and feet

A healthcare provider prescribes ampicillin 150 mg IV every 6 hrs. The label instructions state, "reconstitute 1 g with 8 mL of bacteriostatic water". How many mL should the nurse draw when preparing to administer a dose? a) 0.5 mL b) 0.9 mL c) 1.0 mL d) 1.2 mL

correct answer: D

A nurse working in a clinic is providing discharge teaching to the parent of a school-age child who has juvenile idiopathic arthritis (JIA). Which of the following instructions should the nurse include? a) encourage the child to nap for 1 hr daily b) allow the child to stay at home on dats when her joints are painful c) apply cool compresses for 30 min every hr d) administer prednisone on an alternate-day schedule

correct answer: D Rationale: Prednisone is an effective anti-inflammatory agent that can have serious adverse effects, such as immunosuppression, inhibition of bone growth, the development of osteoporosis, and cardiomyopathy. Taking prednisone on an alternate-day schedule can help maintain joint mobility and minimize adverse effects

An RN works for a temporary staffing agency for several night shifts each month in the ED. When entering the lounge during a break, the agency nurse is surprised by a senior staff nurse who is pouring from what appears to be a vodka bottle into a thermos cup. The staff nurse hurriedly closes the items in a locker but has exhibited loud and inappropriate behavior on several occasions in the past that now seem suspicious for intoxication at work. Which of the following is the most appropriate initial intervention by the agency nurse? a) remain silent unless the nurse appears unable to perform the job safely b) file an anonymous complaint with the department of human resources c) confront the nurse and ask for an explanation d) discuss these concerns with the nursing supervisor

correct answer: D Rationale: a licensed healthcare professional has certain legal and ethical reporting duties if there is concern about substance abuse by a co-worker, as this could result in client harm and may also be a criminal violation. The nurse should report the concerns confidentially to the nursing supervisor, who can then determine the next intervention. The nursing supervisor must take a reasonable report of suspicion of substance abuse to the correct authorities, which include the nursing board and a designated institutional representative within the facility. The supervisor on duty can require the senior nurse to submit to a drug and alcohol screening test

Which of the following is the most appropriate recommendation by the nurse who is caring for a client at 23 weeks' gestation with a complaint of significant heartburn? a) take an antacid with sodium bicarbonate b) lie on the side after a meal c) avoid dairy items in the diet d) eat 6 small meals daily

correct answer: D Rationale: during pregnancy, the stomach is displaced upward and compressed by the growing uterus. An increase in the hormone progesterone during pregnancy results in a slowly of the GI tract motility, delayed emptying time of the stomach, and relaxation of the esophageal sphincter, which can cause heartburn (pyrosis). The nurse should advise the client to eat frequent small meals in place of 3 larger meals each day. Other interventions to reduce heartburn include reduction of fluid intake with meals and elimination of dietary triggers like fatty or fried foods, carbonated drinking, spicy food, and caffeine or chocolate. The nurse should advise the client to stay in an upright position after meals to reduce reflux from the stomach into the esophagus. Clients should also be advised to elevate the head of the bed 4-6 inches

A nurse is caring for a client who has an indwelling foley catheter following bladder repair surgery. Which of the following tasks can be delegated to UAP? a) observe the type and amount of urinary discharge b) monitor for complications such as bleeding c) irrigate the catheter with the ordered irrigation solution to ensure the catheter does not become blocked d) perform perineal care e) removal of the catheter

correct answer: D Rationale: perineal care is within the UAP's scope of practice, therefore this task can be assigned to the UAP

A nurse is caring for a newborn who has necrotizing enterocolitis (NEC). Which of the following findings should the nurse recognize as a risk factor for this condition? a) macrosomia b) transient tachypnea of the newborn c) maternal gestational HTN d) gestational age of 35 weeks

correct answer: D Rationale: the causes of NEC is unknown, but infants who were born prematurely are at the greatest risk. Gestational age of 35 weeks, or preterm birth, places a newborn at risk for NEC. This could be due to the lack of oxygen during delivery and a weakened immune system.

A nurse is caring for a client who has OCD and is constantly reorganizing books on a shelf in the day room. The nurse should recognize that the client uses this behavior to do which of the following? a) limit dissociative reactions to stressful situations b) focus attention on meaningful tasks c) manipulate and control other' behaviors d) decrease anxiety to a tolerable level

correct answer: D Rationale: with OCD, obsessions give rise to anxiety, and the anxiety is then reduced by compulsive behaviors. Compulsive rituals are strengthened and maintained because they decrease the anxiety

Which of the following is an expected finding in an assessment of an 18-month-old child? a) eats with a spoon b) builds a 6-7 block tower c) says sentences with 2-4 phrases d) grips crayons with fingers

correct answer: A Rationale: an 18 month old should be able to meet the following milestones: -gross motor skills: walks up and down steps with help, jumps in one place, throws ball overhand -motor skills: builds 3-4 block towers, uses spoon and cup, scribbles, grips crayon with fist, turns 2-3 book pages -language skills: 10+ words, can identify common objects -social and cognitive skills: expresses ownership, has temper tantrums, imitates others

A nurse is collecting data from a toddler who has major burns and suspected septic shock. Which of the following findings indicate the toddler is experiencing septic shock? (Select all that apply) a) increased body temperature b) alteration sensorium c) rapid cap refill d) decreased urine output e) chills

correct answer: A, B, D, & E Rationale: increased body temperature is a manifestation of septic shock altered sensorium is a manifestation of septic shock decreased urine output is a manifestation of septic shock chills are a manifestation of septic shock

A nurse is caring for a client who has undergone total hip replacement and is now in the post anesthesia care unit (PACU). Which of the following is an element of postoperative care provided by the nurse for clients who are post-op hip replacement? a) place pillows between the client's legs b) allow the client to cross the legs c) lower the head of the bed d) assist the client to sit in a low chair

correct answer: A Rationale: after total hip replacement, adduction of the affected limb should be prevented, either by placing an abduction splint or 2 pillow between legs

A nurse is caring for a client diagnosed with herpes zoster. Which of the following is an appropriate nursing intervention for this client? a) maintain standard precautions b) instruct the client to refrain from sexual contact c) check perineum for lesions d) apply antifungal cream as prescribed

correct answer: A Rationale: Herpes zoster, otherwise known as shingles, is a condition caused by the varicella-zoster virus. This virus also causes chickenpox and can remain latent in the spinal nerves for years. Older clients or those with otherwise compromised immunity are more likely to have eruptions of latent herpes zoster. Clinical features include painful rash, with localized blisters usually on one side of the face or body in a dermatomal fashion. The rash typically disappears 2-6 weeks after an eruption. Standard precautions are appropriate when a nurse is caring for an immunocompetent person with dermatomal zoster (shingles)

Which of the following clients should the ED nurse in triage immediately prioritize for assessment and care? a) a client with flank pain rated 10/10 and a hx of renal colic b) a 40- year-old client with diarrhea and vomiting that began 6 hours after a picnic c) a 3-week-old infant who has been feeding poorly with a temp of 100.5 F and sunken fontanelle d) a 30-year-old G1P0 client at 7 weeks gestation who complains of "spotting" with a HR of 72 and BP of 120/80 mmHg

correct answer" C Rationale: a fever (>100.4 F) or hypothermia (<98.6F) in a neonate (<28 days old) is a potential sign of life-threatening sepsis. This client must be seen first. Lethargy, poor feeding, and signs of dehydration, including decreased urine output and sunken fontanelle, are often associated with life-threatening infection in neonates. Physiologic needs, according to Maslow's hierarchy of needs, are the top priority when making decisions about prioritization of nursing interventions. Life threatening emergencies involving airway, breathing, or circulation are the highest physiological priorities

A nurse is teaching a client who has a new prescription for pramipexole to treat Parkinson's Disease. The nurse should instruct the client to monitor for which of the following adverse effects? a) hallucinations b) increased salivation c) diarrhea d) urinary retention

correct answer: A Rationale: Pramipexole can cause hallucinations within 9 months of the initial dose and might require discontinuation

A client presents for an initial prenatal assessment, reporting that her last menstrual period began on Jan 1 and ended on Jan 5. She notes she has unprotected intercourse on Jan 15 and some spotting on Jan 22. According to Naegele's rule, which of the following is the estimate date of delivery? a) Oct 8 b) Oct 12 C) Oct 22 d) Oct 30

correct answer: A Rationale: To arrive at the estimated date of delivery, Naegele's rule uses the first day of the date of the last normal menstrual period minus 3 months plus 7 days. Therefore, this client's estimated date of delivery is (Jan 1) - 3 months plus 7 days, or Oct 8. Other methods to determine the estimated date of delivery include measurement of the uterine height (McDonald's measurement); auscultation of fetal heart rate by doppler; are ultrasound, specifically around the 16-18th week of pregnancy. Naegele's rule assumes the client will have a 28-day cycle. The rule is not as accurate when the client has a longer or shorter menstrual cycle.

