CPNRE Study Prep!

During the first home care visit, Mrs. Danielson is lying on the bed crying while her husband is caring for their infant and son. How should the practical nurse establish the nurse-client relationship? 1. Acknowledge the client's emotions. 2. Explore her treatment options and plans. 3. Offer support and reassurance to the family. 4. Ask the husband about her emotional health.

1. Acknowledge the client's emotions. Reason: This is proper protocol to initiate a therapeutic environment.

A hospitalized client is a lactose-vegetarian. Which food item should the nurse remove from the meal tray? 1. Eggs. 2. Milk. 3. Cheese. 4. Broccoli.

1. Eggs. Reason: Lacto-vegetarians eat milk, cheese, and dairy food but avoid meat, fish, poultry, and eggs.

The practical nurse has taught Mr. Riehl, 75 years old, how to change his colostomy appliance. How can the practical nurse determine that Mr. Riehl has thoroughly understood the teaching? 1. Have him demonstrate an appliance change. 2. Ask if he has any other questions. 3. Have him gather all necessary supplies. 4. Ask if he feel comfortable caring for his colostomy.

1. Have him demonstrate an appliance change. Reason: The acquisition of a psychomotor skill is best evaluated by observing how well the client carries out the procedure.

Which finding indicates to the nurse that placental separation has occurred? Select all that apply. 1. Lengthening of the umbilical cord. 2. Sudden trickle or spurt of blood. 3. Fundus is boggy following separation. 4. Change from globular to discoid shape. 5. Fetal membranes are seen at the introitus.

1. Lengthening of the umbilical cord. 2. Sudden trickle or spurt of blood. 5. Fetal membranes are seen at the introitus. Reason: As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, a sudden trickle or spurt of blood appears and fetal membranes may appear at the introitus. The fundus changes from discoid to globular shape. The fundus should not become boggy.

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is hit in riboflavin? 1. Milk. 2. Tomatoes. 3. Citrus fruits. 4. Green, leafy vegetables.

1. Milk. Reason: Food sources of riboflavin include milk, lean meats, fish, and grain. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid.

Q8. Mrs. Tang recalls that the first day of her last menstrual period was December 14. What should the practical nurse document as the client's expected date of delivery using Naegele's rule? 1. September 21st. 2. October 7th. 3. August 17th. 4. November 11th.

1. September 21st. Reason: Naegele's rule states to count back 3 months and add 7 days from the first day of the last menstrual period.

The practical nurse has contacted the physician to obtain an order to manage a client's pain. What step should the practical nurse implement to ensure the accuracy of the order? 1. Write the order on the physician's order form and read it back to the physician. 2. Verify the verbal telephone order with another practical nurse prior to implementing. 3. Document the order on a piece of paper without using abbreviations for the dosage and units. 4. Have the physician repeat the order while th

1. Write the order on the physician's order form and read it back to the physician. Reason: Writing the order directly on the physician's order form reduces the chance for transcription error. Reading the order back to the physician confirms accuracy.

What is the normal range for respirations in an adult?

10-20

Mrs. Jacobs, 75 years old, is newly diagnosed with type 2 diabetes and has recently participated in a diabetes education and insulin administration program. During a home visit, how should the practical nurse proceed to reinforce the teaching? 1. Explain to Mrs. Jacob that glucose monitoring will be covered first. 2. Ask Mrs. Jacob to demonstrate glucose monitoring. 3. Demonstrate an insulin injection. 4. Discuss the benefits of insulin administration.

2. Ask Mrs. Jacob to demonstrate glucose monitoring. Reason: This is the best method to assess her abilities.

The nurse obtains the vital sins on a postoperative client who just returned to the nursing unit. The client's blood pressure(BP) is 100/60mm HG, the pulse is 90 beats per minute, and the respiration rate is 20 beats per minute. On the basis of these findings, which actions should the nurse take? Select all that apply. 1. Ask if the client is thirsty and assist with drinking a glass of water. 2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record t

2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 6. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit(PACU). Reason: In a clinical situation, the nurse must evaluate the vital signs of each postoperative client individually. If complications such as hemorrhage or shock are developing, early intervention in extremely important. Determining how the client feels and asking about dizziness lets the nurse evaluate how the client is tolerating these vital signs.

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter? 1. Urinary output. 2. Blood glucose. 3. Total bilirubin level. 4. Hemoglobin and hematocrit levels.

2. Blood glucose. Reason: The most common metabolic complication in the post-term newborn is hypoglycaemia, which can produce central nervous system abnormalities and cognitive impairment if it is not corrected immediately.

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item? 1. Apples. 2. Cheese. 3. Oranges. 4. Skim Milk.

2. Cheese. Reason: Fruits, vegetables, and skim milk contain minimal amounts of fat. Cheese is high in fat.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time(PT) of 35 (35) seconds and an international normalized ratio(INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium. 2. Holding the next dose of warfarin. 3. Increasing the next dose of warfarin.

2. Holding the next dose of warfarin. Reason: The normal PT is 11 seconds to 12.5 seconds. The normal INR is 0.81 to 1.2.

Mrs. White, 80 years old, is accompanied by her son to the health-care clinic. He accompanies Mrs. white to the examination room. He informs the practical nurse that his mother fell 1 week ago and received injury to both upper arms. What action would be a priority for the practical nurse? 1. Obtain an account of the fall from Mrs. White's son. 2. Verify and assess the report injury with Mrs. White. 3. Ask Mrs. White is she is afraid of anyone at home. 4. Contact the social worker to report

2. Verify and assess the report injury with Mrs. White. Reason: This situation requires the practical nurse to verify the report of injury and conduct an assessment prior to determining the most appropriate course of action.

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should request by making which appropriate statement? 1. "I would try anything that I could if I had cancer." 2. "No, because it will interact with the chemotherapy." 3. "Tell me what you know about complementary therapies." 4."You need to ask your primary health care

3. "Tell me what you know about complementary therapies." Reason: Alternative therapies include a wide variety of treatment modalities that are used in addition to conventional treatment to treat a disease or illness. These therapies should be approved by the person's primary health care provider to ensure that the treatment does not interact with prescribed therapy.

Mr. Jankowshi, 65 years old, diagnosed with prostate cancer, requests that a male nurse be assigned to care for him. Which action by the practical nurse is most appropriate? 1. Provide basic care and defer remainder of care until a male nurse is available. 2. Indicate to the client that the unit is busy and it will be difficult to find a male nurse. 3. Explore the reasons why he is uncomfortable. 4. Sympathize with the client.

3. Explore the reasons why he is uncomfortable. Reason: By exploring the client's concerns, values and goals, the practical nurse will be able to develop mutually acceptable solutions and to negotiate care. This allows the client to act autonomously and provides freedom to act upon his choices.

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. right side. 2. Low Fowler's position. 3. High Fowler's position. 4. Supine, with the head flat.

3. High Fowler's position. Reason: Before insertion of a nasogastric tube the nurse places the client in a sitting or high Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit.

Mrs. Renny, 78 years old, is admitted to the medical unit with a diagnosis of emphysema. Diminished breath sounds and expiratory wheezes are heard bilaterally in the lower lobes. What is the most appropriate nursing diagnosis? 1. Ineffective airway clearance. 2. Risk for infection. 3. Impaired gas exchange. 4. Anxiety.

3. Impaired gas exchange. Reason: Gas exchange is a priority due to emphysema. Gas exchange in the alveoli is affected.

What manifestations would indicate that Ms. Slater has a systemic infection? 1. White blood cell counts within normal range and red streaking from injury to ankle. 2. Decreased red blood cell counts and decreased heart rate. 3. White blood cell counts elevated and increase in heart rate. 4. Decreased red blood cell counts and increase in temperature.

3. White blood cell counts elevated and increase in heart rate. Reason: Systemic response impacts vital signs, and white blood cell count is abnormal.

An antihypertensive medication has been prescribed for a client with hypertension. The client tell the nurse that she would like to take a herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? 1. "Herbal substances are not safe and should never be used," 2."I will teach you how to take your blood pressure so that it can be monitored closely." 3."You will need to talk to your primary health care provider (HCP) before using an

3."You will need to talk to your primary health care provider (HCP) before using an herbal substance." Reason: Not all herbal substances are safe to use. They could also interfere with medication therapy.

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results the nurse determine that which requires a call to the primary health care provider for intervention? 1. 75mg/dL 2. 92 mg/dL 3. 120 mg/dL 4. 240 mg/dL

4. 240 mg/dL Reason: The normal fasting blood glucose level is 70mg/dL to 100 mg/dL in the adult client. Values above the normal range should be evaluated to determine whether further intervention is needed.

Ms. Slater is to receive 100ml of normal saline with 1 g of the prescribed antibiotic over 20 minutes via IV pump. At what rate should the practical nurse program the pump to deliver the medication as ordered? 1. 10ml per hour. 2. 3ml per hour. 3. 200ml per hour. 4. 300ml per hour.

4. 300ml per hour. Iv Pumps are programmed in mL per hour; 300ml per hour/60 minutes x 20 minutes= 100mL. This will deliver the right amount.

Mrs. Ling, 79 years old, dislocated her knee. She is in constant pain. The physician has ordered morphine. The practical nurse offers to bring the client morphine, to which Mrs. Ling responds, "No I do not want to become a drug addict." How should the practical nurse respond? 1. Offer Mrs. Ling acetaminophen (Tylenol) orally os ordered. 2. Suggest a non-pharmacological intervention like music therapy. 3. Promote Mrs. Ling's autonomy and respect her wishes. 4. Ask Mrs. Ling why she thinks

4. Ask Mrs. Ling why she thinks she will become a drug addict. Reason: This action evaluates client learning and allows for possibility of a revised strategy for teaching.

At a previous inter professional care conference, the dietitian implemented a plan to change a client's diet to pureed. The client is not eating the new diet regimen. 1. Contact the physician. 2. Revert back to the previous regimen. 3. Employ the use of distraction during meal times. 4. Inform the dietitian.

4. Inform the dietitian. Reason: The practical nurse has gathered all the information and can provide the dietitian with evidence.

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understand that the purpose of this intervention is to accomplish which? 1. Promote bile flow. 2. Limit client discomfort. 3. Promote hepatic glucose storage. 4. Limit bleeding from the biopsy site.

4. Limit bleeding from the biopsy site. Reason: After a liver biopsy, the client is assisted with assuming a right side lying position with a small pillow or folded towel under the puncture sire for a least 3 hours to apply pressure and limit bleeding from the biopsy site.

What is the normal range for heart rate?

50-95 beats per minute.

What is bradycardia?

A resting heart rate of less than 50 beats/minute.

What is chronic/persistent pain?

Chronic or persistent pain can be defined as pain that has been present for 6 months or longer that the time of expected tissue healing. Can be either malignant or nonmalignant.

Bases

Contain no H+ ions. Are H+ ion acceptors; they accept H+ ions from acids to neutralize or decrease the strength of base or to form a walker acid.

What is diastolic pressure?

Diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly between each contraction.

What is nonmalignant pain?

Often associated with musculo-skeletal conditions, such as arthritis, low back pain, and fibromyalgia.

What is subjective data?

The individuals own perception of the health state.

Day 2 postoperatively, Mr. Miller informs the practical nurse that he is nauseated and does not "feel well." What should the practical nurse do first? 1. Assess Mr. Miller's vital signs and abdomen. 2. Encourage him to ambulate. 3. Administer a p.r.n. antiemetic. 4. Encourage Mr. Miller to rest and eat ice chips.

1. Assess Mr. Miller's vital signs and abdomen. Reason: The practical nurse must check for postoperative complications, including fever, nausea, abdominal pain or distension.

During wound care, the practical nurse has difficulty maintaining a seal on the colostomy because it is within 2.5 cm of the surgical incision. What is the best course of action? 1. Consult with enterostomal nurse to determine possible solution. 2. Place the flange over the surgical incision. 3. Use extra tape for reinforcement. 4.Cleanse the incision twice daily to avoid infection from the effluent discharge.

1. Consult with enterostomal nurse to determine possible solution. Reason: The practical nurse should collaborate with the enterostomal nurse to ensure best outcomes for the client. Moreover, this action supports critical thinking.

Mr. Adams, 87 years old, is admitted with a fractured left shoulder. After his daughter's visit, Mr. Adams states that his money has gone. What should the practical nurse do next? 1. Ensure that the appropriate authorities are notified. 2. Speak with the daughter about the missing money. 3. Arrange a family conference with Mr.Adams and his daughter. 4. Request a social worker evaluation.

1. Ensure that the appropriate authorities are notified. Reason: Abuse or suspected abuse must be reported to the proper authorities.

Tanner is ready for discharge. What is the priority action to limit future asthma exacerbations? 1. Identify Tanner's asthma triggers. 2. Improve air quality in the family home. 3. Maintain a diary of asthma symptoms. 4. Minimize outdoor activities.

1. Identify Tanner's asthma triggers. Reason: Identifying and avoidance will prevent further exacerbations.

Christine, a 17 year old primipara, gave birth to a girl yesterday who she is breastfeeding. She lives alone and states that her friends, who are currently visiting, are her only support. She will be discharged home with her baby tomorrow. What stage is Christine in according to Erikson's Theory? 1. Identity vs. Role confusion 2. Intimacy vs. Isolation 3. Generativity vs. stagnation 4. Ego integrity vs. despair.

1. Identity vs. Role confusion Reason: The stage for those between 11-21 years of age is identity vs. role confusion.

What other manifestations would the practical nurse expect for a patient diagnosed with right-sided heart failure that reports swollen feet? 1. Nausea, ascites and a distended jugular vein. 2. Cyanosis, hemoptysis and activity intolerance. 3. Oliguria, loss of vascular tone and hypotension. 4. Hypotension, warm flushed skin and confusion.

1. Nausea, ascites and a distended jugular vein. Reason: These are manifestations of right-sided heart failure.

The nurse has inserted a nasogastric tube in a client and is checking for the correct placement of a NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach? 1. Place the verified on x-ray. 2. the pH of the aspiration fluid is 5. 3. The aspirated fluid is bile green in colour. 4. Air injection is auscultated in the left upper quadrant.

1. Place the verified on x-ray. Reason: The ned of the NG tube should be in the stomach. An x-ray is the most reliable method of determining correct placement. The radiologist may recommend moving the tube backward or forward fro a preferable placement.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level? 1. Prolonged bed rest. 2. Adrenal insufficiency. 3. Hyperparathyroidism. 4. Excessive ingestion of vitamin D.

1. Prolonged bed rest. Reason: The normal serum calcium level is 9 to 10.5 mg/dL. A client with a serum calcium level of 8.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia.

Mr. Ravi, 21 years old, is a neurosurgery client. The physician has ordered neurological assessments every 12 hours. At 2200h, assessment reveals that Mr. Ravi is taking longer to express himself, has a headache, and his balance is a little off. When should the next assessment be done? 1. 1000h the next day. 2. 2215 that night. 3. 2400h that night. 4. 0200h the next day.

2. 2215 that night. Reason: the client's needs and condition determine when, where, how and by whom the vital signs are measure. As the client's condition worsens, it is important to monitor the vital signs as often as every 5 to 15 minutes.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium? 1. Milk 2. Butter 3. Spinach 4. Collard greens

2. Butter Reason: Butter comes from milk fat and does not contain significant amount of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

Mr. Domingue, 80 years old, presents to his primary care clinic for his annual health exam. He is a non-smoker who enjoys walk in the park, consumes 1 ounce of brandy infrequently in the evenings and complies with a gluten-free diet. What finding discovered by the practical nurse would require follow up from the primary health-care team? 1. HR 94, oxygen saturation 95%. 2. Capillary blood glucose 5.5 mmol/L, BP 146/92 3. BP 106/58, RR 20. 4. Capillary blood glucose 4 mmol/L, T 37.1 C.