A nurse is caring for a client who is on a mechanical ventilator and who receives nutrition through a feeding tube. Which position would most likely reduce the risk of this client developing aspiration pneumonia? a) supine with the head of the bed elevated 30 to 45 degrees b) right side-lying c) supine with the head of the bed elevated 15 degrees d) left side-lying

correct answer: A Rationale: a client who uses a mechanical ventilator and/or a feeding tube for nutrition is at high risk of developing aspiration pneumonia. Unless otherwise contraindicated, the nurse should position the client supine with the HOB elevated 30 to 45 degrees to reduce the risk of aspiration while maintaining a comfortable position.

Before a nurse removes an NG tube from a client, what should the nurse instruct the client to do? a) take a deep breath and hold it b) perform a valsalva maneuver c) exhale d) inhale deeply and exhale rapidly

correct answer: A Rationale: an NG tube is used to administer tube feedings and medications for clients who are unable to eat by mouth, including those who are unable to swallow adequately without aspirating food or liquids into the lungs. They are also used to facilitate suctioning stomach contents for prevention of nausea, vomiting, and gastric distention and to removed stomach contents for analysis. When removing a NG tube, the nurse should assist the client to a seating position if possible, placing a disposable pad across the client's chest to shield it from spillage. The tube should be disconnected and unpinned from the client's gown. Before removing the tube, the nurse may instill 50 mL of air to clear the tube of any contents, but this is optional. Instruct the client to take a deep breath and hold it, which will close the epiglottis and allow the tube to pass easily through the esophagus into the nose. The NG tube should be pinched to prevent contents from draining into the client's throat and removed with a smooth, continuous motion.

A nurse is caring for a client who sees a geometric design on the wallpaper and perceives it as an animal. This is an example of: a) an illusion b) a delusion c) a hallucination d) an idea of reference

correct answer: A Rationale: an illusion is a misinterpretation of actual external stimuli

Which of the following finding during an assessment of a child who is 30 months old requires further evaluation? a) the child's current weight is 6x the weight at birth b) primary dentition (20 teeth) is complete c) chest circumference is greater than head circumference d) the child speaks in 3-word sentences

correct answer: A Rationale: at 30 months, toddlers have usually quadrupled their birthweight, so this suggests the child is overweight and will require further evaluation. Physical development from 1-3 years of age is marked by slowed growth velocity compared to the first year of life. During the first year of life, birth weight doubles by 6 months and triples by 12 months. A child achieves 50% of his or her adult height by 2 years of age

A nurse is caring for a 6-year-old client with ADHD. What techniques should the nurse use to communicate most effectively with the client when asking the client to complete a task? a) obtain eye contact before speaking, use simple language, and have him repeat what was said; praise him if he completes the task b) fully explain to the client the actions required of him, and offer verbal praise and a food reward for task completion c) explain to the client what he is to do, the consequences if he does not comply, and follow through with praise or consequences as appropriate d) demonstrate to the client what he is to do, have him imitate the nurse's actions, and give a food reward if he completes the rask

correct answer: A Rationale: because the client has ADHD and is easily distractible, it is important to obtain eye contact before explaining the task. Simple language and asking the child to repeat what he has heard is necessary. Giving praise encourages the client to complete the task and helps to build self-esteem

A nurse is caring for a client who is receiving brachytherapy. Which nursing diagnosis is most appropriate as based on this therapy? a) the client's family: at risk for exposure to radiation related to this treatment b) the client's family: at risk for cancer relating to genetics c) the client: at risk for an alteration of skin integrity related to this treatment d) the client: at risk for infection related to this treatment

correct answer: A Rationale: brachytherapy is internal radiation therapy material inside the body with the placement of "seeds" or with the introduction of the radioactive material with a wire or needle. It is sometimes referred to as interstitial or intracavity radiation. The client's family and other visitors are at risk for exposure to the radiation from the client's body. Risk for alteration of skin integrity and risk of infection are not associated with brachytherapy

A community health nurse is providing an in-service to a group of clients at a community outreach center about complications related to substance use disorder. Which of the following findings should the nurse identify as the cause of Wernicke-Korsakoff Syndrome? a) alcohol b) caffeine c) cocaine d) hallucinogens

correct answer: A Rationale: chronic alcohol use disorder has many systemic effects. In the central nervous system, it can cause Wernicke-Korsakoff syndrome, a form of encephalopathy and psychosis. This is actually two disorders that often occur in tandem with different manifestations.

A nurse in an ED is assessing a client who reports experiencing intimate partner violence. The client sits quietly and calmly in the exam room and states, "I'm fine". The nurse should identify the client's behavior as which of the following reactions? a) denial b) displacement c) projection d) sublimation

correct answer: A Rationale: denial is a defensive coping mechanism that protects the client from increasing anxiety levels. The client consciously disowns intolerable thoughts and ideas. It is a common response by clients who have experienced violence

A nurse is providing teaching to a client with gastroesophageal reflux disease. Which of the following dietary measures would be useful in preventing esophageal reflux? a) eating small frequent meals b) increasing fluid intake c) avoiding air swallowing with meals d) adding a bedtime snack to the dietary plan

correct answer: A Rationale: esophageal reflux worsens when the stomach is overdistended with food. An important strategy is to eat small, frequent meals

A nurse is providing preoperative teaching to a client who will require a clear liquid diet. Which of the following menu selections by the client indicates an understanding of the teaching? a) flavored gelatin b) carrot juice c) vanilla pudding d) lime sherbet

correct answer: A Rationale: flavored gelatin is an acceptable selection for a clear liquid diet as long as it does not contain any actual fruit. Other components of his diet include clear fruit juices, coffee, and tea without any milk or cream, broth, and carbonated beverages

A nurse is leading an in-service about caring for clients who are receiving peripheral parenteral nutrition (PPN). Which of the following actions should the nurse include when providing info about care for clients receiving PPN? (Select all that apply) a) examine trends in weight loss b) review prealbumin finding c) administer an IV solution of 20% dextrose in NS d) do not refrigerate the PPN solution after it is prepared e) use an IV infusion pump

correct answer: A, B, & E Rationale: examining trends in weight loss will help to evaluate the outcome of PPN reviewing the prealbumin finding will determine if the client has a nutritional deficiency an IV infusion pump is used to regulate the flow and provide accurate delivery of the PPN solution

A client who has liver cancer informs the nurse that the provider has recommended that she consider receiving a liver transplant. The client tells the nurse she does not want to pursue this option because she "has already been through enough suffering". Which of the following responses should the nurse make? a) "it is your right to make decisions regarding your care" b) "your doctor made this recommendation because she feels you are a good candidate for a transplant; perhaps you should reconsider your decision" c) "your family is supportive; maybe you should allow them to make the decision" d) "liver transplants are a common procedure at this hospital, so you shouldn't have to worry about having complications"

correct answer: A Rationale: it is the nurse's responsibility to serve as an advocate for the client and support her right to make decisions regarding health care based on her personal beliefs and values

A nurse is caring for an adult client who is being treated for pancreatitis and required a mechanical ventilator for assistance with breathing. The physician orders an arterial blood gas, which provides the following results: pH: 7.28; pCO2: 51 mmHg, HCO3: 24 mEq/L; SaO@: 92%. Based on these results, which of the following best describes this client's condition? a) respiratory acidosis b) respiratory alkalosis c) metabolic acidosis d) metabolic alkalosis

correct answer: A Rationale: the client is experiencing respiratory acidosis, AEB the low pH level and the elevated pCO2. The HCO3 level in within normal limits, indicating that the acidosis is respiratory and not metabolic

Read the following graphic related to disaster management. Which of the following terms goes in the blank? preparedness -> mitigation -> _____ -> recovery -> evaluation a) reponse b) hazard c) onset d) source

correct answer: A Rationale: the cycle of disaster management involves various steps that serve to plan for, respond to, and recover from a disaster. Before a disaster even occurs, professionals must plan for and take steps to prevent a disaster as much as possible. When a disaster happens, the next step is to respond to the disaster in order to promote recovery. The recovery process is then evaluated to determine what went well and what could be changed.

A nurse is assessing a client who has Cushing's disease. Which of the following manifestations is the priority for the nurse to report? a) peripheral edema b) fatigue c) fragile skin d) joint pain

correct answer: A Rationale: the greatest risk to a client who has Cushing's disease is fluid retention, which can lead to pulmonary edema, hypertension, and heart failure. Therefore, this is the priority finding for the nurse to report.