2. Capillary blood glucose 5.5 mmol/L, BP 146/92 Reason: BP of 142/92 is considered hypertensive and requires follow up within 2 months; the blood sugar is within normal range.

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply? 1. Slight redness along the incision. 2. Check that the drain is decompressed. 3. A temperature of 98.8F 4. The client states that he feels cold. 5. The client states that the incision itches. 6. Tender firmness palpable around the incision.

2. Check that the drain is decompressed. 6. Tender firmness palpable around the incision. Reason: A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision.

In addition to type 1 diabetes, what risk factors for would healing should the practical nurse identify? 1. Dehiscence and demographic information. 2. Poor nutrition status and impaired mobility. 3. CVA and increased weakness. 4. Isolation and decreased activity.

2. Poor nutrition status and impaired mobility. Reason: Both are risk factors for would healing.

Mrs. VanDergale, 83 years old, moved to Canada from Europe 30 years ago and is now a resident in a community-care setting. Recently, she started experiencing a disturbed sleep pattern. Her husband state that she was sleeping well unit she watched a documentary about world war 2 a few weeks ago. What condition may this client be experiencing? 1. Dementia. 2. Post-traumatic stress disorder. 3. Acute stress response. 4. Delirium.

2. Post-traumatic stress disorder. Reason: This client may have issues related to childhood memories while living in Europe during World War 2. A change in sleep pattern is an indicator of this.

The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during the data collection? 1. Respiratory. 2. Psychosocial. 3. Neurological. 4. Cardiovascular.

2. Psychosocial. Reason: The psychosocial data is the lowest priority during the initial admission data collection.

Ms. Slater is being discharged later today with a prescription for oral Penicillin V. What should the practical nurse teach her prior to discharge? 1. Discontinue when symptoms resolve. 2. Take entire prescription. 3. If experiencing heartburn, take antacids. 4. Birth control pill reduce effectiveness of oral antibiotics.

2. Take entire prescription. Reason: The client should be taught to take entire prescription of antibiotics.

To prevent the spread of hepatitis C, what health teaching should the practical nurse provide to Ms. Moher? 1. Use sterile needles and start oral contraceptives. 2. Use condoms and avoid sharing needles. 3. Abstain from drug use and sexual intercourse. 4. Wash hands frequently and avoid touching blood products.

2. Use condoms and avoid sharing needles Reason: Both can help decrease the spread of hepatitis C.

The practical nurse has discontinued a client's IV infusion. After removal of the IV catheter, what is most important for the practical nurse to document? 1. Disposal of the equipment according to agency policy. 2. Application of pressure with gauze over the site. 3. Appearance of redness over the site. 4. Expression of relief by the client.

3. Appearance of redness over the site. Reason: This item should be included in the documentation because it is an important finding related to the IV therapy that requires further attention.

Mrs. Henderson has a history of frequent urinary tract infections. What should the practical nurse do first? 1. Insert an indwelling catheter. 2. Offer cranberry juice. 3. Assess urinary elimination patterns. 4. Obtain a urine specimen.

3. Assess urinary elimination patterns. Reason: This is the first step in assessment and may indicate whether a urinary tract infection is present.

The licensed practical nurse (LPN) enter's a client's room and find the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client throughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider are notified of the incident. Which is the next nursing action regarding the incident? 1. Place the incident report in the client's chart. 2. Make a copy of the incident report for

3. Document a complete entry in the clients record concerning the incident. Reason: The incident report is confidential and privileged information, and it should not be copied, placed in a chart, or have any reference made to it in the client's record.

How should the practical nurse respond to an upset client who is complaining about care received in the hospital? 1. Return when the client is no longer upset. 2. Alter co-workers of the client's inappropriate behaviour. 3. Restate comments back to the client. 4. Listen from a distance and observe non-verbal cues.

3. Restate comments back to the client. Reason: The practical nurse is using the therapeutic technique of paraphrasing. This allows an angry client to know that the practical nurse is actively listening in an attempt to understand the issue and feelings.

Q1. Which of the following indicates that the client is an active participant in his care? 1. The client reads the care plan thoroughly. 2. The client demonstrates an indifference to changes in his care. 3. The client asks questions about his care. 4. The client follows the directions of his family.

3. The client asks questions about his care. Reason: This demonstrates participation in the care plan by asking questions.

Gerry, 11 years old, has type 1 diabetes. He checks his blood glucose four times a day. He asks the practical nurse if he should adjust his morning insulin does when he plays in a hockey tournament this weekend. What is the practical nurse's best response? 1. "You must consult your physician for direction." 2. "Yes, as you will be exercising more, you should increase your dose." 3. "No, you need to stay on the dose of insulin the physician has ordered." 4. "Check your blood sugars more frequ

4. "Check your blood sugars more frequently as your insulin needs may change." Reason: This response promotes the goal of self-management of diabetes and informs the client of his responsibilities for accurate and frequent monitoring of his blood sugars.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breathing sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? 1. Rapid weight loss 2. Flat hand and neck veins 3. A weak and thready pulse 4. An increase in blood pressure.

4. An increase in blood pressure. Reason: Impaired cardiac or kidney function can result in fluid volume excess.

What is objective data?

Information gathered through the use of technical measurements and observations by the health care practitioner.

How is neuropathic pain caused?

Neuropathic pain is caused directly by a lesion or disease affecting the somatosensory nervous system. Can result from damage to the nerve pathway at any point along the nerve, from the terminals of the peripheral nociceptors to the cortical neutrons in the brain.

What is the job of a nociceptor?

Nociceptor detects painful sensations from the periphery and transmit them to the CNS.

What does OPQRSTUV stand for?

Onset, provocative, quality of pain, region of pain, severity of pain, treatment/timing, understanding of pain, values.

Which of these clients is/are most likely to develop fluid (circulatory) overload? Select all that apply. 1. A premature infant. 2. a 101-year-old man. 3. A client with heart failure. 4. A client with diabetes mellitus. 5. A client receiving dialysis. 6. A 29-year-old client with pneumonia.

1. A premature infant. 2. a 101-year-old man. 3. A client with heart failure. 5. A client receiving dialysis. Reason: Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid overload exists with these clients.

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? 1. A urinary output of 20mL/hour. 2. A temperature of 37.6C (99.6F). 3. A blood pressure of 100/70mm Hg 4. Serous drainage on the surgical dressing.

1. A urinary output of 20mL/hour. Reason: Urine output is maintained at a minimum of at least 30mL/hour for an adult. An output of less than 30mL/hour for each of 2 consecutive hours should be reported to the surgeon. A temperature more than 37C(100F) or less than 36.1C(97F) and a falling systolic blood pressure less than 90 mm Hg are to be reported.

Mr. Gruen, 71 years old, has recently been diagnosed with prostate cancer and is scheduled for surgery. He resides in a long-term care facility and during breakfast in the dining room, he begins to cry. How should the practical nurse best respond? 1. Accompany the client to his room with permission, using a gentle touch to his forearm. 2. Gently hug the client for support with the intent to lead him back to his room for privacy. 3. Provide facial tissue for the client until he stops crying a

1. Accompany the client to his room with permission, using a gentle touch to his forearm. Reason: This action provides privacy for the client and uses therapeutic touch within the social zone.

the nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents? 1. Allow the infant to signal a need. 2. Anticipate all of the needs of the infant. 3. attend to the crying infant immediately. 4. Avoid the infant during the first 10 minutes of crying.

1. Allow the infant to signal a need. Reason: According to Erikson, the caregiver should not try to anticipate the infant's need at all time but rather allow the infant to signal his or her needs.

The nurse is assigned to care for the client after a caesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action? 1. Ambulate frequently 2. Wear supportive stockings. 3. Apply warm, moist packs to the legs. 4. Remain on bed rest, with the legs elevated.

1. Ambulate frequently Reason: Stasis is believed to be a major predisposing factor for the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis.

Ms. Smith, 83 years old, has a minor would on her left leg. The practical nurse is completing a dressing and observes that there is a small amount of purulent drainage. What order should the practical nurse anticipate? 1. Apple wet-to-dry dressing twice daily and a non-adherent dressing(Jelonet) 2. Keep the ulcer open to air twice daily and apply transparent film (Tegaderm) 3. Place the client's leg under a heat lamp and apply hydrogel (DuoDERM) 4. Apply ointment and a foam dressing (Mepilex

1. Apple wet-to-dry dressing twice daily and a non-adherent dressing(Jelonet) Reason: The primary purpose of wet to dry dressings is to mechanically debride wounds, specifically full thickness wounds healing by secondary intentions and wounds with necrotic tissue.

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery? 1. Assess latency of airway. 2. Check tubes or drains for patency. 3. Check dressing for bleeding or drainage. 4. Obtain vital sins to compare with those recorded preoperatively.

1. Assess latency of airway. Reason: If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, followed by the dressing, tubes, and drains.

The practical nurse overhears a colleague angrily respond to the client's call bell by stating,"Mrs. Dennis, you have just been up; it is not time for you to go again!"The colleague then leaves the unit to go on a break. What should the practical nurse do first? 1. Assist Mrs. Dennis to the bathroom. 2. Apologize to Mrs. Dennis for the colleague's behaviour. 3. Answer the call bell the next time Mrs. Dennis rings. 4. Confront the colleague in the break room.

1. Assist Mrs. Dennis to the bathroom. Reason: Mrs. Dennis's request to go to the bathroom requires immediate nursing action. Mrs. Dennis has impaired skin integrity; Therefore, it is imperative that she be given excellent elimination care.

How should the practical nurse encourage Tom a 17 year old with genital herpes to assume responsibility for his own health? 1. Assist Tom to identify healthy behaviours. 2. Tell Tom that his lifestyle must be changed. 3. Demonstrate to Tom how to use condoms. 4. Help Tom identify the source of his condition.

1. Assist Tom to identify healthy behaviours. Reason: Assisting Tom to identify responsible health behaviours allows him to have some control in his health care.

Ms. French, a 19-year-old primigravida, delivered a healthy newborn by spontaneous vaginal delivery. Two hours postpartum, the practical nurse notices that the funds is 1 cm above the umbilicus, firm and deviated to the right. Her flow is moderate to heavy. What should the practical nurse do next? 1. Assist the client to void and then palpate the funds. 2. Chart these findings and consider them within normal. 3. Massage the funds gently while observing the perineum for bulging. 4. Assist

1. Assist the client to void and then palpate the funds. Reason: Immediately after birth, excessive bleeding can occur is the bladder becomes distended because this pushes the uterus up and to the side and prevents the uterus from contracting firmly.

The practical nurse assessed Mr. Samson, 78 years old, and the implemented appropriate nursing interventions for a hemolytic transfusion reaction. What is the most appropriate documentation for this situation? 1. BP 78/40; HR 120; RR 60, shallow; red flushing of skin on torso; reports back pain 8 on scale from 0 to 10. Transfusion stopped and saline initiated. 2. Vital signs normal; states "feeling very cold," and head pain 8 on scale of 0 to 10. Transfusion stopped and saline initiated. 3.

1. BP 78/40; HR 120; RR 60, shallow; red flushing of skin on torso; reports back pain 8 on scale from 0 to 10. Transfusion stopped and saline initiated. Reason: This entry documents objective and subjective finding in addition to immediate interventions.

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? 1. Baked turkey. 2. Tomato soup. 3. Boiled shrimp. 4. Chicken gumbo.

1. Baked turkey. Reason: Regular soup (1 cup) contains 900mg of sodium. Fresh shellfish (1oz) contains 50 mg of sodium. Poultry (1oz) contains 25mg of sodium.

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client? 1. Calcintonin. 2. Calcium chloride. 3. Calcium glutinate. 4. Large doses of vitamin D.

1. Calcintonin. Reason: The normal serum calcium level is 9 to 10.5 mg/dL. This client os experiencing hypercalcemia.

Mr. Duke, 67 years old, admitted with a peptic ulcer, tells the practical nurse that he is having problems because of alcohol and wants to get help. He admits that he has never been able to say this to anyone before, not even his wife. What should the practical nurse do next? 1. Complete the substance abuse screening tool. 2. Arrange a meeting with his wife. 3. Request a blood alcohol from Mr. Duke. 4. Send a referral to a social worker.

1. Complete the substance abuse screening tool. Reason: The next step is substance abuse screening which could include such tools as the CAGE questionnaire.

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water seal chamber. Based on this observation, which action would be appropriate? 1. Continue to monitor 2. Empty the drainage 3. Encourage the client to deep breathe. 4. Encourage the client to hold his or her breath periodically.

1. Continue to monitor Reason: The presence of fluctuations in the fluid level in the water-seal chamber indicated a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times and the drainage is never emptied due to risk of disrupting in closed system.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agenc

1. Decline to sign the will. Reason: Living wills are required to be in writing and signed by the client. Most countries prohibit an employee from being a witness, that includes nurses.

Mr. McCauley, 60 years old, is scheduled for a colonoscopy. He has a history of malignant hyperthermia. Which of the following medications could cause complications during the procedure? 1. Inhalation anesthesia. 2. Opioids. 3. Antibiotics. 4. Anti-anxiolytics.

1. Inhalation anesthesia. Reason: Malignant hyperthermia can be a hereditary condition with the administration of certain anesthetic drugs. Onset can occur immediately, during induction or postoperatively.

What is the priority nursing diagnosis for Christine? 1. Knowledge deficit related to newborn care. 2. Risk for altered paren/infant attachment related to client age. 3. Risk for ineffective health maintenance related to client age. 4. Effective breastfeeding as evidence by infant weight gain.

1. Knowledge deficit related to newborn care. Reason: Christine is a primipara with a limited support group.

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. 1. Listening to lung sounds. 2. Obtaining the client's temperature. 3. Checkin the strength of peripheral pulses. 4. Obtaining information about the client's respirations. 5. Performing a musculoskeletal and neurological examination. 6. Asking the client

1. Listening to lung sounds. 2. Obtaining the client's temperature. 4. Obtaining information about the client's respirations. Reason: A focused data collection process is entered around limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse should focus on the respiratory system and the presence of an infection.

The practical nurse is logged into a computer terminal. A colleague, who has just treated a client, asks the practical nurse to document the treatment on her behalf. What should the practical nurse do? 1. Log off the computer and allow the colleague to chart the treatment. 2. Confirm the detail of the treatment prior to charting them. 3. Ask the colleague to write down the information so it can be entered later. 4. Offer to enter the informations as soon as the practical nurse is done cha

1. Log off the computer and allow the colleague to chart the treatment. Reason: The security of computer systems and client information is top priority. The practical nurse's signature on an entry designates that particular practical nurse's accountability for the contents of that entry.

Ms. Vaters, 72 years old, is 24 hours postoperative and has returned to long-term care facility. At the beginning of the day shift, she reports incisional pain. In what order should the practical nurse provide care for Ms. Vaters? 1. Take her vital signs, administer pain medication and assist with morning care. 2. Administer pain medication, take her vital signs and assist with morning care. 3. Take her vital signs, assist with morning care and administer pain medication. 4. Administer pai

1. Take her vital signs, administer pain medication and assist with morning care. Reason: Initially, an assessment is required, including vital signs.

Which of the following tasks should the practical nurse delegate to an unregulated health worker? 1. Administering daily medications to a newly admitted client. 2. Applying anti embolism stockings to a stable client. 3. Teaching a client how to change a colostomy appliance. 4. Performing a respiratory assessment on a client.