A nurse is the newborn nursery has just received report. Which of the following infants should the nurse see first? a) a two day old who is lying quietly alert with a HR of 185 b) a one day old who is crying and has a bulging anterior fontanelle c) a 12-hour-old who is being held, with respirations that are 45 breaths per minute and irregular d) a five hour old who is sleeping and whose hands and feet are blue bilaterally

correct answer: A Rationale: the normal heart rate for this age is 120 to 160 bpm. The other options are all normal for the age

A nurse is creating a plan of care for a client who has chemotherapy-induced nausea and vomiting. Which of the following dietary interventions should the nurse include to minimize the client's nausea? a) provide the client with foods that are at room temperature b) request foods that have a high fat content to increase the client's interest in eating c) allow the client to use an assortment of spices to enhance the flavor of bland foods d) serve additional liquid beverages for the client at mealtimes

correct answer: A Rationale: the nurse should chill the client's foods, or serve them at room temp to make them more palatable. Providing the client with foods that are hot in temp can worsen the nausea and increase the chance of vomiting

A nurse is preparing to administer an IM injection to a client. The nurse should complete the third and final medication check at which of the following times? a) at the clients bedside before administration b) at the time the medication is drawn up into the syringe c) at the time the nurse documents administration of the medication d) at the nurses station while reviewing the providers prescription

correct answer: A Rationale: the nurse should perform the final medication check at the client's bedside while reviewing the medication label prior to administering the medication

A nurse is caring for a client who received preoperative atropine to dry up secretions. Which of the following is a side effect of anticholinergic medications like atropine? (Select all that apply) a) urinary retention b) delirium c) diaphoresis d) hypothermia E) diarrhea

correct answer: A & B Rationale: atropine is administered by the anesthetist prior to surgery to reduce oral and airway secretions. Urinary retention, hesitancy, impotence, and dysuria are side effects of atropine. Delirium is one of the CNS side effects. Other side effects include dry mouth, blurred vision, sensitivity to light, lack of sweating (anhidrosis), dizziness, nausea, loss of balance, hypersensitivity reactions (such as skin rash), tachycardia, palpitations, arrhythmias, tachypnea, pulmonary edema, hot dry skin, reduced GI motility, and constripation

A nurse working in a busy urban ED understands that the following clients have a right to be informed about all aspects of their care and to participate in making decisions about that care (Select all that apply) a) a 17-year-old female client who presents with a positive pregnancy test and vaginal bleeding b) a 60-year-old client with HTN, DM, and chest pain who is seen in an urgent care setting c) a 40-year-old client with peritonitis admitted to the ICU with impending respiratory failure requiring urgent intubation and mechanical ventilation d) an 89-year-old client with multi-infarct dementia and pneumonia who is disoriented to place and time e) an 34-year-old client with severe mental illness who has been ruled incompetent and is a ward of their parents

correct answer: A, B, & D Rationale: competent individuals have the right to be informed about all aspects of their care regardless of the healthcare setting, the needs of the client, or the client's age. Clients have the right to participate actively in the decision-making process. Client rights refer to legal guarantees to the client about the healthcare experience. A client who is cognitively impaired retains their client rights, but a surrogate may be designated to act on the client's behalf to exercise those rights in the client's interest.

A nurse is providing info to a client with renal calculi. Which of the following is true about renal calculi? (Select all that apply) a) proteus bacteria causes struvite stones b) increase purine intake causes renal calculi c) cystine stones occurs in 15 to 20% of cases d) allopurinol is prescribed to treat oxalate calculi e) acidic urine is a risk factor

correct answer: A, B, and E Rationale: renal calculi refers to the formation and deposition of stones in the kidney. The definition does not include the formation of stones in the ureter or urinary bladder, as these are called renal calculi. A kidney stone or renal calculus is a crystallized or solidified mineral that should have been eliminated from the body during urinary elimination. Kidney stones can be composed of calcium phosphate, oxalate, struvite, uric acid, and cystine. When stones are 3 mm or more, pain occurs as the passageway is blocked and nerves are stimulated. Diagnosing renal calculi is done using imaging, urinalysis, client history, and physical exam. Surgery and lithotripsy are the main approaches for treating renal calculi. UTI and Proteus infection cause struvite stones

A nurse at a health fair is performing health screenings for clients to determine the risk for developing osteoporosis. The nurse should identify that which of the following clients are at risk for osteoporosis? (Select all that apply) a) a 40-year-old client who takes prednisone for asthma b) a 42-year-old client who jogs 8 km (5 miles) daily c) a 45-year-old client who takes phenytoin for seizures d) a 65-year-old client who has sedentary lifestyle e) a 70-year-old client who has smoked for 50 years

correct answer: A, C, D, & E Rationale: Prednisone affects the absorption and metabolism of calcium and places the client at risk for osteoporosis Phenytoin affects the absorption and metabolism of calcium and places the client at risk for osteoporosis A sedentary lifestyle places the client at risk for osteoporosis because bones need the stress of weight-bearing activity for bone rebuilding and maintenance Smoking increases the risk for osteoporosis because it decreases osteogenesis

A nurse is caring for a client at risk for falling. Which of the following components are part of a fall risk assessment? (Select all that apply) a) LOC b) HR c) elimination status d) gait and ambulation e) RR

correct answer: A, C, and D Rationale: fall risk is assessed by identifying conditions that can contribute to the client's risk of falling and subsequent injury. A checklist or designated assessment form can be used, in accordance with the facility policy. Components of a fall risk assessment include the client's LOC, elimination status, gait and ambulation abilities, presence of orthostatic hypotension, and vision status

A nurse must interview a 15-year-old client about her health habits and gain some information about her history. Which of the following interventions should the nurse employ while working with a client in this age group? Select all that apply. a) listen and display interest in the client b) ask "yes or no" questions to provide structure and organization c) remind the client that her information is not confidential because she is a minor d) take the client's comments seriously e) talk about issues that affect the teen and not just the parents

correct answer: A, D, & E Rationale: adolescents can be a difficult group to work with. They are between the ages of young, school-age children but they are not yet adults. The nurse should try to establish rapport with adolescent clients by listening carefully and taking their comments seriously. Often, situations that may not seem important to adults are very meaningful to adolescents and must be recognized as such. A teen's parents may be present at the exam, and the nurse should consider the needs of both the teen and the teen's parents

A nurse is assigning clients on a medsurg floor. Which clients would be appropriate to assign a LVN? (Select all that apply) a) a client who is two days postop following a cholecystectomy b) a client who is three days post colectomy with a fever of 101.0 c) a client who has been admitted with pancreatitis and reports a pain level of 10/10 d) a client who was admitted two days ago with a broken arm following a fall and is set to be discharged tomorrow e) a client who was admitted with hypertensive crisis three days ago and has had BP controlled via oral medication

correct answer: A, D, and E Rationale: a LVN can be assigned stable clients who are unlikely to experience a change in their condition. The gall bladder removal client, the client with the broken arm and the client with resolving hypertensive crisis are all stable and unlikely to change

A nurse is assisting with insertion of a pulmonary artery catheter for a client who needs invasive hemodynamic monitoring. Place each of the following steps in the proper order for assisting with insertion of a PAC: a) prime IV tubing and the transducer flush lines b) assist the provider with insertion by passing lines and catheters as needed c) inflate the balloon on the catheter once inserted d) connect transducers to the distal and proximal lumens e) secure the catheter to the client f) zero the transducers

correct answer: A, F, D, B, C, & E Rationale: the PAC is used to measure pressures in the right atrium; pulmonary artery systolic and diastolic pressures; mean pulmonary artery pressure, and pulmonary artery wedge pressure. A pulmonary artery catheter is passed through the vena cava to the right atrium, where the balloon tip is inflated. The catheter is then carried rapidly through the tricuspid valve to the right ventricle of the heart, then through the pulmonic valve and into a pulmonary artery branch. When the catheter reach the pulmonary artery, the balloon is deflated and the catheter is secured in place using sutures. Insertion of the PAC can be performed under fluoroscopy. This procedure may be performed at bedside in critical care in the operating suite, under general anesthesia, or in the cardiac cath lab. The pulmonary artery cath is inserted into a great vessel near the heart and then threaded into the heart, passing through the right atrium and right ventricle and into the pulmonary artery. The nurse's role during placement of the catheter is to assist the physician as needed with supplies and with the placement process. The nurse will monitor the client's condition during the procedure, including changes in VS, or waveform, while the catheter is being advanced. The physician may check a wedge pressure by inflating a balloon at the tip of the pulmonary artery cath; the nurse may assist with inflating the balloon to get a wedge pressure. Measurement of the pulmonary artery wedge pressure and pulmonary artery diastolic pressure provide an estimate of the normal left ventricle filling pressure in a critically ill patient.

A nurse is conducting health teaching concerning HIV for new nursing students. Which of the following individuals is considered to have the highest risk of acquiring the infection? a) volunteer who assists HIV-positive clients with referrals b) phlebotomist who collects blood from high-risk clients c) nurse who is assessing the history of an HIV-positive client who is coughing d) lab technician who gathers a saliva sample for ELISA testing

correct answer: B Rationale: HIV infection is transmitted through blood and body fluids. The virus attacks the T-cells of the body's immune system, making the client vulnerable to other opportunistic infections and some forms of cancer. HIV is also transmitted through sexual contact. The phlebotomist, who is regularly at risk for needlestick injury, is at greatest risk

A client with ankylosing spondylitis is discouraged because of his inability to continue working as a carpenter without severe pain. He has received a new prescription for etanercept. Which of the following nursing diagnoses is the priority for this client with regards to the new prescription? a) depression b) risk for infection c) risk for cardiac arrhythmia d) impaired physical mobility

correct answer: B Rationale: ankylosing spondylitis (AS) is a rheumatological disease that causes spinal stiffness and back pain. It is a systemic disorder that can result in pain in other joints and effects on the eyes, heart, lungs, and kidneys. In addition to treatment with NSAIDs, sulfasalazine, and physical therapy, tumor necrosis factor inhibitors may be used to treat AS and other rheumatological disorders

A nurse in a provider's office is providing teaching to the parent of a child who has allergic rhinitis and a new prescription for diphenhydramine. Which of the following manifestations should the nurse instruct the parent to monitor for as an adverse effect of diphenhydramine? a) increased urination b) drowsiness c) drooling d) weight gain

correct answer: B Rationale: diphenhydramine can cause drowsiness due to CNS depression. The nurse should instruct the parent to administer the medication at bedtime to avoid daytime sedation

The nurse is assessing an elderly client for the risk of falls. Which of the following should the nurse collect? a) the facility restraint policy b) info on gait, balance, and visual impairment c) psychosocial history d) the facility environmental safety plan

correct answer: B Rationale: fall risk should always include an assessment of gait, balance, and visual impairments. The other options are not relative to the fall assessment

A nurse smells smoke when entering a client's room and finds a fire is burning in the bathroom. What is the most appropriate response? a) find other staff members to assist b) take the client out of the room c) check the bathroom to find out if anything is broken d) find the closet fire extinguisher

correct answer: B Rationale: here are the actions to take in the event of a fire, using mnemonics "RACE" and "PASS" RACE: 1. rescue clients who are in immediate danger 2. activate the fire alarm 3. confine the fire 4. extinguish the fire and obtain the fire extinguisher PASS: 5. pull the pin on the fire extinguisher 6. aim at the base of the fire 7. squeeze the extinguisher handle 8. sweep the extinguisher from side to side to coat the area of the fire evenly

The nurse has provided education for a group of new licensed vocational nurses (LVNs). Which statement made by one of the LVNs indicates the teaching has been understood? a) "I can perform assessments on clients newly admitted to the floor from surgery" b) "I will plan plenty of time for medication administration" c) "I look forward to teaching classes for clients newly diagnosed with DM" d) "I am going to apply to work in the intensive care unit (ICU) once I am off my orientation period"

correct answer: B Rationale: medication administration is within the scope of practice for the LVN on stable clients who are unlikely to change

A nurse is preparing a client for a nuclear imaging procedure for suspected esophageal cancer. Which of the following statements should the nurse make about nuclear imaging procedures? a) "this procedure will identify your liver enzyme levels" b) "you will be given an injection of radioactive substance" c) "an endoscope tube will be inserted through your mouth" d) "fluid will be aspirated with a needle:

correct answer: B Rationale: nuclear imaging involves the administration of an oral or IV radioactive tracer to identify cancerous tissue

During routine prenatal testing, it is determined that a pregnant client is not immune to rubella. Which of the following considerations must the nurse consider when preparing to administer the rubella vaccine? a) educate the client that she will need at least 2 doses of the vaccine to provide rubella immunity b) do not provide the vaccine to a pregnant client. The client cannot receive the vaccine until after childbirth c) many clients develop fever, swelling at the site of injection, and bleeding into the joints after rubella vaccine administration d) the client must wait at least six months after receiving the vaccine before becoming pregnant again

correct answer: B Rationale: routine testing for rubella immunity during pregnancy may determine that a pregnant client is not immune to rubella and that the vaccine is necessary to avoid potential birth defects in future pregnancies. Although the client needs the vaccine for protection, it should not be given during pregnancy. The rubella vaccine is often administered the first postpartum day while the client is still in the hospital

A nurse is caring for a client with osteoarthritis who is receiving an injection of hydrocortisone into the knee joint. Which of the following does the nurse understand is the most significant reason for this treatment? a) repair cartilage b) reduce inflammation caused by arthritis c) provide physiotherapy to the joint d) prevent ankylosis of the joint

correct answer: B Rationale: steroids have anti-inflammatory properties and reduce the inflammation caused by arthritis

A nurse is assessing a client who is 2 days postpartum. There is 8 cm of bright red lochia with small clots saturating the perineal pad. How should the nurse document these findings? a) scant b) light c) moderate d) heavy

correct answer: B Rationale: the amount of lochia is characterized by the quantity that saturates the perineal pad. From 2.5 cm to 10 cm is characterized as light lochia. Lochia should be assessed for amount, consistency, and color. It usually trickles from the vaginal introitus, but during uterine contractions, flow is more consistent. When assessing the client, the nurse should look for pooled lochia on the pad. Lochia that has pooled in the vagina can be expelled by the uterine massage or when the client is ambulating. After expression of any clots or dark blood that has collected in the vagina, the flow should return to a bright red trickle. Abnormalities include excessive blood loss, foul odor, spurts of bright red blood, persistence of bright red lochia after the third day postpartum, or continuous flow of lochia alba or serosa, particularly when accompanied by fever or abdominal pain

A nurse is caring for an elderly male client following a hip replacement. When asked about his plans to go home, he states, "my daughter offered to stay with me, but she and her family live out of state. I dont want them to come. I dont want to be a bother." Based on this info, which of the following should be added to the client's plan of care? a) depression b) risk for social isolation c) risk for suicide d) risk for spiritual distress

correct answer: B Rationale: the client's statement indicates the risk for social isolation

A nurse is caring for a client who has dysphagia and who must follow the dysphagia diet for eating. The client is at level 1 of the diet. Which of the following foods should the nurse offer the client? Level 1: Dysphagia pureed-> totally pureed foods with no sticky substances, such as peanut butter -> __________ Level 2: Dysphagia, mechanically altered -> soft, moist foods that are easy to chew -> well-cooked potatoes and noodles, scrambled eggs, ground meat, cottage cheese, soft cookies Level 3: dysphagia advanced -> near-normal texture foods, crunchy or sticky foods are not allow -> bread, pasta, meat, cooked vegetables except for corn, cooked cereal, rice, cheese, cooked or soft fruit without rinds or seeds a) soft pancakes with syrup b) custard c) cooked fruit d) casserole

correct answer: B Rationale: the dysphagia diet has been developed to guide practitioners about the type of foods clients can eat and swallow depending on the amount of dysphagia present. A client who is at level 1 of the diet should have foods that are completely pureed, such as pudding, custard, or applesauce

A nurse in an emergency department is assigned to care for a client diagnosed with benzodiazepine ingestion. Which of the following actions should the nurse take first? a) administer flumazenil b) determine the client's level of orientation c) administer activated charcoal d) prepare the client for gastric lavage

correct answer: B Rationale: the first action the nurse should take when using the nursing process is to assess the client. Identifying the client's level of orientation is the priority action because lethargy, drowsiness, and confusion are symptoms of benzodiazepine toxicity.

A nurse is visiting a home care client at home to assess safety. The nurse notices that there are no fire alarms in the client's home. The client responds that he has never had any fire alarms and doesn't see the need for them. Which of the following is the appropriate response by the nurse? a) without telling the client, call the client's family and request that they install fire alarms in the home immediately b) educate the client regarding the importance of having working fire alarms and encourage him to think about having a fire alarm installed on each floor c) advise the client that he will be sent to a nursing home is a report is filed that states he does not live in a safe environment d) call the client's primary care provider and report the absence of working fire alarms in his home

correct answer: B Rationale: the nurse should attempt to provide the client with enough info to make an informed decision

A nurse is caring for a client who received a permanent pacemaker 6 weeks ago and is experiencing dysrhythmias. Which of the following orders should the nurse clarify with the provider? a) cardiac enzymes b) MRI of the chest c) daily physical therapy d) low-sodium diet

correct answer: B Rationale: the nurse should identify that a permanent pacemaker is contraindication for an MRI of the chest. The magnets in the machine can create electromagnetic interference, causing the pacemaker to malfunction. Therefore, the nurse should clarify this prescription before scheduling.

A nurse is caring for a client with bipolar disorder who has had five acute manic episodes in one year requiring hospitalization. What feature of bipolar disorder is this client most likely exhibiting? a) mixed episodes b) rapid cycling c) post-traumatic response d) continuation

correct answer: B Rationale: this client has experienced rapid cycling, which is defined as the presence of four or more episodes of acute mania within one year

A nurse is caring for a client who is undergoing tracheostomy. Which of the following complications is associated with this procedure? a) decreased CO b) damage to the laryngeal nerve c) pneumothorax d) ARDS

correct answer: B Rationale: tracheostomy tubes are associated with several potential complications, including laryngeal nerve damage, bleeding, and infection. They do not cause a decrease in CO or respiratory distress

Which of the following situations constitutes an indication for a non-stress test? (Select all that apply) a) maternal hypothyroidism b) decreased fetal movement c) twin or triplets d) maternal fever e) at 12 week visit

correct answer: B & C Rationale: a NST can be performed on a pregnant client as a non-invasive test to evaluate fetal response to in utero stimulation, such as fetal movement. A NST is typically performed after 28 weeks; gestation and is used to assess fetal response in certain situations, such as during preterm labor or when twins or triplets are present. If there is decreasing fetal movement, the provider may also order a NST to determine the baby's response

A nurse has selected a vein to place an IV catheter for a client who will be receiving antibiotics via intermittent IV bolus. Identify the order in which the nurse should perform the following steps: a) apply a tourniquet b) clean the site with an antiseptic swab c) insert the catheter d) advance the catheter e) flush the catheter

correct answer: B, A, C, D, & E Rationale: to select a vein for IV infusion, the nurse should apply a tourniquet or BP cuff, removing the device after the selection. Then, to insert the catheter, the nurse should first clean the site with soap and water, allow it to dry, and clean it with an antiseptic swab. After allowing it to dry again, the nurse should then reapply the tourniquet or BP cuff and check for the presence of the distal pulse. Third, the nurse should insert venous access device with the bevel up. After noting a blood return, which indicates that the cannula is in the vein, the nurse should advance the catheter approximately 0.6 cm (0.25 in) and stabilize the catheter. The nurse should then release the tourniquet, flush the catheter, and secure it.