2. Applying anti embolism stockings to a stable client. Reason: This client is medically stable; the task would be routine for this client.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? 1. Monitor the maternal vital signs. 2. Notify the registered nurse (RN) immediately. 3. Continue monitoring labor and the fetal heart rate. 4. Encourage relaxation and breathing techniques between contractions.

2. Notify the registered nurse (RN) immediately. Reason: Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse should immediately contact the RN, who then contacts the health care provider. Monitoring maternal vital signs, labor progress, and encouraging relaxation and breathing techniques still delay necessary and immediate interventions.

When administering an initial dose of morphine sulphate, what should the practical nurse consider as a priority in the client history? 1. Problems with constipation. 2. Previous exposure to narcotics. 3. Addiction to nicotine. 4. Nausea and vomiting.

2. Previous exposure to narcotics. Reason: Narcotic-naive clients may need less medication initially until they build up tolerance. Before administering opioids, it is important to consider the client's situation, including current treatments, diseases and conditions, and organ function. Opioid doses often need adjusting according to client circumstances.

Mrs. Adamanski, 72 years old, is newly diagnosed with type 2 diabetes and states that she feels weak. After assessing the client's blood glucose level at 3 mmol/L, what should the practical nurse do? 1. Explain to the client that she is having a hypoglycaemic reaction and offer suggestions for treatment. 2. Provide a carbohydrate and monitor blood glucose levels in 15 minutes. 3. Offer a protein snack and monitor glucose levels in 15 minutes. 4. Administer glucagon (GlucaGen) by subcutane

2. Provide a carbohydrate and monitor blood glucose levels in 15 minutes. Reason: The hypoglycemia state needs to be corrected and monitored to prevent further hypoglycemic crisis. Carbohydrates will produce the quickest response.

Q16. Mrs. Burke tells the practical nurse that she suddenly has a headache and feels nauseous. She is diaphoretic and her face is flushed. Mrs. Burke's blood pressure is assessed and is now significantly elevated. What should the practical nurse do next? 1. Check Mrs. Burke's temperature, heart rate and respiration and administer a p.r.n. analgesic. 2. Reassess Mrs. Burke's vital signs and assess the urinary drainage system. 3. Place Mrs. Burke in the Trendelenburg position and administer an

2. Reassess Mrs. Burke's vital signs and assess the urinary drainage system. Reason: Mrs. Burke is presenting with manifestations of autonomic dysreflexia which can be fatal if the triggering stimulus is not removed as quickly as possible.

Mr. Toss, 84 years old, is admitted with a diagnosis of acute pulmonary edema. The practical nurse administers furosemide (Lasix) 40 mg IV. What should the practical nurse do first? 1. Limit the client's salt intake. 2. Increase the client's fluid intake. 3. Assess urine output. 4. Weigh client twice a week.

3. Assess urine output. Reason: Furosemide is a loop diuretic and the practical nurse must evaluate the effectiveness of the medication.

Mrs. Abbot, 78 years old, is ready for discharge. The practical nurse is ready to remove her IV and notices that Mrs. Abbot is lethargic and is no longer oriented to time and place. What should the practical nurse do first? 1. Review the client's medication profile. 2. Call the physician. 3. Maintain IV access. 4. Initiate a code blue.

3. Maintain IV access. Reason: By maintaining IV access, the practical nurse can ensure proper circulation and emergency access for medication if it is required.

The physician had ordered digoxin. What is the primary action of this medication? 1. To decease the preload pressure on the heart muscle. 2. To stimulate the distal tubule of the kidney to excrete fluid. 3. To improve the strength of contraction and slow the heart. 4. To increase vasodilatation in the heart.

3. To improve the strength of contraction and slow the heart. Reason: The main effect is to increase the contractility of the heart.

Which intervention should be implemented for the older client with presbycusis who has hearing loss? 1. Speak louder. 2. Speak more slowly. 3. Use low-pitched tones. 4. Use high-pitched tones.

3. Use low-pitched tones. Reason: Presbycusis refers to the age-related, irreversible degenerative change of the inner ear that lead to decreased hearing acuity. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched tones of voice are more easily heard.

What is a stable body temperature?

37.2 C

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1. Unwrapping the eating utensils for the client. 2. Replacing the plastic utensils with metal utensils. 3. Carefully transferring the food from paper plates to glass plates. 4. Allowing the client to unwrap the utensils and prepare his own meal for eating.

4. Allowing the client to unwrap the utensils and prepare his own meal for eating. Reason: Kosher meals arrive on paper plates and with plastic utensils sealed. Primary health care providers should not unwrap the utensils or transfer the food to another serving dish.

When answering the call bell, the practical nurse notices that while Mrs. Matiko is supine with her legs elevated to decrease edema, she is also experiencing dyspnea. What should the practical nurse do first? 1. Document the clinical findings. 2. Call the physician to reassess her as soon as possible. 3. Assess vital signs including oxygen saturation. 4. Assist Mrs. Matiko into a high-Fowler's position.

4. Assist Mrs. Matiko into a high-Fowler's position. Reason: The first nursing action is to decrease venous return and improve the client's ventilation.

Mrs. May, 88 years old, has dementia and recently fell on the unit. What action should the practical nurse take? 1. Leave side rails up at all times. 2. place call light within reach. 3. Provide a commode at bedside. 4. Complete a falls risk assessment.

4. Complete a falls risk assessment. This will allow the practical nurse to identify risk factors and pan interventions that will reduce the risk of falls.

What is tachycardia?

A resting heart rate that is over 95 or 100 beats/minute.

Acids

Acids are produced as end products of metabolism. Contains H+ ions. Acids donate H+ ions, they give up H+ ions to neutralize or decrease the strength of an acid or to form a weaker base.

What is acute pain?

Acute pain is short term and self-limiting. Examples are surgery, trauma, or kidney stones.

What is the purpose of acute pain?

Acute pain serves a self protect purpose: It warns of actual or potential tissue damage.

Buffers

The fastest-acting regulatory system . Provide immediate protection against changes in H+ ion concentration in the extracellular fluid. Transports H+ to the lungs.

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. the nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets i the way. Which is the appropriate nursing response? 1. "I have a legal obligation to report this type of abuse." 2."I promise I won't tell anyone, but let's

1. "I have a legal obligation to report this type of abuse." Reason: The nurse must report situations related to child, older adult abuse, and other types of abuse.

The nurse is reinforcing discharge instructions to the parents of a 2 year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess my child needs to understand what the word "hot" means." 3. "We will be sure that our child stays in his room when we work in the kitchen." 4. "We will instal a safety gate as soo

1. "We will be sure not to leave hot liquids unattended." Reason: Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level.

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value? 1. 2000mm 2. 5800mm 3. 8400mm 4. 11,500mm

1. 2000mm Reason: The normal white blood cell count ranges from 5000mm to 10,000mm. The client who has decreased in the number of circulating white blood cells is immunosuppressed.

A client with a history of cardiac disease is due fo a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1. 3.2 mEq/L (3.2mmol/L) 2. 3.8 mEq/L (3.8mmol/L) 3. 4.2 mEq/L (4.2mmol/L) 4. 4.8 mEq/L (4.8mmol/L)

1. 3.2 mEq/L (3.2mmol/L) Reason: The normal serum potassium level in the adult is 3.5 mEq/L to 5.0 mEq/L. The correct option is the only value that falls below the therapeutic range.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring the signs of placental separation knowing that which indicated that the placenta has separated? 1. A change in the uterine contour. 2. Sudden and sharp abdominal pain. 3. A shortening of the umbilical cord. 4. A decreased in blood loss from the introitus.

1. A change in the uterine contour. Reason: Signs of separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape. The client may experience vaginal fullness, but not sudden and sharp abdominal pain.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform? 1. Aim at the base of the fire. 2. Squeeze the handle on the extinguisher. 3. Sweep the fire from side to side with the extinguisher. 4. Sweep the fire from top to bottom with the extinguisher.

1. Aim at the base of the fire. Reason: A fire can be extinguished by using a fire extinguisher. To use the extinguisher, the pin is pulled first. the extinguisher should then be aimed at the base of the fire. The handle of the extinguisher is squeezed, and the fire is extinguished by sweeping from side to side.

The nurse is preparing an intravenous(IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hit the top of the medication cart. The nurse should plan to take which action? 1. Change the IV tubing. 2. Wipe the tubing with Betadine. 3. Scrub the tubing with an alcohol swab. 4. Scrub the tubing before attaching it to the IV bag.

1. Change the IV tubing. Reason: The nurse should change the IV tubing. The tubing has become contaminated, and, is used could result in a systemic infection in the client.

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which action should the nurse take in the care of the drain? Select all that apply. 1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours. 6. Secure the drain by curling of folding it and taping it firmly to the

1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours. Reason: A drain is a tube that is placed to drain out fluid and blood near the surgical site and could lead to infection.

Mr. Ross, 93 years old, has a stage IV pressure ulcer that requires packing. The practical nurse notices that the dressing should be changed today. However, the practical nurse is not familiar with packed dressings. What should the practical nurse do? 1. Check the orders and refer to the policy manual regarding packed dressing. 2. Ask another practical nurse who has cared for his would to assist with the packed dressing. 3. Review the previous nursing notes to determine the appropriate acti

1. Check the orders and refer to the policy manual regarding packed dressing. Reason: When the practical nurse is unclear about the procedure, the first step is always to check the order and refer to the policy manual.

Mr. Jamieson, 67 years old, is ordered to receive 2 units of packed red blood cells to be administered with D5W. What should the practical nurse do first? 1. Clarify the order with the physician. 2. Compare blood product with blood requisition. 3. Assess baseline vital signs. 4. Ensure that the IV gauge is appropriate for administering blood.

1. Clarify the order with the physician. Reason: Red blood cells must be given with 0.9% normal saline.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? Select all that apply. 1. Collect data to determine factors for fall risk. 2. Close the blinds and turn off the overhead light. 3. Instruct the client to ask for assistance when getting up to walk. 4. Teach the client to lift legs high while walking, as if walking over planks. 5. Ensure the client is upright when

1. Collect data to determine factors for fall risk. 3. Instruct the client to ask for assistance when getting up to walk. Reason: In the Romberg test, the client is asked to stand with feet together, the arms at the sides, and to clothe eyes and hold position. Normally the client can maintain posture and balance. A positive Romberg is a vestibular neurological sin that is found when a client elicits a loss of balance when closing eyes.

What strategies should the practical nurse include in order to ensure that Christine's health teaching needs are met? 1. Complete as much teaching as possible while including Christine's friends. 2. Wait for Christine's friends to leave so as not to embarrass her in front of her friends. 3. Provide Christine with community resource pamphlets. 4. Have the public health nurse follow up with Christine to complete the teaching at home.

1. Complete as much teaching as possible while including Christine's friends. Reason: Peer groups are very important to teens and Christine's friends are her support group.

Q4. Since the initial assessment and his admission to the unit, Mr. Bell's abdominal girths increased by 14cm. What order should the practical nurse anticipate first? 1. Decrease his IV therapy to keep the vein open. 2. Apply oxygen at 2 L per minute via nasal cannula. 3. Apply anti embolic stockings to his legs. 4. Decrease his caloric intake to 1,400 calories daily.

1. Decrease his IV therapy to keep the vein open. Reason: Fluid accumulation can be increased by IV therapy.

Mrs. Connor, 70 years old, has an IV of normal saline infusing at 50 mL per hour in her right hand. On assessment, the practical nurse notices that the IV site is swollen, cool and tender to the touch. What should the practical nurse do next? 1. Discontinue the IV infusion. 2. Notify the physician that the IV needs to be removed. 3. Elevate the client's right hand on a pillow. 4. Determine whether the client requires IV medication.

1. Discontinue the IV infusion. Reason: Infiltration has occurred, and the IV needs to be removed.

The practical nurse has been assigned as a team leader. The practical nurse notices that a colleague had been consistently late for work. This has been affecting teamwork and client safety. What should the practical nurse do? 1. Discuss the importance of arriving at work on time with the colleague. 2. Seek advice of other colleagues on the unit to determine a solution. 3. Document the colleague's lateness and report the behaviour to the unit manager. 4. Determine why the colleague is late

1. Discuss the importance of arriving at work on time with the colleague. Reason: This approach provided important feedback that is not confrontational and allows for improvement. Opening dialogue create ethical moments that provide an opportunity for discussion, which can create change without exercising power.

During the admission procedure, Mrs. Nicholson states that she has frequent urinary tract infections (UTIs). What should the practical nurse recommend to Mrs. Nicholson to address her recurring infections? 1. Drink more fluids, void frequently and maintain good hygiene. 2. Take antibiotics and drink plenty of cranberry juice. 3. Finish all her antibiotics and then collect a urine sample for analysis. 4. Notify her physician about her recurrent UTIs.

1. Drink more fluids, void frequently and maintain good hygiene. Reason: These actions are preventative measures of UTIs.

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1. Enables the client to speak. 2. in necessary for mechanical ventilation. 3. Must have the cuff deflated when capped. 4. Eliminates the need for tracheostomy care. 5. Prevent air from being inhaled through the tracheostomy opening.

1. Enables the client to speak. 3. Must have the cuff deflated when capped. Reason: A fenestrated tracheostomy tube is used when a client is being weaned from breathing through the tracheostomy to breathing normally through the nose and mouth. A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enable the client to speak.

What should the practical nurse consider as the priority health teaching when Ms. Moher resumes her lithium? 1. Encourage Ms. Moher to have her serum lithium level checked regularly. 2. Ensure Ms. Moher is taking her lithium at the same time every day. 3. Ensure Ms. Moher is taking her lithium after meals. 4. Advise Ms. Moher to lower sodium intake while taking lithium.

1. Encourage Ms. Moher to have her serum lithium level checked regularly. Reason: Dosages may need to be altered to maintain a therapeutic level. Blood tests also confirm compliance. Toxicity can also be determined by serum levels.

Q15. Mrs. Burke has skin breakdown over her coccyx. She rarely rings for assistance in repositioning and sits for prolonged periods in her wheelchair. What should the practical nurse do initially? 1. Ensure that Mrs. Burke understands the importance of relieving pressure to reduce risk of skin breakdown. 2. Make not on the chart to reposition Mrs. Burke every 2 hours to prevent pressure on the coccyx. 3. Cleanse the coccyx with sterile water and place a sterile dressing over the broken skin

1. Ensure that Mrs. Burke understands the importance of relieving pressure to reduce risk of skin breakdown. Reason: It is important to provide the client with the information to assume responsibility for her health.

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous(IV) of an assigned client who is receiving fluid replacement therapy how frequently? 1. Every hour. 2. Every 2 hours. 3. Every 3 hours. 4. Every 4 hours.

1. Every hour. Reason: Safe nursing practice includes monitoring an IV infusion at least once every 1 hour for an adult client. The remains options do not provide time frames that are safe or acceptable.

The nurse is planning to begin a continuous tube feeding on a client with NG tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply. 1. Explain the procedure to the client. 2. Irrigate the NG tube with saline. 3. Aspirate all stomach contents and discard. 4. Elevate the head of the bed to 45 degrees. 5. Have a pair od scissors for emergency use at the bedside. 6. Ensure that the end of the NG tube is in the esophagus.

1. Explain the procedure to the client. 2. Irrigate the NG tube with saline. 4. Elevate the head of the bed to 45 degrees. Reason: When a tube feeding is initiated, the most important intervention is to make sure the NG tube is properly placed in the stomach to prevent aspiration of the formula. The nurse should irrigate the line with saline to ensure formula flows well. You evaluate the head of the bed to allow gravity to help the flow of formula and prevent aspiration.

The nurse is developing a plan of care for a client who is scheduled for surgery. the nurse should include which activities in the nursing care plan for the client on the day of surgery? Select all that apply. 1. Have the client void before surgery. 2.Avoid oral hygiene and rinding with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Determine that the client has signed the informed consent for the surgical procedure. 5. Report immediately any slight increase in bl

1. Have the client void before surgery. 4. Determine that the client has signed the informed consent for the surgical procedure. Reason: The nurse caring for clients who will be having surgery must ensure that the client is properly identified and prepared according to the prescriptions by the surgeon and anesthesiologist. The nurse should assist the client with voiding before surgery so that the bladder is empty at the beginning of the procedure.

Jack, 17 years old, has been feeling weak and nauseous for the past 7 days. His blood work results are normal except for an elevated calcium level. What condition might be causing his symptoms? 1. Hyperparathyroidism. 2. Hypothyroidism. 3. Vitamin K deficiency. 4. Vitamin B12 deficiency.

1. Hyperparathyroidism. Reason: In hyperparathyroidism, the bones decalcify and renal calculi develop. Laboratory work demonstrates elevated serum calcium.

Q 18. The physician's order reads intermediate-duration insulin NPH (Novolin ge NPH) 36 units with regular insulin 12 units subcutaneously. What process should the practical nurse use? 1. Inject 36 units of air into the insulin NPH followed by 12 units of air into the regular insulin, invert vial and withdraw regular insulin. 2. Inject 12 units of air into the regular insulin followed by 36 units of air into the insulin NPH, invert vial and withdraw insulin NPH. 3. Withdraw 12 units of regul

1. Inject 36 units of air into the insulin NPH followed by 12 units of air into the regular insulin, invert vial and withdraw regular insulin. Reasons: This is the correct sequence to use when mixing an intermediate-duration insulin.

Mr. Rehal, 66 years old, is admitted with a low-grade fever of unknown source. The client informs the practical nurse that he had a tuberculin skin test last week. The practical nurse notices that there is a red induration at the test site. What should the practical nurse do next? 1. Inquire about the result of the mantoux test. 2. Administer an antipyretic and monitor the client's temperature. 3. Give the client a mask and instruct him to wear it when in close contact with people. 4. Contact

1. Inquire about the result of the mantoux test. Reason: The result of the Mantoux test is available 48 to 72 hours after injection. Inquiring will provide the practical nurse with more information.

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric tube. The nurse checks the residual and obtains an amount of 200ml. Which actions should the nurse take? Select all that apply? 1. Listen to the client's bowel sounds. 2. Document and discard the residual. 3. Offer the client sips of water to drink. 4. Question the client regarding nausea. 5. Determine whether the client has abdominal distension. 6. Hold the feeding after flushing the tubing wit

1. Listen to the client's bowel sounds. 4. Question the client regarding nausea. 5. Determine whether the client has abdominal distension. 6. Hold the feeding after flushing the tubing with 30 ml saline. Reason: Large-volume aspirates in clients receiving intermittent tube feedings indicate delayed gastric emptying and place the client at risk fro aspiration. The nurse should obtain data concerning the presence of nausea, bowel sounds, and abdominal distention indicating possible bowel obstruction. When 200ml of residual formula is obtained, the feeding is held and the RN in notified because this is an indicator that the feeding is not being absorbed.

Q9. Mrs. Tang delivered a healthy baby girl 2 hours ago. What is the practical nurse's priority assessment of the mother? 1. Location and tone of the uterus. 2. Parent and infant attachment behaviours. 3. Vital signs, especially blood pressure. 4. Perineal edema and lochia.

1. Location and tone of the uterus. Reason: Hemorrhage is frequently caused by uterine atony and it is a major complication during the recovery period.

A nurse student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply. 1. Many choose not to have health insurance. 2. The believe that health is a gift from god. 3. The authority of women is equal to that of men. 4. They remain secluded and avoid helping others. 5. They use both traditional and alternative health care, such as health, herbs, and massage. 6. Funerals are conducted in the home without a eulogy, flower de

1. Many choose not to have health insurance. 2. The believe that health is a gift from god. 5. They use both traditional and alternative health care, such as health, herbs, and massage. 6. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment. Reason: The Amish society maintains a culture that is distinct and separate from the non-Amish society, and some members generally remain separate from the rest of the world, both physically and socially. Family life has a patriarchal structure, and although the roles of woman are considered equally authority. Amish society rejects materialism and worldliness.

On the last day of his long-term care practicum, Mark, a student practical nurse, has his photo taken with his favourite client. He posts the picture on an on-line social media page. Is this an acceptable action? 1. No, because confidentiality will have been breached. 2. Yes, as long as the client gives verbal consent. 3. Yes, because technology allows for this type of social networking. 4. No, because facility policy may prohibit client photos from being taken.

1. No, because confidentiality will have been breached. Reason: There is a professional and ethical responsibility to protect the confidentiality of a client's personal information.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardia. Which actions should the nurse take? Select all that apply. 1. Notify the RN. 2. Notify the Rapid Response Team. 3. Finish the suctioning as quickly as possible. 4. Discontinue suctioning until the client is stabilized. 5. Contact the respiratory department to suction the client.

1. Notify the RN. 4. Discontinue suctioning until the client is stabilized. Reason: When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized.

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). Which instructions should the nurse include? Select all that apply? 1. Perform TSE after a shower or bath. 2. Perform TSE after emptying the bladder. 3. Perform TSE on the same day each month 4. Observe for urethral discharge after performing TSE. 5. Perform TSE by rolling each testicle between the thumb and fingers.

1. Perform TSE after a shower or bath. 3. Perform TSE on the same day each month 5. Perform TSE by rolling each testicle between the thumb and fingers. Reason: The nurse needs to teach the client how to perform a testicular self exam. The nurse should instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm.

The nurse is checking the insertion site of a peripheral intravenous(IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? 1. Phlebitis of the vein. 2. Infiltration of the IV line. 3. Hypersensitivity. 4. An allergic reaction to the IV catheter material.

1. Phlebitis of the vein. Reason: Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The Iv catheter should be remove, and a new IV line should be inserted at a different site. The remaining options are not incorrect; the signs and symptoms in the question are not associated with these conditions.

Several laboratory tests are prescribed for a client, and the nurse reviews the result of the test. Which laboratory test results should the nurse report? Select all that apply? 1. Platelets 35,000mm3(35x10/L) 2. sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L(5.0 mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 mcmil/L) 6. White blood cells, 3000 mm3 (30 X10/L)

1. Platelets 35,000mm3(35x10/L) 2. sodium 150 mEq/L (150 mmol/L) 4. Segmented neutrophils 40% (0.40) 6. White blood cells, 3000 mm3 (30 X10/L) Reason: The normal values include the following: platelets 150,000mm to 400,000mm; sodium 135mEq/L to 145 mEq/L; potassium 3.5 mEq/L to 5.0 mEq/L; segmented neutrophils 60% to 70%; serum creatinine 0.6mg/dl to 1.3 mg/dL; white blood cells 5000mm to 10,000 mm.

Mr. Christensen, 83 years old, weighs 54 kg. He has chronic obstructive pulmonary disease (COPD) and has lost 4 kg over the past month. He is receiving continuous oxygen at 2 L per minute per nasal cannula. He has difficulty eating an entire meal because he becomes fatigued. What should the practical nurse do? 1. Provide nutritious high-calorie snacks between meals. 2. Decrease his exercise regimen to reduce fatigue. 3. Increase the oxygen rate to 4 L per minute when eating meals. 4. Rest

1. Provide nutritious high-calorie snacks between meals. Reason: Oral commercial supplements like Ensure, puddings with whole milk, cream soups and ice cream are high-calorie supplements. This would ensure sufficient calories are consumed while helping with the client's eating difficulty.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all the apply. 1. Put on a mask. 2. Don gown and gloves. 3. Apply shoe protectors. 4. Wear a pair of protective goggles. 5. Have the cleint wear a mask and goggles.

1. Put on a mask. 2. Don gown and gloves. 4. Wear a pair of protective goggles. Reason: Contact precautions are in place, which include wearing gloves and a gown while providing care to the client. The mask and goggles are indicated because of the potential of splash contact during the wound irrigation procedure.

The Physiotherapist has assessed Mrs. Dennis and recommend increased physical activity. How should the practical nurse develop a successful plan that will be maintained by the client? 1. Recognize Mrs. Dennis' reluctance to ambulate and discuss any concerns she may have. 2. Collaborate with the physiotherapist to develop arm exercises using weights that Mrs. Dennis can use at her bedside. 3. Understand that morbid obesity contributes to decreased physical activity. 4. Discuss the proposed

1. Recognize Mrs. Dennis' reluctance to ambulate and discuss any concerns she may have. Reason: The practical nurse must address the client's concerns; the client must feel safe to ambulate.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with a mastitis. Which instructions should be included on the list?Select all that apply. 1. Rest during the acute phase. 2. Wear a supportive, nonunderwiire bra. 3. Maintain a fluid intake of at least 3000ml. 4. Continue to breastfeed if the breasts are not to sore. 5. Take prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breastfeeding or breast

1. Rest during the acute phase. 2. Wear a supportive, nonunderwiire bra. 3. Maintain a fluid intake of at least 3000ml. 4. Continue to breastfeed if the breasts are not to sore. Reason: Mastitis in an infection of the lactating breast. Client instructions include resting during the acute phase, wearing a supportive nonunderwiire bra, maintaining a fluid intake of at least 3000ml per day, and taking analgesics to relive discomfort. Antibiotics may be prescribed and are taken until the complete prescription course if finished. They are not stopped when soreness subsides.

The nurse consults with a dietitian regarding the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan? 1. Rice 2. Fruit 3. Red meat 4. Fried foods

1. Rice Reason: Asian American food preferences usually include raw fish, rice, and soy sauce.

The nurse working in a prenatal clinic reviews a client's chart and note that the primary health care provider documents that the client has a gtnecoid pelvis. The nurse plans care understanding that which findings are characteristics of this type of pelvis?Select all that apply. 1. Round shape. 2. Shallow depth. 3. Narrow pubic arch. 4. Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spine.

1. Round shape. 4. Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spine. Reason: A gtnecoid pelvis is a normal female pelvis, and it is the most favourable for successful labor and birth. Characteristics of a gtnecoid pelvis include a round shape, blunted ischial spines that are widely separated, a diagonal conjugate of at least 12.5 cm to 13cm.

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? 1. Scallops. 2. Chocolate. 3. Cornbread. 4. Macaroni products.

1. Scallops. Reason: Scallops should be omitted from the diet of a client who has gout because of the high purine content. The food items identified in the remaining options have negligible purine content and may be consumed by the client with gout.

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? 1. Stand in front of the client. 2. Exaggerate lip movements. 3. Obtain a sign-language interpreter. 4. Pantomime and write the client notes.

1. Stand in front of the client. Reason: The nurse should ensure that the hearing-impaired client can see the nurse when the nurse is speaking by providing adequate lighting and standing in front of the client.

The practical nurse is receiving an orientation on a surgical unit. While observing a dressing change, the practical nurse notices a colleague drop the sterile forceps on the floor, pick them up and place them back on the sterile field. What should the practical nurse do first? 1. Suggest that the colleague prepare a new sterile field. 2. Offer to complete the dressing change on the colleague's behalf. 3. Hand the colleague a new pair of sterile forceps. 4. Report the colleague to the nur

1. Suggest that the colleague prepare a new sterile field. Reason: The colleague has contaminated the sterile field, and the practical nurse must intervene to keep the client safe.

After a precipitous delivery, the Nurse notes that the new mother is passive and only touches her new born briefly with her fingertips. The nurse should do which to help the woman process what has happened? 1. Support the mother in her reaction to the newborn. 2. Encourage the mother to breastfeed soon after birth. 3. Tell the mother that it is important to hold the newborn. 4. Document a complete account of the mother's reactions in the birth record.

1. Support the mother in her reaction to the newborn. Reason: Woman who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor had progressed so rapidly. To assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn. Encouraging the mother to breastfeed, telling the mother the importance of holding her newborn and documenting the maternal reaction to the birth do not acknowledge the mother's feelings.

A client is being prepared for a thoracentesis. the nurse reinforces instructions with the client given by the registered nurse. Which points should be included in the instructions? Select all the apply? 1. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 3. The procedure involves obtaining a biopsy. 4. A time-out is performed before the procedure. 5. The procedure is performed during a bronchoscopy. 6. A local anesthetic is administered before the proc

1. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 4. A time-out is performed before the procedure. 6. A local anesthetic is administered before the procedure. Reason: A thoracentesis is a procedure in which fluid is removed from the pleural space. The procedure involves insertion of a needle percutaneously and then removal of the fluid by connecting the needle to a vacuum bottle.

Which identifies accurately nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal would dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital signs measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3cm in length without redness, drainage, or edema.

1. The client slept through the night. 2. Abdominal would dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3cm in length without redness, drainage, or edema. Reason: Factual documentation contains descriptive, objective information about what the nurses see, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because is can be misunderstood.

Q10. At the second feeding, Mrs. Tang asks the practical nurse how to recognize when breastfeeding is going well. How should the practical nurse respond? 1. The newborn has at least six wet diapers per day. 2. the mother breastfeeds at least 8-12 times per day. 3. The newborn falls asleep readily after each feed. 4. The mother experiences let-down and uterine cramping with each feed.

1. The newborn has at least six wet diapers per day. Reason: This is a good indicator of adequate intake and hydration.

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all the apply? 1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 3. Place the client in Trendelenburg position. 4. Keep elbows close and work close to the body. 5. Administer oral pain medication 5 minutes before moving the client. 6. Obtain assistance of a second caregiver to assist with mechanical aids.

1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 4. Keep elbows close and work close to the body. 6. Obtain assistance of a second caregiver to assist with mechanical aids. Reason: Manually lifting or transferring clients can result in work-related injuries and back problems for health care workers. In addition, the shearing of the client's skin over bony prominences may occur when health care workers move clients independently. The nurse should get assistance from another care giver, utilize correct body mechanics while utilizing mechanical aids such as a ceiling lift or friction-reducing slide sheet.

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? 1. Vital signs. 2. Skin colour. 3. Oxygen saturation. 4. Latest hematocrit level.

1. Vital signs. Reason: A change in the vital signs my indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter.

The nurse is caring for a client who take ibuprofen for pain. the nurse is gathering information on the client's medication history and determines it it necessary to consult with the registered nurse if the client is also taking which medications? Select all the apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide

1. Warfarin 2. Glimepiride 3. Amlodipine Reason: NSAID's can amplify the effects of anticoagulants; therefore these medications should not be taken together. Hypoglycemia may result.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply? 1. Wearing gloves when emptying the client's bedpan. 2. Keeping all linens in the room until the implant is removed. 3. Wearing a film badge when in the client's room. 4. Wearing a lead apron when providing direct care to the client. 5. Placing the client in a semiprivate room at the endow the hallway.

1. Wearing gloves when emptying the client's bedpan. 2. Keeping all linens in the room until the implant is removed. 3. Wearing a film badge when in the client's room. 4. Wearing a lead apron when providing direct care to the client. Reason: The nurse should follow standard precautions when caring for any client and wear gloves when emptying a bedpan. Linens are kept in the room as a safety precaution in case these is contamination or part of the implant is lost.

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical setter. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply. 1. is allergic to penicillin. 2. Quit smoking 3 months earlier. 3. History of tonsillectomy at the age of 7 years. 4. Wonders if the surgery could cause incontinence. 5. Takes daily multivitamins and calcium supplements. 6. History of deep

1. is allergic to penicillin. 2. Quit smoking 3 months earlier. 4. Wonders if the surgery could cause incontinence. 6. History of deep venous thrombosis in right leg 10 years earlier. Reason: The nurse conducts an interview and reviews current health practices and health history preoperatively with clients. Specific client data that are likely to affect a surgery is communicated promptly. The nurse reports any client allergies, especially an antibiotic allergy to avoid an allergic reaction perioperatively.