A nurse is assessing an adolescent who has autism spectrum disorder. Which of the following manifestations should the nurse expect? (Select all that apply) a) attempts to intimidate others b) has delated language development c) spins a toy repetitively d) exhibits ritualistic behavior e) tests limits consistently

correct answer: B, C, & D Rationale: a delay in speech and language development is an expected finding of autism spectrum disorder interest in repetitive activities is an expected finding of autism spectrum disorder a need for routine and the presence of ritualistic behavior are expected findings of autism spectrum disorder

A nurse is caring for a client who was admitted to the med-surg unit with acute diverticulitis. Which of the following orders should the nurse question? a) Metronidazole (Flagyl) b) Morphine 2 mg IV q4 hours prn pain c) colon prep for a colonoscopy d) NS iv infusion at 100 mL/hr

correct answer: C Rationale: colonoscopy is contraindicated in acute diverticulitis because of the risk of perforation. Diverticulitis is usually found on routine screening colonoscopy, but the diagnosis of diverticulitis is clinical. Barium enema can also be used to diagnose diverticular disease but is contraindicated in acute diverticulitis because of the risk of perforation.

Which of the following would a nurse expect on assessment of a client with fat embolism syndrome after femur fracture? (Select all that apply) a) pain with movement of the affected extremity b) restlessness and confusion c) fever d) petechial rash on the neck, and axilla

correct answer: B, C, & D Rationale: fat embolism syndrome is a life-threatening condition that develops in clients who have experiences a pelvic or long-bone fracture, although it can also occur in clients after liposuction or in those with other non-traumatic conditions, including pancreatitis After a long bone fracture, fat embolism syndrome typically takes 12-60 hrs to develop, Signs include dyspnea, tachypnea, and hypoxemia, which occur after a fat embolism lodges in the pulmonary circulation, impairing gas exchanges and resulting in acute respiratory failure Similar to pulmonary embolism, fat embolism causes areas distal to the obstruction to be ventilated by not perfused, resulting in a ventilation-perfusion mismatch. Neurologic signs include confusion, agitation, and restlessness. There is no definitive test for diagnosis of this syndrome, but a key characteristic is a petechial rash on the neck, chest, and axilla. A petechial rash refers to pin-sized purple spots that do not turn pale (blanch) under pressure. Fever may also be present due to activation of the immune response

A nurse is obtaining data from the parents of an infant who has acute otitis media. Which of the following statements should the nurse expect the parents to make? (Select all that apply) a) "my baby prefers to sleep and nap on her back" b) "my baby has been pulling at her ears" c) "my baby has not been drinking her bottles lately" d) "my baby is not sleeping at night" e) "my baby has been very irritable and crying more lately"

correct answer: B, C, D, & E Rationale: infants who have acute otitis media will pull or tug at their ears because they cannot verbalize their pain, which occurs due to increased pressure and inflammation. Infants who have acute otitis media will exhibit a loss of appetite due to the pain and pressure in the ear. Sucking could put more pressure on the middle ear and intensify the pain. Infants who have acute otitis media can be irritable and unable to sleep at night because of the increased pain, fluid, and pressure in the ear. Because infants cannot verbalize their pain, they might exhibit crying and irritability

A nurse is caring for a client who is receiving chemotherapy and is on neutropenic precautions. Which of the following interventions should the nurse implement? (Select all that apply) a) apply prolonged pressure to puncture sites b) remove fresh flowers from the room c) have the client wear a mask when leaving the room d) leave client-specific equipment in the room e) eliminate raw foods from the clients diet

correct answer: B, C, D, & E Rationale; neutropenic precautions include the client not having contact with fresh flowers and plants, due to the presence of infectious agents in the water and soil. Neutropenic precautions include having the client war a mask when leaving the room to reduce the incidence of infection. Neutropenic precautions include having equipment that is kept in the client's room and only used when caring for the client to reduce the incidence of infection. A client who has neutropenic should avoid consuming raw foods due to the presence of infectious agents on the peels and rinds

A nurse is caring for an elderly client with moderate hearing loss. Which of the following should the nurse do when communicating with this client? (Select all that apply) a) use exaggerated facial expressions and normal tone b) decrease background noise c) raise the pitch of his voice d) face the client e) speak slowly

correct answer: B, D, & E Rationale: facing the client and speaking slowly in a lower tone with limited background noise optimizes hearing for clients with presbycusis.

While working at a community clinic, a nurse teaches some parents about proper car seat use. Which of the following information, according to American Academy of Pediatrics, should the nurse give to the families? (Select all that apply) a) Infant car seats should face the rear until the infant weighs 10 lbs b) car seats should never be placed in a front seat with an airbag c) when children outgrow the rear-facing car seat, they should be placed in a forward-facing booster seat with a lap and shoulder belt d) children should use a booster seat with a lap and shoulder belt until they are at least 4 feet 9 inches tall, or approximately 8 to 12 years old e) all children under the age of 13 should be restrained in the back seat of the car when possible, and not the front seat

correct answer: B, D, & E Rationale: while some car seats may vary according to each manufacturer, the American Academy of Pediatrics has given guidelines to follow when restraining a child or baby in a car seat in order to best uphold the safety of the child. All babies should be restrained in a rear-facing car seat until they are two years old or they have reached the highest weight given by the car seat's manufacturer. Booster seat is used until the child is approximately 4 feet, 9 inches tall or 8 to 12 years old. It is recommended that children sit in the back seat until they are 13 years old and if using a car seat in the front seat, it should never be placing in front of an airbag.

The nurse is assessing a client with Parkinson's disease who experiences unsteadiness when turning. According to this finding, which stage of the disease is the client experiencing? a) second b) first c) third d) fourth

correct answer: C Rationale: Parkinson's disease is a progressive neurological disorder that causes destruction of dopamine-generating cells in the substantia nigra of the brain. Loss of dopaminergic neurons affects movement. There are 5 stages in the progression of Parkinson's disease. Stage 1 is characterized by unilateral involvement with minimal or no functional impairment in the movement. In stage 2, there is bilateral and midline involvement but without impairment of balance. Stage 3 is characterized by impairment of reflexes, which results in symptoms that include unsteadiness with turning. Tremors become more profound in this stage, often restricting activities. Stage 4 is characterized by fulminant manifestation of symptoms that include tremor, bradykinesia, rigidity, postural instability, and festination. Stage 5 of Parkinson's disease is characterized by confinement to bed or wheelchair as the client's condition worsens.

A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is unable to sit still and is disrupting a group activity. Which of the following actions should the nurse take? a) recommend the client play a game of table tennis with another client b) offer the client a soda and a snack c) take the client outside for a walk d) praise the client's efforts to engage in social interaction

correct answer: C Rationale: clients who are experiencing mania can experience increased anxiety and loss of control in situations with increased environmental stimuli. This can result in aggressive behaviors by the client. Taking the client outside for a walk places the client in an environment with a low level of stimuli, which can decrease anxiety. The low-impact physical activity of walking outside with the nurse provides a means for the client to decrease tension and increases the ability of the client to focus and their sense of security

A nurse has just received reports for 4 clients. Which client should the nurse prioritize? a) a client with afib who missed the last dose of warfarin b) a client with pyelonephritis who has blood in her urine c) a client post surgical repair of a right tibia-fibula fracture who complains of severe pain after surgery and now has no feeling in the right foot d) a client with COPD who has wheezes and diminished breath sounds bilaterally with an oxygen saturation reading of 90% on pulse ox

correct answer: C Rationale: compartment syndrome is a serious complication of fractures and crush injuries that is caused by swelling tissues in the compartments of the leg or forearm. As pressure rises within a compartment as a result of swelling and inflammation, the capillary perfusion pressure is reduced, causing ischemic injury to the tissues within the compartment. Compartment Syndrome is characterized by severe pain, pain with passive stretching, pallor in the distal extremity, paresthesia, and pulselessness or reduced pulses. A fasciotomy is performed surgically to relieve the compartmental pressure. It is an emergency since necrotic muscle will not recover. Failure to recognize compartment syndrome in a timely manner can cause contractures, infections, and amputation.