Mr. Troy, 44 years old, is participating in a group session for clients with schizophrenia. He has started interrupting the other group members and making sarcastic comments. As the co-facilitator, what should the practical nurse do? 1. privately ask Mr. Troy to stop interrupting others and being sarcastic. 2. Ignore Mr. Troy's impulsive behaviours and sarcastic comments. 3. In private, inform Mr. Troy that if his behaviour continues, he may have to leave the group. 4. During the group pr

1. privately ask Mr. Troy to stop interrupting others and being sarcastic. Reason: This maintains the clients dignity, avoids embarrassment and addresses the impact his behaviour has on others. The practical nurse is addressing the behaviour so he will not be confused.

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure? 1." The uterus weighs about 2 ounces" 2. "The uterus weighs about 2.2 pounds" 3. "The uterus has a capacity of about 50 millilitres" 4. "The uterus is round in shape and weighs appromimately 1000 grams."

1." The uterus weighs about 2 ounces" Reason: Before conception, the uterus is a small, pear shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60g(2oz) and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid.

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? 1. "This diet will help lower my blood pressure." 2. "Fresh foods such as fruits and vegetables are high in sodium." 3. "This diet is not a replacement for my antihypertensive medication." 4. "The reason I need to lower my salt intake is to reduce fluid retention."

2. "Fresh foods such as fruits and vegetables are high in sodium." Reason: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increase fluid volume. Fresh foods such as fruits and vegetables are low in sodium.

Mr. Ellis, 45 years old, is being discharges with a nasogastric feeding tube for enteral nutrition. What statement made by Mr. Ellis would indicate to the practical nurse that discharge teaching has been effective? 1. " I can expect diarrhea while taking enteral feeding" 2. "I must check the tube placement before every feed." 3. "I should flush the tube with 150 ml of water daily." 4. "It is okay if I've pulled back 150 ml before starting the next feed."

2. "I must check the tube placement before every feed." Reason: If the tube placement is not checked, aspiration may take place.

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicates an understanding of the instructions? Select all that apply. 1. "I will bend over to tie my shoes" 2. "I will not sleep lying on my left side" 3. I will sit at the table to eat breakfast" 4. "I will sit in my recliner with my feet elevated" 5. "I will not lift anything heavier than 10 pounds" 5. "I will resume my exerc

2. "I will not sleep lying on my left side" 3. I will sit at the table to eat breakfast" 4. "I will sit in my recliner with my feet elevated" 5. "I will not lift anything heavier than 10 pounds" Reason: After cataract surgery, the client should not assume positions that will increase the intraocular pressure. This could lead to injury to the surgical site and danger the lens implant. The client should not sleep on the side of the body that was operated on.

Ms. Stanley, 83 years old, has just been admitted to a long-term care facility. She shouts, "Let me out of here! I want to go home!" Which response by the practical nurse best demonstrates respect for Ms. Stanley? 1. "I'm sorry, but you can't go home, Ms Stanley." 2. "It must be hard for you to leave your home." 3. "Do not be upset, Ms. Stanley. We will take good care of you." 4. "Would you like me to call your family?"

2. "It must be hard for you to leave your home." Reason: This response is appropriate because it reflects empathy. Empathy indicates that the practical nurse heard the content of the client's statement. Empathetic statements are non-judgmental and help to provide validation.

Mr. Dunn, 74 years old, has Alzheimer's disease and is being cared for at home by his daughter. He is withdrawn and paranoid and becomes upset when his daughter does out. The daughter displays manifestations of caregiver stress. Which statement by the practical nurse would be most appropriate? 1. "I know that you find this situation stessful but remember that this is to be expected with your father's illness." 2. "This is stressful for you and you are doing very well with your father's care. H

2. "This is stressful for you and you are doing very well with your father's care. How can I help?" Reason: This empathetic response recognizes the daughter's reality and communicates understanding. It encourages her to express her concerns and promotes problem-solving.

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value? 1. 3 mg/dL (1.05 mmol/L) 2. 15 mg/dL(5.25 mmol/L) 3. 29 mg/dL(10.15 mmol/L) 4.35 mg/dL(12.25 mmol/L)

2. 15 mg/dL(5.25 mmol/L) Reason: The normal blood urea nitrogen level is 6mg/dL to 20 mg/dL. Values of 29mg/dL and 35mg/dL reflects continued dehydration. A value of 3mg/dL reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 1. 5 minutes. 2. 15 minutes. 3. 30 minutes. 4. 45 minutes.

2. 15 minutes. Reason: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a transfusion reaction will occur. This helps the nurse to be able to detect reaction and intervene quickly.

Which situation would require the nurse to perform a focused assessment? Select all that apply. 1. A client denies a current health problem. 2. A client reports a new symptom during rounds. 3. A previously identified problem needs reassessment. 4. A baseline health maintenance examination is required. 5. An emergency problem is identified during physical examination.

2. A client reports a new symptom during rounds. 3. A previously identified problem needs reassessment.

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose? 1. Providing clients with necessary stabilizing treatments. 2. A method of promoting quality care and risk management. 3. Determining the effectiveness of interventions in relation to outcomes. 4. The appropriate method of

2. A method of promoting quality care and risk management. Reason: Proper documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result of the occurrence are internal to the institution or agency.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS? 1. A length of 19 inches. 2. Abnormal palmar creases. 3. A birth weight of 6 pounds and 14 ounces. 4. A head circumference that is appropriate for gestational age.

2. Abnormal palmar creases. Reason: Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restrictions, cardiac abnormalities, abnormal palmar creases, and respiratory distress.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be bought to the emergency department. Which should be the initial nursing action? 1. Prepare the triage rooms. 2. Activate the agency emergency response plan. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist with treating the casualties.

2. Activate the agency emergency response plan. Reason: During a widespread disaster, many people will be brought to the emergency department for treatment. Health care institutions are required to have an emergency response plan in place and perform practice drills.

The nurse notes documentation that a client has conductive healing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply. 1. a defect in the cochlea. 2. Acute otitis media with effusion. 3. a defect in the 8th cranial nerve. 4. A defect in the sensory fibres that lead to the cerebral cortex. 5. A physical obstruction to the transmission of sound waves.

2. Acute otitis media with effusion. 5. A physical obstruction to the transmission of sound waves. Reason: A conductive heparin loss is a result of a physical obstruction to the transmission of sound wave. Acute otitis media with effusion, a fluid buildup in the middle of the ear, can block the transmission of sounds waves.

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse would tell the client that which foods are best to include in the diet for this disorder? Select all the apply. 1. Beans. 2. Apples. 3. Cabbage. 4. Brussels. 5. Whole-grain bread.

2. Apples. 5. Whole-grain bread. Reason: A high-fiber, his-residue diet is used for constipation, irritable bowel syndrome when the primary symptom is alternating constipation and diarrhea, and asymptomatic diverticular disease. High-fiber foods include fruits and vegetables and whole-grain products. Gas-forming foods such as beans, cabbage, and brussels sprouts should be limited.

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with this event?Select all that apply. 1. Turn the client to the side with the knees bent. 2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse and primary health care provider at once. 4. Explain to the client that obesity is a r

2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse and primary health care provider at once. Reason: Wound dehiscence is the separation of the wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues.

Mrs. Kerr has colon cancer and is still experiencing pain after several weeks of altering her pain medications. Her daughter is very upset because she believes her mother is being over medicated. What should the practical nurse do? 1. Refer Mrs. Kerr and her daughter to the physician and pharmacist. 2. Arrange a meeting with the client, daughter, practical nurse and physician. 3. Meet with her daughter to investigate her claims. 4. Review Mrs. Kerr's current medications with the physician

2. Arrange a meeting with the client, daughter, practical nurse and physician. Reason: The practical nurse works with a variety of professionals as client care is planned, provided and evaluated and work toward a collaborative partnership that includes the active participation and agreement of all partners. The clients shares responsibility for her health.

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? 1. To the right of the abdomen. 2. At the level of the umbilicus. 3. About 4 cm above the level of the umbilicus. 4. One fingerbreadth above the symphysis pubis.

2. At the level of the umbilicus. Reason: After delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 finger breadths below it and in the midline of the abdomen. If the fundus is 4 cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage.

A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2C(97.2F) orally, pulse 52 beats per minute, blood pressure 101/58mm Hg, respiratory rate 11 breaths per minutes, and SpO2 of 93% on 3 litres of oxygen via nasal cannula. Which action should the nurse take first?

2. Attempt to arouse the client. Reason: The primary concern with opioid analgesic is respiratory depression and hypotension. Based on the finding the nurse should suspect overdose. The nurse should first try to arouse the client and then reassess the vital signs.

The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply. 1. pin the tubing to the bed linens. 2. Be sure all connections remain airtight. 3. be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed. 5. Empty the drainage from the drainage collection chamber daily.

2. Be sure all connections remain airtight. 3. be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed. Reason: The chest tube system must be maintained as a closed system in order for the air to be removed by suction and for the lungs to reexpand to a normal state. The connections should be air tight (no leaks), and all connections should be taped and secure.

The nursing student is preparing a conference on Freud's psychosexual stage of development, specifically the anal stage. Which appropriately relates to this stages? 1. Gratification of self. 2. Beginning of toilet training. 3. Tapering off of conscious biological and sexual urges. 4. Association with pleasurable and conflicting feelings about genital organs.

2. Beginning of toilet training. Reason: Toilet training generally occur during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces. Self-gratification relates to the oral stage.

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing? 1. veal, potatoes, gelatine, and orange juice. 2. Chicken breast, broccoli, strawberries, and milk. 3. Peanut butter and jelly sandwich, cantaloupe. 4. Spaghetti with tomato sauce, garlic bread, and ginger ale.

2. Chicken breast, broccoli, strawberries, and milk. Reason: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatine and jelly have no nutrient value. Spaghetti is a complex carbohydrate.

The nurse is preparing to administer a medication through a nasogastric tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply? 1. Position the client supine to assist with medication absorption. 2. Clamp the NG tube for 30 minutes after medication administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5

2. Clamp the NG tube for 30 minutes after medication administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during administration of medication. Reason: Oral medications are sometimes administered to a client who is prescribed suction through a nasogastric tube. The nurse must verify that the tube has correct placement by checking drainage characteristics and pH to avoid aspiration of the medication into the trachea. The NG tube should be flushed with saline before and after medication administration to facilitate delivery and promote absorption.

The nurse in the newborn nursery receives a telephone call to prepare for the administration of a neonate born at 43 weeks gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority? 1. Turning on the apnea and cardiorespiratory monitor. 2. Connecting the resuscitation bag to the oxygen outlet. 3. Setting up the intravenous line with 5% dextrose in water. 4. Setting the radiant warmer control temperature to 36.5C(97.6F)

2. Connecting the resuscitation bag to the oxygen outlet. Reason: The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment.

The nurse is assigned to assist the primary health care provider with the removal of a chest tube. Which intervention should the nurse anticipate performing during this process? Select all that apply? 1. Reinforce instructions to breathe deeply while the tube is removed. 2. Cover the site with an occlusive dressing after the tube is removed. 3. clamp the chest tube near the insertion site just before the removal. 4. Raise the drainage system to the level of the chest tube insertion site. 5.

2. Cover the site with an occlusive dressing after the tube is removed. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out. Reasons: A chest tube is removed when the lung has fully reexpanded or there is limited drainage. When the chest tube is removed, the client is asked to perform a Valsalva maneuver, the tube is quickly withdrawn, and an airtight dressing is taped in place.

The nurse is assigned to care for a client with a peripheral intravenous infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown? 1. Using a hospital gown with snaps at the sleeves. 2. Disconnecting the IV tubing from the catheter in the vein. 3. Checking the IV flow rate immediately after changing the hospital own. 4. Putting the bag and tubing through the sleeve, followed by the client's arm.

2. Disconnecting the IV tubing from the catheter in the vein. Reason: The tubing should not be removed form the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Using gowns with snaps and insertion the IV bag and tubing through the sleeve of the gown first are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90ml of residual from the tube. What should the nurse do? Select all that apply. 1. Hold the feeding. 2. Document the amount of residual. 3. Place it into a container for laboratory analysis. 4. Reinstall the residual and administer the feeding. 5. Deduct the amount of residual from the new feeding before administering.

2. Document the amount of residual. 4. Reinstall the residual and administer the feeding. Reason: Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100ml is reinstalled; then a normal amount of prescribed tube feeding is administered.

Mr. George, 65 years old, has been admitted to a long term care facility following a cerebrovascular accident (CVA). He states that he does not wish to be turned at night. What should the practical nurse do? 1. Explain the facility's policy regarding turning schedules to the client. 2. Educate the client regarding the purpose of turning him at night. 3. Obtain an order from the physician to ensure that the client is turned at night. 4. Inform the client that it is his right to refuse but

2. Educate the client regarding the purpose of turning him at night. Reason: The practical nurse owes a duty of care to the client and part of this duty is an explanation of the possible consequences should the client refuse treatment. This approach allows the client to make the final decision and ensures that the decision is made using a collaborative approach between practical nurse and client.

A client who has recently diagnosed with human immunodeficiency virus (HIV) is upset and does not want his family to know. HIs wife demands to know what is wrong with her husband. What should the practical nurse do? 1. Tell her the husband's diagnosis. 2. Encourage her to discuss it with her husband. 3. Tell the wife that the diagnosis is unknown. 4. Encourage her to talk to her husband's physician.

2. Encourage her to discuss it with her husband. Reason: The husband should have the right to choose how he will tell his wife the diagnosis. This respects the ethical principle of autonomy and maintains confidentiality and the nurse-client relationship. The practical nurse should not disclose the client's confidential medical information without the client's consent. The practical nurse should not assume that a client's spouse knows all of the client's medical history.

A licensed practical nurse is preparing to assist a registered nurse with removing a NG tube from the client. Which interventions should be included in the procedure? 1. Remove the air from the balloon. 2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continues steady motion. 5. Remove the device or tape securing the tube from the nose.

2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continues steady motion. 5. Remove the device or tape securing the tube from the nose. Reason: Before removing the tube, the client should be told about the procedure and review the instructions. The tape or securing device needs to be removed from the client's nose. When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for easy removal of the tube.

Q6. Mr. Bell's family has arranged for a meeting with the transplant coordinator. Mr. Bell does not agree with his consultation and yells at his family. What should the practical nurse do first? 1. Arrange for a meeting between the client, his family and a social worker. 2. Explore Mr. Bell's understanding of the pros and cons of a transplant. 3. Reinforce Mr. Bell's disinterest in meeting with the transplant coordinator. 4. Respect his right to refuse and accept the client's decision.

2. Explore Mr. Bell's understanding of the pros and cons of a transplant. Reason: This would help the client make an informed decision.

While the practical nurse is assisting Mrs. Dennis with her personal care, she begins to cry quietly and states, "Look at what my life has become. My niece will not be able to care for me now and my husband is dead. How will I cope at home?" What should the practical nurse do? 1. Ask Mrs. Dennis how she has been coping since her husband died. 2. Explore Mrs. Dennis' Feelings about her care needs. 3. Meet with Mrs. Dennis' niece to discuss family dynamics. 4. Comfort Mrs. Dennis and tell h

2. Explore Mrs. Dennis' Feelings about her care needs. Reason: It is essential to explore and validate Mrs. Dennis' thoughts and feeling related to her care needs. This promotes therapeutic communication, trust and respect.

Q12. In preparing the newborn for discharge, the practical nurse notices that the baby is jaundiced. Which strategy should the practical nurse teach Mrs. Tang to address this concern? 1. Supplement with sterile water between feedings. 2. Feed the newborn a minimum of every 4 hours. 3. Feed the newborn whenever she demands. 4. Supplement with glucose water between feedings.

2. Feed the newborn a minimum of every 4 hours. Reason: An adequate caloric intake is necessary for formation of hepatic binding proteins. The jaundiced newborn is likely to be lethargic and should be awakened for feedings.

Ms. Hurley, 35 years old and a single mother, has been diagnosed with stage 4 ovarian cancer. She expresses concern regarding the care of her three young children. What is the best action for the practical nurse to take? 1. Suggest a team conference. 2. Further explore the client's concern. 3. Refer her to a social worker. 4. Request that her family support her.

2. Further explore the client's concern. Reason: In order to determine the most appropriate action, the practical nurse would need to gather information from the client to identify the source of her concern.

What is an important consideration for the practical nurse to discuss with Mr. Miller during discharge planning? 1. He should avoid lifting heavy object for 7-12 days. 2. He should contact his physician if he develops abdominal discomfort. 3. He should be able to return to work in 6 weeks. 4. He can resume normal activities 4 weeks following discharge.

2. He should contact his physician if he develops abdominal discomfort. Reason: Because of earlier discharge of laparoscopic clients, these symptoms may not occur unit after discharge.

Mrs. Spain, 53 years old, is admitted with pulmonary emphysema. Her oxygen saturation is 88% with oxygen via nasal cannula at 3 L. She is short of breath, coughing and using accessory muscles. She is pink in colour and reports not feeling well. What is the primary nursing diagnosis? 1. Activity intolerance related to breathing difficulty. 2. Impaired gas exchange related to decreased lung expansion. 3. Impaired nutrition related to difficulty breathing. 4. Ineffective coping related to fa

2. Impaired gas exchange related to decreased lung expansion. Reason: This is the priority when the client is having respiratory problems; this needs to be corrected or the client could risk hypoxemia and respiratory acidosis.

Mr. Henderson asks why his wife is rapidly becoming more debilitated. He states that her aunt has has this condition for years but is in better health than his wife. What is the practical nurse's best response? 1. Discuss with Mr. Henserson further treatment options to slow the disease progression. 2. Inform his that people with multiple sclerosis each have their own pattern of progression. 3. Ask Mr. Henderson why he is concerned about his wife's condition. 4. Explain to Mr. Henderson th

2. Inform his that people with multiple sclerosis each have their own pattern of progression. Reason: Clinical manifestations vary according to areas of the central nervous system involved.

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0mg.dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action? 1. Document the value in the client's record. 2. Inform the registered nurse of the laboratory value. 3. Place the laboratory result form in the client's record. 4. Reassure the client that the laboratory result is normal.

2. Inform the registered nurse of the laboratory value. Reason: The normal serum calcium level ranges from 9 to 10.5 mg/dL. The client is experiencing hypercalcemia and the nurse would inform the registered nurse of the lab value.

Ms. McKean, 19 years old, is in the postpartum unit, after delivery of her first child. The baby's father in no longer involved with Ms. McKean. Ms. McKean is found to be crying and tells the practical nurse that she is unsure if she will keep the baby. what should the practical nurse do first? 1. Reassure her that these feelings are normal. 2. Inquire about which factors are affecting her decision. 3. Suggest that she should discuss this with the baby's father. 4. Ask Ms. McKean if she w

2. Inquire about which factors are affecting her decision. Reason: Clarifying helps to understand the client's massage.

A urine specimen for culture and sensitivity is ordered for a 17 year old with genital herpes. What should the practical nurse do to ensure that the specimen is free from external contamination? 1. Wash the outside of the specimen container before sending it to the laboratory. 2. Instruct Tom not to touch the inside of the container. 3. Provide a clean container for the specimen collection. 4. Have Tom place the tip of his penis on the edge of the container.

2. Instruct Tom not to touch the inside of the container. Reason: the inside of the container is sterile and touching it would introduce external contamination.

Mr. Dahl is receiving an opioid analgesic following his surgery. On his second postoperative day, an antihistamine is administered for his allergic rhinitis. Mr. Dahl currently reports dizziness and has poor coordination when he ambulates. Which rationale best explains Mr. Dahl's present manifestations? 1. Antihistamines lessen the effect of opioids. 2. Medications may interact by potentiating the effect of another. 3. Opioids elevate blood pressure causing dizziness. 4. Antihistamines cause

2. Medications may interact by potentiating the effect of another. Reason: A synergistic effect occurs when the combined effect of two medications is greater than the effects of each medication given alone.

Q14. Mrs. and Mr. Burke tell the practical nurse that they would like to become pregnant but are unsure if this is possible due to Mrs. Burke's spinal cord injury. What information should the practical nurse share with the couple? 1. the only way for Mrs. Burke to become pregnant is by in vitro fertilization. 2. Mrs. Burke may experience a higher incidence of complications during pregnancy and delivery. 3. Mrs. Burke's ability to reproduce is unaffected by her injury. 4. If pregnancy occ

2. Mrs. Burke may experience a higher incidence of complications during pregnancy and delivery. Reason: The couple should understand that pregnancy can be dangerous for Mrs. Burke and the practical nurse should refer them to an expert.

A practical nurse is attending an inter professional care plan conference that also includes the client's family. The practical nurse works with the client daily and feels that the care plan being suggested is not appropriate. What should the practical nurse do? 1. Accept the directions of the other health-care professionals to promote a collaborative approach. 2. Offer alternatives to the group since the practical nurse is most familiar with the client. 3. Tell the family to bring any conc

2. Offer alternatives to the group since the practical nurse is most familiar with the client. Reason: This would be an assertive way to advocate for the client. The practical nurse is also offering alternatives based on his/her knowledge of the client.

What is the practical nurse's best action to prevent nosocomial infection when caring for Mrs. McPhee, 68 years old, who is 2 postoperative? 1. Screen Mrs. McPhee's visitors. 2. Perform hand hygiene practices. 3. Take routine swabs for infection. 4. Wear a mask when caring for Mrs. McPhee.

2. Perform hand hygiene practices. Reason: Most nosocomial infections are transmitted by health-care workers and clients by direct contact during the delivery of care.

Mrs. Nicholson offers the practical nurse $20 for being so kind and helpful. After thanking Mrs. Nicholson, how should the practical nurse respond? 1. Accept the money and donate it to charity. 2. Refuse the money and explain that staff cannot accept money. 3. Refuse the money and tell Mrs. Nicholson to buy something for herself. 4. Accept the money and return it to the daughter.

2. Refuse the money and explain that staff cannot accept money. Reason: This is proper ethical conduct and it will not negatively impact the therapeutic relationship with her.

Mr. Pinner, 32 years old, has a drain following surgery for a ruptured appendix. After the initial dressing change, he reports a burning sensation at the drain site. What should the practical nurse do first? 1. Administer an analgesic as ordered. 2. Remove Mr. Pinner's dressing and assess the skin underneath. 3. Check Mr. Pinner's chart for documentation of similar concerns. 4. Tell Mr. Pinner that this is a normal reaction to the drain.

2. Remove Mr. Pinner's dressing and assess the skin underneath. Reason: The practical nurse should remove the dressing immediately and assess the skin before determining the next action.

Prior to administering blood, the practical nurse sees from the client's history that a past blood transfusion caused a mild case of urticaria. What is the priority action? 1. Transfuse the client as ordered. 2. Report this information to the physician. 3. Stay with the client after the transfusion. 4. Reassure the client that this type of reaction reocuurs rarely.

2. Report this information to the physician. Reason: For clients who have had mild urticarial reactions to blood, antihistamine administration is advisable prior to the next infusion. Because complications of transfusion may be significant, judicious evaluation of the client is required.

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel(UPA). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery. 2. Taking an oral temperature for a client who has a cough and nasal congestion. 3. Taking an axillary temperature on a client who has just consumed hot coffee. 4. Ta

2. Taking an oral temperature for a client who has a cough and nasal congestion. Reason: An oral temperature should be avoided if the client has a nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Less invasive measures should be used if available.

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings should the nurse expect to observe because of meningeal irritation? Select all that apply. 1. Pupils are unequal and react slowly to light. 2. The client reports stiffness and soreness in the neck area. 3. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion. 4. The client flexes a leg at the hip and knee and reports

2. The client reports stiffness and soreness in the neck area. 3. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion. 4. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. Reason: Meningitis is the inflammation of the meninges, the membranes covering the brain and spinal cord. It is caused by organisms such as bacteria, viruses or fungi.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis. 2. The client with a ileostomy. 3. The client with heart failure. 4.The client with decreased kidney function.

2. The client with a ileostomy. Reason: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and ileostomy.

The nurse obtains a prescription to restrain and instructs the unlicensed assistive personnel to apply the restraint. Which observation, if made by the nurse indicates unsafe applications of the restraint? 1. a safety knot is made in the restraint strap. 2. The restraint straps are safely secured to the side rails. 3. The restraint strap does not tighten when forced is applied against it. 4. The restraint is secure, and the client is able to turn from back to side.

2. The restraint straps are safely secured to the side rails. Reason: The restraint strap is secured to the bed frame (Never the side rail) to avoid accidental injury in case the side rail is released. The nurse recognizes that tying the strap to the side sail is not correct and unsafe. A half-bow or safety knot should be used when applying a restraint, because it does not tighten when force is applied against it and allows for the quick and easy removal of the restraint in case of an emergency.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5. mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea. 2. Traumatic burn. 3. Cushing's syndrome. 4. Overuse of laxatives.

2. Traumatic burn. Reason: A serum potassium level that exceeds 5.0 mEq/L(5.5 mmol/L) is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (trauma, burns, sepsis, or metabolic or respiratory acidosis.) are at risk for hyperkalemia.

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components? 1. Two umbilical veins and one umbilical artery. 2. Two umbilical arteries and one umbilical vein. 3. Arteries that carry oxygenated blood to the fetus. 4. veins that carry deoxygenated blood to the fetus.

2. Two umbilical arteries and one umbilical vein. Reason: Blood pumped by the fetus's heart leaves the fetus through two umbilical arteries. After the blood is oxygenated, it is then returned by one umbilical vein. The umbilical arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus.

Mrs. MacFarlane, 53 years old, has been admitted with a diagnosis of right lower lobe pneumonia. How should the practical nurse proceed with a lung assessment? 1. Using the bell of the stethoscope, auscultate the lungs starting at the apexes and move side to side to the bases. 2. Using the diaphragm of the stethoscope, auscultate the lungs starting at the apexes and move side to side to the bases. 3. Using the diaphragm of the stethoscope, auscultate the right lung starting at the apex and

2. Using the diaphragm of the stethoscope, auscultate the lungs starting at the apexes and move side to side to the bases. Reason: Using the diaphragm of the stethoscope is preferable to the bell for listening to lung sounds because it transmits the high-pitched sounds better and covers a broader area of sound. Moving side to side allows for comparison, and the practical nurse moves from the apex to the base.

The nurse is assigned to assist with caring for a client with abrupt placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abrupt placentae is accompanied by which additional finding? 1. Soft abdomen on palpation. 2. Uterine tenderness on palpation. 3. No complaints of abdominal pain. 4. Lack of uterine irritability or tetanus contractions.

2. Uterine tenderness on palpation. Reason: Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta. The abdomen will fell hard and board-like during palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained titanic contraction can occur if the client is in labor and the uterine muscle cannot relax.

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? 1. Sore throat or earache. 2. chills, itching, or rash. 3. Unusual sleepiness or fatigue. 4. Mild discomfort at the catheter site.

2. chills, itching, or rash. Reason: The client is told to report chills, itching, or rash immediately, because these could be signs of a possible transfusion reaction. Mild discomfort at the catheter site may be indicative of a problem, or it could result from the size of the catheter required to infuse the blood product. Sore throat, earache, sleepiness, and fatigue are unrelated to a transfusion reaction.

At 0300h, Mr. Claude, a 68-year-old client on the palliative care unit, tell the practical nurse that he is ready to speak with a spiritual advisor. What should the practical nurse do? 1. Offer to read spiritual reflections. 2. contact the appropriate on-call person. 3. Leave a telephone voice message for the pastor care staff. 4. Inform him that his request will be passed along to day staff.

2. contact the appropriate on-call person. Reason: This action responds to the client's immediate need and respects the client's dignity and choice.

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider? 1. Garlic. 2.Valerian. 3. Lavender. 4. Glucosamine.

2.Valerian. Reason: Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety and restlessness.

Mrs. Pearl, a 71-year-old woman with dementia, is admitted to a long-term care facility. Which statement by Mrs. Pearl should indicated to the practical nurse that she is distressed by this move? 1. "I'm only here for a visit. My mother is coming to pick me up soon." 2. "Could you tell me where my room is? I can't find it?" 3. "I don't know why my family brought me here. Please let me go." 4. "There are so many people here. I would like to meet them."

3. "I don't know why my family brought me here. Please let me go." Reason: This response is indicative of a client who is distressed or anxious. She indicates that she does not understand the reason for being there and wants to return to a familiar place.

The practical nurse overhears Mrs. Latini her roommate, "I find my decongestant nasal spray really helpful. Whenever I feel Stuffed up, I just take a few sprays of it." What is the most important information for the practical nurse to include in health teaching about this medication? 1. "Its important to blow your nose gently before taking nasal sprays." 2. "Spray the medication toward the midline of the ethmoid bone to help prevent if from running down the eustachian tube." 3. "Nasal spray s

3. "Nasal spray should be taken only as directed or it may cause rebound congestion." Reason: Nasal decongestant spray may cause rebound congestion. This information is most important to explain to the client at this time because she has been in the habit of taking the medication whenever she feels it is needed.

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply. 1. excessive bubbling in the water-seal. 2. Vigorous bubbling in the suction-control chamber. 3. 50ml of drainage in the drainage collection chamber. 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is i

3. 50ml of drainage in the drainage collection chamber. 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation. Reason: In a thoracotomy the lung is opened and exposed, and a wedge resection is the removal of part of the lung. The chest tube is placed during the surgery to remove fluid and air so the remaining ling can reinflate. The bubbling of water in the water-seal chamber should be gentle and indicates air drainage from the client.

The nurse enter's a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3. Activate the fire alarm. Reason: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors. Finally, the fire is extinguished.

Mrs. Hoogstein, 82 years old, is receiving enteric-coated acetylsalicylic acid (Entrophen) 325 mg 2 tablets orally every 6 hours p.r.n. Recently she has been reporting mild dysphagia. How should the practical nurse give the medication to Mrs. Hoogstein? 1. Place Mrs. Hoogstein in a low-fowler's position to assist in swallowing pills. 2. Crush medication and administer in applesauce to facilitate swallowing. 3. Administer her pills one at a time for ease of swallowing.

3. Administer her pills one at a time for ease of swallowing. Reason: Enteric-coated medication should be swallowed whole to prevent absorption in stomach. Dissolving the medication removes the enteric coating.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon? 1. immediately inflate the balloon. 2. Insert the catheter 2.5cm to 5cm and inflate the balloon. 3. Advance the catheter to the bifurcation and inflate the balloon. 4. Insert the catheter until resistance is met and inflate the balloon.

3. Advance the catheter to the bifurcation and inflate the balloon. Reason: Urinary catheterization is a sterile procedure. When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur.