When advising an elderly client with osteoporosis who is at risk for a fall at home, the nurse knows that which of the following is the most effective measure to prevent falls? a) purchasing a hearing aid b) using a walker or cane in the home c) removing throw rugs d) undergoing an eye exam with a change of prescription if necessary

correct answer: C Rationale: falls in older adults are a common cause of significant morbidity and mortality, often resulting in loss of independence. Older people are at greater risk of falling as a result of age-related impairment or balance problems. The most effective measures among those listed are the installation of grab bars and removal of throw rugs. Throw rugs can easily cause a fall for an older client, even when using a walker. Although younger individuals are more likely to regain balance after slipping on a loose rug, an older adult lacks the balance and rapid reflexes to prevent injury. Other measures to reduce the risk of falls include improving lighting, installing grab bars in the bathroom, removing clutter and obstacles that could potentially cause tripping, avoiding of thick-soled shoes, engaging in exercises to improve strength and balance, avoiding alcohol consumption, and use of vit D supplements and appropriate medications in clients with osteoporosis

You are caring for a client with terminal cancer who asks for info about home care. Which best describes the difference between hospice and palliative care? a) palliative care involves providing comfort care at the end of life, while hospice provides care to promote comfort and ease suffering at any time b) clients receiving hospice care must be within 7 days of death, while palliative care provides care for anyone who is experiencing pain c) hospice care involves providing care at the end of life, while palliative care promotes comfort and eases suffering at any time d) palliative care is designed to ease suffering without treating the underlying illness, while hospice eases suffering while curing the underlying illness

correct answer: C Rationale: hospice and palliative care may be used at the same time. The terms can be confused because of similarities between the two types of care. Hospice care is care provided to people who are dying, usually within the next 6 months. Palliative care promotes comfort and eases suffering with or without trying to cure the underlying condition. Clients who are receiving hospice care may also have palliative care, but not all palliative care clients are hospice clients

When a nurse is evaluating a formula-fed infant for seizures, irritability, and diarrhea for a day, they note facial edema. The parents state they have had to dilute the infant's formula with boiled water because of cost concerns. What is the most likely cause of these symptoms? a) hyperkalemia b) hypoglycemia c) hyponatremia d) hypernatremia

correct answer: C Rationale: infant formula, whether milk- or soy- based, is designed to approximate breast milk. It comes in various forms, including a condensed liquid that is diluted with an equal amount of water or a powder that is diluted with water. If too much water is added, the infant can experience water intoxication. Mothers who breastfeed may supplement water for breastmilk when feeding infants, which also results in water intoxication. Symptoms include drowsiness, irritability, low body temperature, pale or clear urine, more than 6-8 wet diapers, swelling or a puffy face, and seizures. Dilutional hyponatremia occurs due to the excess of water and this results in cerebral edema and neurologic signs and symptoms. Because the infant renal system is not fully mature, it has a low glomerular filtration rate. This decreases elimination of excess water and makes infants more susceptible.

A female client with a BMI of 31 tells the nurse she has decided to fast for 1 week on water and cabbage soup to get a quick start on a weight loss program. When responding to the client, the nurse stresses which of the following? a) fasting reduces hunger over time b) fasting uses fat preferentially c) fasting provides initial weight loss primarily due to loss of fluids d) a week-long fast is unlikely to cause significant health problems

correct answer: C Rationale: initial weight loss during a fast is the result of fluid loss. This occurs largely because of the degradation of glycogen stores in the liver to use for enegy. The process of glycogen metabolism results in the release of water and fluid loss. During a fast, the body shifts from the use of dietary intake as an energy source to glycogenolysis, which refers to the breakdown of glycogen stores in the liver. Catabolism occurring during a fast refers to lipolysis and muscle breakdown for conversion of amino acids to glucose.

The nurse is caring for an elderly man who has hip pain related to rheumatoid arthritis. This client is practicing appropriate self-care activities when the client chooses to sit in which of the following chairs? a) reclining chair with arms to support wrists and hands b) couch with soft cushions to support thighs c) straight-backed chair with elevated seat d) curved back rocking chair

correct answer: C Rationale: it is important for clients with rheumatoid arthritis to maintain proper posture and body alignment to support joints and decrease pain and stiffness. The client will be most comfortable sitting in a straight-backed chair with an elevated seat

Select the disorder that is accurately paired with the correct etiology or symptoms: a) cardiac tamponade: loud heart sounds and JVD b) bacterial endocarditis: this most commonly occurs after a respiratory infection or MI c) venous thromboembolism: risk factors include stasis and hypercoagulability d) venous insufficiency: an inflammatory process that places clients at risk for pulmonary emboli

correct answer: C Rationale: venous thromboembolism is a peripheral vascular disorder that can occur as a result of stasis, impaired venous return, and a hypercoagulation clotting disorder

A nurse is talking with a client about the benefits of quitting smoking by using the 5 A's method of smoking cessation. Based on the info in the chart below, which of the following is an example of the "assess" value of promoting smoking cessation? -ask = question the patient about his smoking habits -advise= recommend that the patient quit smoking to benefit his health -assess = ?????? -assist= provide treatment as ordered by the physician, help the patient make a plan to quit -arrange= schedule a follow-up appointment to meet with the patient to discuss the situation again a)talk to the client about how long he has smoked b) ask the client if he thinks his family is affected by his smoking c) consider if the client demonstrates willingness to change d) help the client fain access to smoking-cessation programs

correct answer: C Rationale: most people know that it's difficult to quit smoking. A nurse who is counseling a client who wants to quit smoking can utilize the 5 A's method of smoking cessation; ask, advise, assess, assist, and arrange. For each of the "A's", the nurse intervenes to help the client see why it is important to quit, and to take steps to follow through with quitting. During the "assess" stage, the nurse would determine if the client demonstrates a willingness to make changes and to quit

A client with angina shows the nurse the nitroglycerin tablets (Nitrostat) that he carries in a plastic bag in his pocket. Where should the nurse advise the client to store his nitroglycerin tablets? a) the refrigerator b) a cool moist place c_ a dark container to shield it from light d) a plastic pill container that is readily available

correct answer: C Rationale: nitroglycerin in all forms (sublingual, transdermal, or intravenous) should be shielded from light to prevent deterioation

A nurse is conducting a home visit with a client who has a history of angina. Which of the following statements by the client BEST demonstrates that further teaching about nitroglycerin therapy is required? a) "I take a tablet about 10 min before I walk up the stairs" b) "I take no more than 3 doses in a 15 min period" c) "I keep the tablets in a glass dish on the windowsill so they are readily available" d) "I will call my doctor immediately if I experience blurred vision"

correct answer: C Rationale: nitroglycerin tablets may lose effectiveness if not protected from light. Therefore, they should be kept in a dark container

A nurse is caring for a client who is in labor with cervical dilation of 5cm. Which of the following findings on the assessment requires intervention by the nurse? a) contraction intensity of 45 mmHg b) resting uterine tone of mmHg c) duration of contractions of 100 sec d) frequency of contractions every 4 min

correct answer: C Rationale: normal uterine contractions in the active phase of the first stage of labor (which begins at some point when the cervix is dilated between 4-7 cm) should not last longer then 90 sec. The uterus contracts to dilate and efface the cervix while causing the fetus to descend. During contractions, blood flow through the intervillous space and spiral arterioles can decrease, which places stress on the fetus. Typically, the length of uterine contraction is 40-70 sec. During the active phase of the first stage of labor, contractions are more regular, at a frequency of 3-5min. During this stage of labor, there is rapid dilation and effacement. Fetal descent begins. Maternal feelings of helplessness, anxiety, and restlessness often increase as the contractions become stronger.

A nurse is serving on a committee that is exploring the use of the auditing process to improve client care at a facility. Which of the following aspects of client care should the nurse identify as measured by a process audit? a) availability of supplies b) nursing staff ratios c) how nursing care was provided d) results of a specific nursing intervention

correct answer: C Rationale: process audits evaluate the process of how nursing care was provided and determine if the nursing care is consistent with facility policy

A nurse in the pediatric unit is caring for several infants and toddlers with severe physical developmental problems resulting in immobility and subsequent inactivity. Which physical nursing diagnosis is a priority for these infants? a) a lack of maternal bonding related to immobilization b) impaired cognitive development related to immobilization c) impaired musculoskeletal development related to immobility d) impaired nutritional status related to immobilization

correct answer: C Rationale: the priority physical diagnosis for these infants is are related to immobility. Infants who are immobile at this stage of life are often affected by arrested musculoskeletal and intellectual development. However, cognitive nursing diagnosis. Maternal bonding can be impaired, but there is no evidence in this question that is the case, and if it were, it would also not be physical, but rather a psychological nursing diagnosis. Unless the infant is developmentally impaired in terms of sucking and swallowing, there is no reason to believe that the nutritional status is impaired. Elimination, however, may be impaired.