When the practical nurse enters the room, tanner begins crying and clings to his mother. In order to administer a nebulizer, how should the practical nurse proceed? 1. Restrain Tanner and instruct him to breath deeply. 2. Ask the physician for a sedative for tanner to calm him down. 3. Advise the mother to take Tanner onto her lap to administer the medication. 4. Ensure that Tanner stops crying before administering the medication.

3. Advise the mother to take Tanner onto her lap to administer the medication. Reason: This decreases fear and is appropriate given the growth and development of a 2-year-old child.

What is the best example of the practical nurse actively participating in improving the quality of nursing care? 1. Adhering to the current policies and procedures. 2. Following standardized care plans for newly admitted clients. 3. Agreeing to membership on the infection control committee. 4. Reading the agency's nursing skills manuals.

3. Agreeing to membership on the infection control committee. Reason: Providing input and participating in decision making are activities that help achieve healthy workplace environments and quality care.

Q2. The client was provided with preoperative teaching on deep breathing and coughing. How should the practical nurse best evaluate the outcomes of the teaching. 1. Have the client explain deep breathing and coughing. 2. Have the client identify barriers to performing these exercises. 3. Ask the client to demonstrate deep breathing and coughing. 4. Demonstrate deep breathing and coughing to the client.

3. Ask the client to demonstrate deep breathing and coughing. Reason: Client action demonstrates learning. This provides an opportunity for the practical nurse to evaluate client learning.

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How should the nurse initially address the clients concerns? 1. Tell the client that preoperative fear in normal. 2. Explain all nursing care and possible discomfort that may result. 3. Ask the client to discuss information known about the planned surgery. 4. Provide explanations about the procedures involved in the planned surgery.

3. Ask the client to discuss information known about the planned surgery. Reason: The client is concerned about having surgery and needs to discuss it. This will offer the client the opportunity to verbalize his or her current and specific understanding. Explanations should begin with the information that the client knows. Option 1 is a block to communication and minimizes the clients feelings.

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? 1. Induce vomiting. 2. Call an ambulance. 3. Call the poison control centre. 4. Bring the child to the emergency department.

3. Call the poison control centre. Reason: If a suspected poisoning occurs, the poison control centre should be contacted immediately. The nurse can assist the mother with contacting the poison control centre. Vomiting should not be included without instructions from the poison control centre. Brining the child to the emergency department of calling an ambulance would delay treatment.

Mrs. O'Reilly, 80 years old, has ovarian cancer. The physician tell Mrs. O'Reilly that chemotherapy will be started soon. Later, Mrs. O'Reilly states in a quiet voice "I have to do what the doctor says." How should the practical nurse respond? 1. Provide Mrs. O'Reilly with a list of other qualified physicians for a second opinion. 2. Encourage Mrs. O'Reilly to strongly consider other forms of treatment. 3. Clarify Mr.s O'Reilly's statement. 4. Support the physician's plan of care.

3. Clarify Mr.s O'Reilly's statement. Reason: This supports the ethical principle of autonomy and ensures that the client's choices are free and informed. The practical nurse must ensure that the client is competent to make her own decision. Gathering subjective data can direct future nursing actions and interventions.

Mr. Doucette, 77 years old, is admitted with serve abdominal pain that has last 1 week. He is lying on his left side and his face it tense. The practical nurse asks Mr. Doucette, "On a scale of 0 to 10, how would you rate your pain?" Which communication technique has the practical nurse used? 1. Paraphrasing 2. Open-ended question 3. Closed-ended question 4. Summarizing

3. Closed-ended question Reason: The pain scale would describe the quality of the pain more effectively. This help the client to describe his pain objectively. Close-ended questions require a precise response.

The practical nurse sees Mr. Huntley, 74 years old, fall out of his geri chair. Assessment concludes that no injuries were sustained. What should the practical nurse do first? 1. Restrain the client in the geri chair. 2. Request a change of medication. 3. Complete an occurrence report. 4. Request that physiotherapy perform a sensory motor assessment.

3. Complete an occurrence report. Reason: A fall is an incident that is not consistent with the routine operation of a health-care unit or routine care of client. it is necessary to complete an occurrence report even if an injury does not occur or is not apparent.

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venous. The instructor determines that the student understands the structure of the ductus venous if the student states which about the ductus venous? 1. Connects the pulmonary artery to the aorta. 2. Is an opening between the right and left aria. 3. Connects the umbilical vein to the inferior vena cava. 4. Connects the umbilical artery to the infe

3. Connects the umbilical vein to the inferior vena cava. Reason: The ductus venous connects the umbilical vein to the inferior vena cava. The foramen oval is a temporary opening between the right and left atria. The ductus arterioles joins the aorta and the pulmonary artery.

An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity? 1. Decreased salivation and gastrointestinal motility. 2. Decreased muscle strength and loss of bone density. 3. Decreased lean body mass and glomerular filtration rate. 4. Decreased cardiac output and decreased efficiency of blood return to the heart.

3. Decreased lean body mass and glomerular filtration rate. Reason: The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate.

Mr. Chalifoux, 64 years old, is admitted into palliative care with end-stage cancer. He requests a ceremony that involved lighting sweet grass and producing smoke. How can the practical nurse best support the needs of the client? 1. Arrange for the ceremony to be performed outside. 2. Explain that hospital policy will not allow this ceremony. 3. Discuss the client's request with the nurse-in-charge. 4. Ask a spiritual leader to perform the ceremony.

3. Discuss the client's request with the nurse-in-charge. Reason: It is important to inquire about the possibility of customizing nursing intervention so that they are appropriate for the population on the unit and not only this client.

Q7. Mr. Bell has been transferred to a long-term care facility. As the team leader in the facility, what should the practical nurse do first? 1. Refer Mr. Bell to dietitian for a high-iron diet. 2. Delegate Mr. Bell's total care to an unregulated health worker. 3. Discuss with the team Mr. Bell's increased need for skin care. 4. Continue to educated Mr. Bell on the advantages of a liver transplant.

3. Discuss with the team Mr. Bell's increased need for skin care. Reason: This uses the practical nurse's leadership skills within the inter professional team.

The RPN enters a clients room and finds the client lying on the bathroom floor. The RPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The RPN completes an incident report, and the nursing supervisor and primary health care provider are notified of the incident. Which is the next nursing action regarding the incident? 1. Place the incident report in the client's chart. 2. Make a copy of the incident report for the PHCP. 3. Document a comp

3. Document a complete entry in the client's record concerning the incident. Reason: The incident report is confidential snd privileged information, and it should not be copied, placed in the chart, of have any reference made to it in the client's record. The incident report is not a substitute fro a complete entry in the client's record concerning the incident.

Ms. Rands, 25 years old, has just been told she has genital warts. She is crying and wondering if she should break up with her partner. She asks the practical nurse what she should do next. How should the practical nurse respond? 1. Ask if she wants to talk to the social worker. 2. Reassure her that the practical nurse understands how she feels. 3. Explore her concerns about her relationship. 4. Remind her that the public health nurse will enquire about her sexual contacts.

3. Explore her concerns about her relationship. Reason: This is an open-ended response that will allow the client to take the lead and introduce pertinent information.

Mr. Salter, 44 years old, has been admitted to the medical unit. The practical nurse asks Mr. Salter if he uses recreational drugs. He states that he drinks alcohol "Once in a while." In confidence, his wife states that he has a history of alcohol abuse. What is the practical nurse's next step? 1. Inform the client that his wife has disclosed that he has a drinking problem and needs treatment. 2. Ask the client if he has felt a need to cut down on his drinking or felt guilty about drinking.

3. Explore what the client means by "Once in a while" and document his recent alcohol intake. Reason: This action will provide clarity on the client's current alcohol intake through the collection of subjective data. It also opens the conversation to further discussion and acknowledgement of the problem.

Mrs. Martin, a 26-year-old mother of two children, has terminal breast cancer. She says, "I can't die now. What will happen to my kids?" Which of the following responses is the most appropriate for the practical nurse to make? 1. Reassure Mrs. Martin that her husband can look after them. 2. Ask Mrs. Martin who is taking care of them now. 3. Focus on Mrs. Martin's concerns about her children. 4. Ask Mrs. Martin if she would like to speak to the social worker.

3. Focus on Mrs. Martin's concerns about her children. Reason: This allows the client to discuss issues related to the problem and keep the communication goal directed.

The nurse is planning to reinforce nutrition instructions to an African American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African American heritage? 1. Raw fish 2. Red meat 3. Fried foods 4. Rice as the basis for all meals

3. Fried foods Reason: African American food preferences usually include chicken, pork, greens, rice, and fried foods.

The physician visits Ms. Karch and orders the following: full fluid diet, morphine 5-10 mg IV every 4-6 hours p.r.n. for pain, increase IV rate to 125 ml per hour and activity as tolerated. What order should the practical nurse question? 1. Activity as tolerated. 2. Morphine. 3. Full fluid diet. 4. IV rate

3. Full fluid diet. Reason: With diverticulitis the goal is to rest the bowel; the client should receive nothing by mouth because she has signs of perforation.

A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development? 1. Egocentric judgment. 2. Law-and-order orientation. 3. Good boy-nice-girl orientation. 4. Social contract and legalistic orientation.

3. Good boy-nice-girl orientation. Reason: According to Kohlber's theory or moral development, during the good boy-nice girl orientation, the child actin a way to please others. A child in the egocentric judgment stage has no awareness of right and wrong.

What are the practical nurse's priority assessments for a 2-year-old client diagnosed with acute asthma exacerbation. 1. Urinary output, muscle tone and vital signs. 2. Neurological status, chest sounds and urinary output. 3. Hydration status, vital signs, chest sounds. 4. Neurological status, hydration status and muscle tone.

3. Hydration status, vital signs, chest sounds. Reason: Dehydration can occur quickly and cause thickening of mucous. Changes to vital signs and a detailed respiratory assessment are most important.

Mr. Moncion, 65 years old, has pneumonia. What can the practical nurse suggest to facilitate clearing of respiratory secretions? 1. Longer rest periods. 2. Pursed-lip breathing. 3. Increasing fluids. 4. Lying on the unaffected side.

3. Increasing fluids. Reason: The increase in fluids helps aid the expectoration of secretions.

During the fourth visit, the practical nurse finds Mrs. Danielson alone in her room. Later, her husband says that she has been avoiding the children. What is the priority nursing diagnosis? 1. Exhaustion related to low hemoglobin. 2. Discomfort related to postoperative incision. 3. Ineffective coping related to postpartum transition. 4. Altered body image related to colostomy.

3. Ineffective coping related to postpartum transition. Reason: Apathy and lack of interest are early signs of postpartum depression.

The nurse is doin a routine assessment of a client's peripheral intravenous(IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? 1. Phlebitis. 2. Infection. 3. Infiltration. 4. Thrombosis.

3. Infiltration. Reason: An infiltrated IV is one that has dislodge from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being despoiled into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness.

What should the practical nurse do first when providing preoperative teaching to Mr. Miller?(refer to previous question) 1. Explain to the client about the harmful effects of smoking and its impact on his health. 2. Discuss the need to strictly follow a low-fat diet following his surgery. 3. Instruct the client about deep breathing, coughing and use of the incentive spirometer. 4. Inform him that he will not be able to ambulate for 2 days after his surgery.

3. Instruct the client about deep breathing, coughing and use of the incentive spirometer. Reason: This will have an impact on his recovery because deep breathing and coughing promote optimal lung expansion and oxygenation after anesthesia.

An adult female client has a hemoglobin level of 10.8g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration. 2. Heart failure. 3. Iron deficiency anemia. 4. Chronic obstructive pulmonary disease.

3. Iron deficiency anemia. Reason: The normal hemoglobin level for an adult female client is 12g/dL to 16g/dL. Iron deficiency may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level a a result of the body's need for more oxygen-carrying capacity.

Tom states, "I don't want my parents to know." What should the practical nurse consider when responding to Tom? Tom is a 17 year old with genital herpes 1. Tom's parent have a right to know his diagnosis. 2. Visits to the clinic by minors must be reported to their parents. 3. It is Tom's responsibility to inform his parents. 4. Tom's physician will determine if the parents must be informed.

3. It is Tom's responsibility to inform his parents. Reason: Confidentiality is maintained because the client is giving out the information.

Q3. What is the primary objective for the practical nurse using aseptic technique when changing a postoperative dressing? 1. It allows the practical nurse to maintain a sterile field. 2. It helps to prevent the spread of HIV. 3. It reduces the risk of contamination and wound infection. 4. It promotes the repair of abdominal tissue.

3. It reduces the risk of contamination and wound infection. Reason: The primary objective of aseptic technique is to prevent microorganisms from being introduced to the surgical wound, therefore reducing the risk of contamination and infection.

A client is receiving a blood transfusion via a Y blood tubing set-up. The client develops chills, flushed face, flank pain and burning sensation along the vein in which blood is being transfused. After stopping the blood transfusion, what should the practical nurse do next? 1. Run normal saline to keep the vein open and notify the team leader. 2. Check vital signs and open the normal saline line to keep the vein open. 3. Keep the vein open with normal saline using a new IV tubing and check

3. Keep the vein open with normal saline using a new IV tubing and check vital signs. Reason: This is the correct sequence of events and correct procedure.

The practical nurse is assessing a wound and changing the dressing. A moderate amount of pinkish clear drainage is present, and there is a bluish area below the would site. In addition to noting that the would is well-approximated and the sutures are intact, what should the practical nurse document? 1. Moderate amount of purulent drainage. Hematoma observed lateral aspect of wound. 2. Moderate amount of purulent drainage. Hematoma observed inferior aspect of wound. 3. Moderate amount of ser

3. Moderate amount of serosanguineous drainage. Hematoma observed inferior aspect of wound. Reason: This documentation accurately describes the wound.

Three days post-bowel resection and colostomy, Ms. Karch reports feeling tired and short of breath. Her HR is 88 and RR 24. On auscultation of the lungs, the practical nurse notices diminished air entry. What should the practical nurse do next? 1. Check arterial blood gases. 2. Notify the physician. 3. Monitor oxygen saturation. 4. Assess the abdominal wound.

3. Monitor oxygen saturation. Reason: Clinical manifestations indicate possible postoperative pulmonary complications and hypoxemia.

The physician has also ordered hydrochlorothiazide 25 mg orally daily. What potential adverse effect should the practical nurse monitor when Mrs. Matko is taking the medication? 1. increases hearing loss. 2. Increased potassium levels. 3. Orthostatic hypotension. 4. osteoporosis.

3. Orthostatic hypotension. Reason: This is a common side effect. The client should rise slowly from laying to sitting to standing.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive? 1. Observe the skin in the wrist area for redness. 2. Check the temperature of the skin in the hands. 3. Place two fingers under the restraint to determine snugness. 4. Remove the restrain and exercise the extremity in 2 hours.

3. Place two fingers under the restraint to determine snugness. Reason: Limb restraint are often prescribed to prevent clients from pulling out tubes and injuring themselves. The restraint is prescribed for 24 hours, and the nurse must verify that the restraint is protecting the client form self-injury but not too constrictive to impair circulation or harm the skin.

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: Temperature 37.9C, pulse 104 beats per minute, respirations 22 breaths per minutes, blood pressure 128/74 mmHg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem? 1. Hypoxia. 2. Atelectasis. 3. Pneumonia. 4. Fluid overlo

3. Pneumonia. Reasons: Pneumonia is a postoperative condition caused by inflammation and infection in the lungs. Frequently it results from shallow breathing that leads to atelectasis.

Mrs. Lewis, 33 years old, on a postoperative unit, presents with tachycardia, tachypnea and an increase in pulmonary secretions. After assessing vital signs, what should the practical nurse do next? 1. Notify the physician. 2. Document the findings in the client's second. 3. Position the client in high-Fowler's position. 4. Recheck vital signs in 15 minutes.