A nurse is caring for a client who is postop roux-en-y gastric bypass surgery for management of morbid obesity. The client will most likely require a multivitamin with additional supplementation of which of the following to avoid a frequent complication of the procedure? a) vit B6 b) vit E c) vit B12 d) intrinsic factor

correct answer: C Rationale: there are 2 types of bariatric (weight loss) surgical procedures: restrictive surgery and malabsorption surgery. Restrictive surgeries include gastric band surgery and sleeve gastrectomy, both performed laparoscopically. Roux-en-Y gastric bypass restricts the stomach volume and bypass most of the stomach and duodenum. As a result of malabsorption caused by bypass of parts of the GI tract, the client will require supplements. These include vit A, vit B1 (thiamine), folate, vit B12, vit E, and vit K. Minerals that require supplementation include iron, selenium, and zinc. B12 deficiency occurs because of the reduced number of partial cells, which produce gastric acid necessary to cleave vit B12 from protein in the diet, and reduced levels of intrinsic factor. Vit B12 deficiency is characterized by pernicious anemia and peripheral neuropathy and is common within the first year of surgery if supplementation isnt administered

A nurse administers the wrong medication to a client, which causes the client to experience a severe allergic reaction. The medical record indicates the client is allergic to the medication, and the client is wearing an allergy wrist band. The nurse has committed which of the following torts? a) battery b) assault c) malpractice d) libel

correct answer: C Rationale: this is an example of malpractice, which is an unintentional tort, which is the failure to meet the standard of conduct expected in these circumstances in a way that causes harm. This nurse has made an error that harmed the client, and the client could legally sue the nurse for malpractice.

A nurse is reviewing snake bite management with a group of parents. Which of the following info should the nurse include in the teaching? a) apply ice as soon as possible after the bite occurs b) attempt to orally suck out the venom c) wash the bite area with soap and water d) perform passive ROM exercises to facilitate circulation

correct answer: C Rationale: washing the bite area with soap and water is part of the initial management for a snake bite Management of a snake bite: -clear the area with soap and water -cover with a clean dry dressing -immobilize the area -keep the child calm -place the child in a reclined position -remove restrictive clothing -arrange for immediate transport to a medical facility -when possible and can be done safely, take a picture of the snake and bring it to the medical facility with the client so that it can be tested

A nurse is planning care for a group of client. Which of the following tasks should the nurse assign to an AP? a) applying antibiotic ointment to the arm of a client who has dermatitis b) obtaining medical history info from a stable client who is being admitted c) monitoring VS of a client who had an appendectomy 12 hr ago d) removing the NG tube of a client who has been receiving enteral feedings

correct answer: C Rationale: when planning delegation, the nurse should ensure the task can be legally delegated to the AP. This involves knowledge of the state's nurse practive act and the facility's policies and procedures. Delegating the monitoring of VS of a stable client 12 hr after surgery is within the range of function of an AP

A nurse is counseling a parent of a 5-year-old child who has night terrors. Which of the following should the nurse advise the parent about this disorder? (Select all that apply) a) co-sleeping is recommended after an episode b) the child will respond quickly to parental reassurance during an episode c) waking the child 30-45 min after falling asleep for a week may be helpful d) the parent should not attempt to wake the child when the episode is occurring e) use of a night light or low-voltage lamp will usually stop night terrors

correct answer: C & D Rationale: Night terrors are distinct from nightmares. Shortly after falling asleep, a child with night terrors seems to be awake and is screaming, but arousal is partial, and the child usually doesn't respond to soothing. Eventually, the child stops screaming and falls asleep again. The child usually has no memory of the event. The parent should be advised not to wake the child but to remain close by and to refrain from touching or speaking with the child unless the child awakens. Usually, the child will return to sleep quickly. In contrast, nightmares occur most often in the second half of the night. The parents are awaked by the child after the episode is over, and the child is responsive to the parent's reassurance. The child with nightmares may have difficulty returning to sleep if afraid and may also remember the dream and discuss is later. A technique that may help to prevent night terrors is to wake the child 30-45 min into the sleep cycle. If this is done each night for about a week, it may be helpful in resolving the night terror cycle.

A nurse is caring for a client who has a third degree burn. Which of the following would the nurse expect to find when assessing the burn? (Select all that apply) a) pain b) erythema c) edema d) eschar e) fluid-filled vesicles

correct answer: C & D Rationale: the depth and extent of the burn are used to categorize the burn. A third-degree burn is a full-thickness burn that involves the epidermal, dermal, and subcutaneous layers and nerve endings. The table below provides assessment findings used to classify 4 degree burns. The "Rule of Nines" is used to estimate the size of the area involves in the burn. Burns can result from chemical, electrical, friction, radiation, or thermal causes. First Degree: -characteristics: superficial, partial thickness -clinical findings: erythema, edema, pain, and blanching Second Degree: -characteristics: partial thickness involving dermal layer -clinical findings: pain, erythema, oozing vesicles that rupture to expose shine/wet subcutaneous tissue Third Degree: -characteristics: full thickness, involves epidermis, dermis, subcutaneous layer, nerve elements -clinical findings: eschar, edema, usually painless Fourth Degree: -characteristics: extends through all layers to muscle and bone -clinical findings: charred subcutaneous tissue, to muscle and bone

A nurse is assisting with the care of a child who is experiencing respiratory failure. Which of the following findings are considered early cardinal manifestations of this condition? (Select all that apply) a) stupor behavior b) peripheral cyanosis c) tachycardia d) diaphoresis e) restlessness

correct answer: C, D, & E Rationale: tachycardia is an early manifestation of respiratory distress. The heart tries to compensate for the lack of perfusion by pumping harder. Diaphoresis is an early manifestation of respiratory distress due to decreased oxygenation and perfusion restlessness is an early manifestation of respiratory distress due to decreased oxygenation and perfusion issues

A nurse in the ED is caring for a 2 month old in acute respiratory distress who is receiving oxygen via a mask, but keeps trying to pull the mask off. The most appropriate intervention by the nurse will include which of the following? a) administer a sedative to calm the child b) restrain the child's hands c) explain to the child the importance of keeping the mask on d) encourage the mother to hold the child and sing to him

correct answer: D Rationale: a 2 year old in respiratory distress should be kept calm. Often, the best way to do this is to provide a rocking chair and allow a parent to rock the child and sing or read to him

A nurse is teaching a newly licensed nurse about hemodialysis for clients who have chronic kidney disease. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a) "hemodialysis restores kidney function" b) "hemodialysis requires the placement of a catheter into the peritoneal space" c) "hemodialysis allows an unrestricted diet" d) "hemodialysis returns a balance serum electrolytes"

correct answer: D Rationale: the nurse should explain to the newly licensed nurse that hemodialysis restores balance in the fluid, electrolyte, and acid-base components of the client's blood. This is completed through the use of diffusion of the client's blood and dialysate containing water and electrolytes across a semi-permeable membrane. Diffusion allows the movement of waste products, excess electrolytes, and fluids from the blood across the semi-permeable membrane and into the dialysate solution and movement of needed electrolytes, such as calcium and bicarbonate, from the dialysis solution and into the blood

A nurse is caring for a client who has been charged with a traffic violation that resulted in injuries to others. After a visit to the victims on the trauma floor,, a local police officer visits your unit requesting info about the client. What is the appropriate response by the nurse? a) provide the police officer with the chart because he is a law enforcement official b) inform the officer you would be able to provide him with the needed info yourself, so that you can protect more sensitive data enclosed in the chart c) provide the officer the direct line to the hospital health records department, since the patient has already been discharged d) provide the officer with info regarding the privacy rule restriction according to HIPAA

correct answer: D Rationale: according to HIPAA privacy rules, the RN may provide the following in to a law enforcement officer under six circumstances and subject to specified conditions: 1) as required by law (including court order, court-ordered warrants, subpoenas) and administrative requests 2) to identify or locate a suspect, fugitive, material witness, or missing person 3) in response to a law enforcement official's request for information about a victim or suspected victim of a crime 4) to alert law enforcement of a person's death, if the covered entity suspects that criminal activity caused the death 5) when a covered entity believes that protected health info is evidence of a crime that occurred on its premises 6) by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime

A nurse is teaching a client who has a new prescription for clozapine. Which of the following client statements indicates an understanding of the teaching? a) "this medication will help prevent me from having seizures" b) "this medication will be administered by intramuscular injection every 2 years" c) "I will likely have tremors and muscle twitching while taking this medication" d) " I will need to get up slowly from a lying position while taking this medication"

correct answer: D Rationale: clozapine, a second-generation antipsychotic medication, can cause orthostatic hypotension, especially during the first few weeks of therapy. The client should be instructed to rise slowly from a lying or sitting position to prevent dizziness or fainting

A nurse is caring for a 7-year-old client with pinworm infection. Which of the following symptoms is consistent with this diagnosis? a) weight loss and nutritional deficiency b) scaly red rings on the skin c) pale skin and anemia d) complaints of anal itching that increase at night

correct answer: D Rationale: pinworms are a common infection in the US. The eggs of this parasite are spread through contaminated items or food and drink. They are microscopically small. When swallowed, the eggs hatch in the intestine. The female pinworm lays eggs around the anus at night. This causes itching and some clients with pinworm infection have difficulty sleeping. Pruritus is also a source of spreading infection, as the eggs are transferred to the fingers/fingernails with scratching and are easily spread to other surfaces. Anti-parasite medications are used to treat pinworm infection

A charge nurse on the med-surg unit is implementing a new initiative intended to identify clients at high risk for decubitus ulcer formation in order to intervene with additional preventive measures. Which of the following clients is at greatest risk of developing a decubitus ulcer? a) an 84-year-old client with dementia who is 1 day postop hip replacement with a jackson-pratt drain b) a 40-year-old client with paraplegia after a spinal cord injury and a hct of 43% who is being treated with norepinephrine infusion for hypotension c) an 80-year-old client with incontinence who is 2 days postop radical prostatectomy with an albumin of 2.0 dg/dL d) a 30-year-old client with sepsis and hypotension postop repair of a femur fracture sustained in a MVC and a MAP of 52 mmHg with PaO2 64 mmHg despite mechanical ventilation, who is receiving a norepinephrine infusion

correct answer: D Rationale: pressure ulcers develop when the capillaries that supply the skin and subcutaneous tissues are compressed and impede perfusion, leading to tissue necrosis. Contributory factors are listed in the table below. This client has 5 contributory factors: postoperative surgical procedure, hypoxia, hypotension, norepinephrine infusion, and infection

A charge nurse in a pediatric unit is providing a room assignment for a child who is postoperative following an appendectomy. The charge nurse should place the postoperative child with which of the following clients? a) a child who is experiencing sickle cell crisis b) a child who has pertussis c) a child who has a head injury d) a child who has a new diagnosis of type 1 DM

correct answer: D Rationale: the child who has DM requires monitoring and teaching, and the child who is postoperative following appendectomy requires frequent assessments and interventions. Furthermore, both of these children are in stable condition and are noninfectious. Therefore, the RN should assign these two clients to the same room

A nurse is caring for a client who is scheduled to be discharged home. When performing discharge teaching, the client indicates they do not feel like they will be able to bathe themselves, climb stairs or dress at home. What is the most appropriate response by the nurse? a) teach the client prior to discharge how to add safety measures to their home to prevent falls b) discharge the client and tell them to visit with their PCP as soon as possible to have their needs addressed c) have a hospital physical therapist visit with the client to address their needs d) consult with the physician to get an order for a home health nurse, physical therapist, and occupational therapist to visit the client and assess their home and health needs

correct answer: D Rationale: the client needs a visit from a home health nurse, PR, and OT to address their needs

A nurse is caring for a client in the PACU who arrived 1 hr ago after undergoing a total hip arthroplasty and is no longer responding to verbal stimuli. Which of the following actions should the nurse take first? a) compare and contrast the peripheral pulses b) apply a warm blanket c) obtain the client's BP d) place the client in a lateral position

correct answer: D Rationale: the greatest risk to a client who is unresponsive or unconscious is injury from aspiration. The nurse should turn the client to the side in order to protect their airway. Respiratory assessment is the most critical action to take after surgery for any client who has undergone anesthesia.

A nurse is preparing to administer the hep B vaccine to an adolescent. Which of the following questions should the nurse ask the adolescent prior to administering the vaccine? a) "do you have an allergy to eggs?" b) "have you ever had encephalopathy following immunizations?" c) "are you currently taking a corticosteroid medication?" d) "have you ever had an anaphylactic reaction to yeast?"

correct answer: D Rationale: the hep B vaccine is contraindicated for clients who have had an anaphylactic reaction to yeast

Which of the following interventions is most appropriate when working with a family member who has been given the nursing diagnosis of caregiver role strain? a) teach the family member appropriate caregiving techniques to make the most of her time b) make a referral to a dietician for nutrition care of the family member c) encourage the caregiver to start a support group to meet other people d) acknowledge the role the caregiver plays and her value in the client's life

correct answer: D Rationale: the nurse should provide support and encouragement to the family member with caregiver role strain by acknowledging the role she plays in the client's life. In this way, the nurse opens the opportunity for the family member to discuss her situation further, and the nurse may be able to determine if there are other areas where she can help

A nurse is performing a complete physical assessment of the endocrine system. Which endocrine gland will the nurse be able to palpate? a) the pituitary gland b) the hypothalamus c) the parathyroid gland d) the thyroid gland

correct answer: D Rationale: the only endocrine gland that can be palpated during the physical assessment process is the thyroid gland, a butterfly-shaped gland located anterior to the upper part of the trachea and just inferior to the larynx. The pituitary and hypothalamus are located within the skill, and the parathyroid glans are located behind the thyroid gland so they cannot be palpated.

A regressed 19 year old is admitted to the behavioral unit. After the end of the romantic relationship, the client has been refusing to get out of bed, has not been attending his college classes or taking care of his grooming needs. The nurse's initial efforts should be directed toward: a) assist the client with bathing and dressing b) encourage the client to join other his age in group sessions to foster social relationships c) speaking to the client at the level to which he has regressed d) encourage the client to be a partner in his treatment

correct answer: D Rationale: this can help establish meaningful relationship with the client the initial action by the nurse is to establish a trusting and meaningful relationship with the client; therapeutic relationships with nursing staff will be beneficial to the client

A nurse is caring for a client who complains of itching of the vulva and a frothy grey vaginal discharge that smells "fishy". The nurse knows that these clinical signs and symptoms are associated with which of the following? a) chlamydia b) genital herpes c) syphilis d) trichomoniasis

correct answer: D Rationale: typically, a female client with trichomoniasis experiences itching, burning, redness or soreness of the genitals; discomfort with urination; and a change in the character or volume of vaginal discharge (thin discharge or increased volume). Vaginal discharge can be clear, white, yellowish, or greenish, but it is classically described as malodorous, with an unusual fishy smell.

What is the correct order of steps that the nurse should follow to irrigate the ears of a 70 year old client with hearing impairment? a) place the client in the sitting position and tilt the head to the affected ear b) place a towel and emesis basin under the clients ear c) pull the pinna up and back to straighten the ear canal d) assess the client for injury to the tympanic membrane, evidence of ear infection, or fever e) gently irrigate the ear canal with solution, using a slow and steady flow

correct answer: D, A, B, C, E Rationale: ear irrigation may be prescribed to remove impacted cerumen or excess cerumen. Obstruction of the ear canal by cerumen can sometimes contribute to hearing loss and is often as initial step in the management of individuals with hearing impairment of gradual onset. First, the client should be assessed for any contraindications to irrigation, which include fever and ear infection. The tympanic membrane should be assessed with an otoscope to verify that it is intact before proceeding with irrigation. The nurse should explain the procedure before preparing the client by placing the client in a sitting position with the head tilted to the side that will be irrigated. A towel and emesis basin should be placed under the ear. Before beginning irrigation, the nurse should ensure that the solution used to irrigate is at body temperature to minimize discomfort to the client. The pinna of the ear should be pulled up and back in adults, which will straighten the ear canal. In children, the pinna is pulled downward and back. The nurse should irrigate gently, using a slow and steady flow of solution. If the client experiences any nausea, dizziness, or significant pain, the irrigation must be stopped immediately. When irrigating, the tip of the syringe should be directed to the top of the ear canal. Irrigation is repeated as tolerated until the prescribed amount of solution has been instilled or until the ear canal is clear Documentation should include the type, volume, and temperature of the instilled solution; the client's response to the procedure; description of any exudate; and client teaching

A nurse is caring for a client who has just passed away. Place in order the following items to perform for post-mortem care: a) speak to the family members about their possible participation b) accurately tag the body, indicating the identity of the deceased and safety issues regarding infection control c) collect any needed specimens d) remove all tubes and indwelling lines e) bathe the body of the deceased f) elevate the head of the bed g) position the body for family visit/viewing h) notify a support person (e.g., spiritual care provider, bereavement specialist) for the family i) confirm that request for organ/tissue donation and/or autopsy has been made

correct answer: i, f, c, a, h, d, e, g, & b

A nurse is administering medications to treat heart failure. Which of the following belong to this general classification of drugs? (Select all that apply) a) Digoxin b) Paroxetine c) Cisplatin d) Fosinopril e) Triamterene f) Furosemide

correct answers: A, D, E, & F Rationale: heart failure is a condition in which the heart is unable to pump sufficient blood to the different parts of the body. Its causes can be traced to factors such as valve disorders, pulmonary embolus, pneumothorax, infection, CAD, HTN, and autoimmune disorders. Symptoms can vary according to area (right side, left side, or both) affected. Right-sided failure is usually manifested by peripheral edema while left-sided failure is manifested by dyspnea. The treatment of choice is administration of drugs that prevent fluid overload and assist the pumping mechanism of the heart. These drugs include ACE inhibitors, ARB, diuretics, and digitalis glycoside. ACE inhibitors include fosinopril (Monopril), captopril (Capoten), and lisinopril (Zestril). ARBs include telmisartan (Micardis), losartan (Cozaar), and irbesartan (Avapro). Diuretics include triamterene (Dyrenium), furosemide (Lasix), and erthacrynic acid (Edecrin). Cardiac glycosides include digoxin (Lanoxin)