3. Position the client in high-Fowler's position. Reason: Assisting the client to a high-Fowler's position will help improve ventilation and promote effective deep breathing and coughing.

Mrs. Dennis has developed a pressure ulcer on her coccyx. What short-term goal should the practical nurse establish to manage the client's pressure ulcer? 1. Regain bladder function to eliminate incontinence. 2. Adhere to strict caloric intake to facilitate weight loss. 3. Prevent further deterioration of the pressure ulcer. 4. Work with client to increase standing tolerance.

3. Prevent further deterioration of the pressure ulcer. Reason: This is a realistic short-term goal for managing a pressure ulcer.

Jenna is 15 year old and pregnant. She has come to the outpatient clinic wanting to know where she can go for an abortion and how much it will cost. What are the practical nurse's responsibilities? 1. Ensure that Jenna informs her parents and obtains their consent because she is a minor. 2. Teach Jenna the risks associated with abortion and provide information about options for unplanned pregnancy. 3. Provide a list of available clinics that perform abortions and inquire if she is aware of

3. Provide a list of available clinics that perform abortions and inquire if she is aware of other options. Reason: Providing the basic information the client needs to make choices is prudent. Opening the possibility of dialogue regarding other options does not devalue her decision but may enhance her knowledge. Autonomy in decision-making must be respected. This is a judicial intervention.

The practical nurse assists a nursing colleague in positioning Mrs. Saunders, 87 years old, for a Foley catheter insertion. During the procedure, the practical nurse notices the colleague cleansing Mrs. Saunders from the anal to suprapubic area. What should the practical nurse do? 1. Complete the cleansing procedure for the colleague and finish the catheter insertion. 2. Wait unit the procedure is completed and the speak privately with the colleague. 3. Provide guidance to the colleague on

3. Provide guidance to the colleague on proper cleansing technique and monitor the catheter insertion. Reason: The colleague's action is placing the client at risk for infection. Therefore, intervention must be immediate.

Mr. Peterson, 81 years old, has congestive heart failure. The practical nurse enters the room and finds him in an orthopneic position experiencing disorientation, dyspnea and hemoptysis. On auscultation of his chest, the practical nurse hears crackles from the bases up to the scapulae posteriorly. How should the practical nurse respond initially? 1. Leave the room and immediately call the physician. 2. Chart the assessment findings and report to the team leader. 3. Raise the head of the bed

3. Raise the head of the bed to high-Fowler's position and administer oxygen. Reason: This action recognizes the assessment findings as being pulmonary edema and provides immediate intervention to assist the client.

Q11. After attempting a variety of breastfeeding techniques, Mrs. Tang says that she is considering switching to formula feeding. What should the practical nurse do first? 1. Agree with the client's decision to switch to bottle feeding. 2. Reinforce techniques to use for successful breastfeeding. 3. Recommend that the client meet with a lactation consultant. 4. Provide the client with literature on the benefits of breast feeding.

3. Recommend that the client meet with a lactation consultant. Reason: It is the practical nurse's responsibility to support the client in her decision- making and promote her self-confidence. The client may still change her mind at a later time.

Mrs. Henderson's heath rapidly declines, and she is no longer able to speak or swallow without choking. Her husband requests that tube feedings be started. There is an advance directive on her chart that states she does not want heroic measures. What should the practical nurse do? 1. Support the husband's concerns and notify the physician. 2. Explain to her husband that tube feedings will prolong her life. 3. Remind her husband of the directive. 4. Follow the advance directive as indicated

3. Remind her husband of the directive. Reason: This action advocates on behalf of the client's wishes not only on admission but on an ongoing basis.

Based on Ms. Moher's clinical presentation, what should the practical nurse so first? 1. Refer Ms. Moher to a social worker to assist with housing. 2. Inform Ms. Moher that she is not married to the Prime Minister. 3. Request that the physician assess Ms. Moher's throat and begin antibiotic treatment. 4. Discuss the importance with Ms. Moher's of resuming her lithium medication.

3. Request that the physician assess Ms. Moher's throat and begin antibiotic treatment. Reason: While it is important to address the other concerns, Ms. Moher could have strep throat. The antibiotics can be working while the other issues are being addressed.

A Spanish- speaking client arrives at the triage desk in the emergency department and states to the nurse, " No speak English, need interpreter." Which action should the nurse take? 1. Have one of the client's family members interpret. 2. Have the Spanish speaking triage receptionist interpret. 3. Seek an interpreter from the hospital's interpreter services. 4. Obtain a Spanish-English dictionary and attempt to triage the client.

3. Seek an interpreter from the hospital's interpreter services. Reason: The nurse should have a professional hospital based interpreter translate for the client.

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply. 1. Prone 2. Supine 3. Semi-fowler's 4. Dorsal recumbent 5. With the foot of the bed flat 6. With the foot of the bed elevated 30 degrees.

3. Semi-fowler's 5. With the foot of the bed flat Reason: After a craniotomy, the client is at risk for developing complication of increased intracranial pressure and cerebral edema. The head o the bed is elevated 30 degree, and the client's head is maintained in a midline, neutral position to facilitate venous drainage.

Day 1 postoperatively, Mr. Miller reports slight pain in his right shoulder. How should the practical nurse respond? 1. Call the surgeon immediately for orders. 2. Administer an antacid to control heartburn. 3. State that this is a common side effect of laparoscopic surgery. 4. Assure Mr. Miller that the pain is only temporary.

3. State that this is a common side effect of laparoscopic surgery. Reason: This pain results from migration of carbon dioxide used to insufflate the abdominal cavity during the procedure.

While visiting a clinic, Mrs. Martin, 60 years old, tell the practical nurse that her spouse has a bad temper. She leaves the room crying. What should the practical nurse document? 1. Client tells the practical nurse that her husband is abusive. 2. Upset and crying; states "husband has a bad temper." 3. States "spouse has a bad temper"; Began to cry. 4. Expressed fear over husband's bad temper.

3. States "spouse has a bad temper"; Began to cry. Reason: This entry documents the client's exact words and includes objective information.

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this clients right? 1. threatening to place a client in restraints. 2. Performing a surgical procedure without consent. 3. Taking photographs of the clie

3. Taking photographs of the client without consent. Reason: Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault.

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? 1. The pharmacy 2. The laboratory 3. The blood bank 4. The risk-management department.

3. The blood bank Reason: The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented.

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented"insensible fluid loss of approximately 800ml daily." Which client is at risk for this loss? 1. The client with a draining wound. 2. The client with a urinary catheter. 3. The client with a fast respiratory rate. 4. The client with a nasogastric tube to low suction.

3. The client with a fast respiratory rate. Reason: Sensible losses are those that the person is aware of, such as those that occur through wound drainage, gastrointestinal tract losses, and urination.

The nurse is administering a cleansing enema to a client with a feral impaction. Before administering the enema, the nurse asks the client to assumes a left Sims' position. The nurse explains that this positioning is preferred because of which reason? 1. The nurse is right-handed. 2. The rectal sphincter will relax. 3. The enema will flow into the bowel easily. 4. The client is more likely to retain the enema solution.

3. The enema will flow into the bowel easily. Reason: When administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon.

The nurse is assisting with caring for a client with abrupt placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? 1. Monitor the urinary output. 2. Monitor the maternal pulse. 3. Turn the client onto her side. 4. Monitor the maternal blood pressure.

3. Turn the client onto her side. Reason: With a pregnant client who is in shock, the nurse should want to increase perfusion to the placenta to minimize fetal distress. A simple way to do this that requires no equipment is to turn the mother on her side. This increases blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The nurse should immediately contact the registered nurse, who then contacts the health care provider.

Mr. Fletcher, 72 years old, is admitted with a recent diagnosis of chronic obstructive pulmonary disease (COPD) with an acute respiratory infection. To manage the hypoxemia, he is being discharged on home oxygen via nasal cannula at 2L per minute. What teaching should the practical nurse provide for Mr. Fletcher? 1. Apply an oil-based lubricant to the lips and nasal mucosa to keep them moist. 2. Increase the rate of oxygen flow when he is feeling short of breath. 3. Use pursed-lip breathing

3. Use pursed-lip breathing exercises to improve oxygen utilization. Reason: Breathing exercises assist the client in controlling periods of dyspnea and improve respiratory function. Pursed-lip breathing helps to slow expiration, prevents the collapse of small airways and helps the client control the rate and depth of respirations.

Mr. Rogers, 22 years old, weighs 110 kg and is 165 cm tall. He is to receive intramuscular iron dextran (DexIron) daily. Which site would be most appropriate for administering the medication? 1. Deltoid 2. Vastus lateralis. 3. Ventrogluteal. 4. Dorsogluteal.

3. Ventrogluteal. Reason: This muscle is the preferred site for deep intramuscular injections.

Christy, 16 years old, post facial mole removal, is being prepared for discharge. What should the practical nurse anticipate as the client's most likely concern? 1. Pain on activity. 2. Absence from school. 3. Visibility of bandage. 4. Infection

3. Visibility of bandage. Reason: The client may have concern of incisional scarring. Self-concept, body image, personal identity and narcissism are areas of emotional vulnerability for his age group.

The nurse should institute which interventions for a client diagnosed with clostridium difficile? Select all the apply. 1. Wear a mask if within 3 feet of the client. 2. Place a mask on the client when client is outside the room. 3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene. 5. Keep the door of the room shut except when entering or exiting the client's room.

3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene. Reason: Contact precautions are necessary for colonization or infection with a multi drug-resistant organism. This includes enteric infection with C.Diff. Measures used to prevent the spread of C. Diff are wearing gowns and gloves while in the room (not just during care) because the spores are on surfaces in the room. Washing with soap and water for hand hygiene is indicated because alcohol-based sanitizers are ineffective against the spores.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client? 1. Stridor and cyanotic lips. 2. Diminished breath sounds and fever. 3. Wheezes and use of accessory muscles. 4. Pleural friction rub and inspirational chest pain.

3. Wheezes and use of accessory muscles. Reason: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway.

The nurses caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications? 1.A 60-year-old male client with rhinitis. 2. A 24-year-old male client with a lower back injury. 3. a 10-year-old female client with a urinary tract infection. 4. A 45-year-old female client with a history of migraine headaches.

3. a 10-year-old female client with a urinary tract infection. Reason: Children should not be given herbal therapies, especially in the home and without professional supervision.

A licensed practical nurse is precasting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicated the need for further teaching regarding pain management? 1. "I will be sure to ask my client what their pain level is on a scale of 0 to 10." 2. "I know that I should follow-up after giving medication to make sure it is effective." 3."I know that pain in the older client might manifest as sleep disturbance of depression." 4. "I will be sure to

4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." Reason: Pain is a highly individual experience, and the nurse should not assume that the client is exaggerating the pain. The nurse should be frequently assessing the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions.

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? 1. An increased hematocrit level. 2. An increased hemoglobin level. 3. A decline of the temperature to normal. 4. A decrease in oozing from puncture site and gums.

4. A decrease in oozing from puncture site and gums. Reason: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding of the oozing of blood from puncture sites, wounds, and mucous membranes. The client's temperature would decline to normal after the infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body.

The nurse is assigned to assist with caring for a client with esophageal varies who has a Sengstaken Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside? 1. An obturator 2. A Kelly clamp 3. An irrigation set 4. A pair of scissors

4. A pair of scissors Reason: When the client has a Sengstaken-Blakemore tube, a pair of scissors must be ket at the client's bedside at all times. If the gastric balloon of the tube ruptures, the tube will move upward and potentially occlude the client's airway. The client needs to be observed for sudden respiratory distress.

Ms. Hildebrande, 20 years old, has an IV of normal saline infusing through an 18-gauge IV catheter. She is scheduled to receive 2 units of packed cells and her regular dose of antibiotic IV. The blood is available in the laboratory. Which of the following should be done first? 1. Stop the infusion and have the IV site changed. 2. Change the IV solution and tubing. 3. Administer the 2 units of packed cells. 4. Administer the antibiotic.

4. Administer the antibiotic. Reason: To keep the antibiotic on schedule, it should be administered first.

A licensed practical nurse attend a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? 1. Anthrax is treated with antibiotic medications. 2. The most lethal form of anthrax is contracted by inhalation of the spores. 3. Anthrax can be transmitted by consumption of meat from an infected animal. 4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis. Reason: Anthrax is caused by Bacillus anthraces, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. Antibiotics are administered. Botulism is caused by a neurotoxin that causes severe paralysis and can be fatal.

Mr. Nguyen, 82 years old, speaks only Vietnamese and is cognitively impaired. His son reports that his father fell last week. When bathing the client, the practical nurse observes several injuries in different stages of healing. What should the practical nurse do? 1. Report finding to the son. 2. Notify the social worker. 3. Request an order to X-ray the affected areas. 4. Arrange a care conference with the inter professional team.

4. Arrange a care conference with the inter professional team. Reason: Reporting the findings to the team will ensure that the right authorities are aware of the situation.

Bruno is an 18-year-old international exchange student. He has been waiting in the outpatient clinic for assessment of painful urination. He seems very uncomfortable in the presence of a female nurse. What is the best approach for the practical nurse to take? 1. Offer to find Bruno a male nurse. 2. Quickly perform the physical exam. 3. Defer the physical exam for the physician. 4. Ask Bruno if he has any concerns about being assessed.

4. Ask Bruno if he has any concerns about being assessed. Reason: By exploring the client's concerns, values and goals, the practical nurse will be able to develop mutually acceptable solutions and to negotiate care. This allows the client to act autonomously and provide freedom to act upon his choice.

During the initial interview, Pam is very frustrated and angry. How should the practical nurse best respond to Pam's behaviour. 1. Suggest that Pam tour the facility while the practical nurse talks to her mother. 2. Listen to Pam's concerns and report her behaviour to the supervisor. 3. Explain to Pam that her behaviour is further upsetting her mother. 4. Ask Pam what suggestions she has to help plan her mother's care.

4. Ask Pam what suggestions she has to help plan her mother's care. Reason: This gives Pam a chance to aid in her mother's care. Involving Pam in planning the care may alleviate her guilt somewhat.

Q 17. The practical nurse is explaining the goals of diabetes management and prevention of complications. What should the practical nurse do first in order to develop an individualized plan of care for Mr. Sutherland? 1. Provide knowledge related to the disease process. 2. Teach about disease processes and therapeutic management. 3. Reassure him that he will be able to manage his own care. 4. Assess health literacy to ascertain his understanding.

4. Assess health literacy to ascertain his understanding. Reason: Individuals with marginal health literacy may have difficulty to read and interpret directions.

Mr. Sutherland's nursing diagnosis is powerlessness related to perceived lack of personal control over his health. How can the practical nurse involve him in developing and prioritizing his plane of care to promote his self-care and wellness? 1. Provide written material describing strategies other people with diabetes have used successfully. 2. Create a plan of care to help manage the client's diabetes. 3. Develop an information booklet on signs of hyperglycaemia to which the client may ind

4. Assist the client to specify his health goals and then prioritize those goals with regard to his immediate concerns. Reason: It is important to establish goals that are valuable and realistic to the client. Accomplishing personal goals will enhance self-efficacy.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply. 1. Uterine rigidity. 2. Uterine tenderness. 3. Severe abdominal. 4. Bright red vaginal bleeding. 5. Soft, relaxed, contender uterus.

4. Bright red vaginal bleeding. 5. Soft, relaxed, contender uterus. Reason: Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft and relaxed contender uterus. In the clients with abrupt placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, with abrupt placentae, the abdomen will fell hard and board-like during palpation as the blood penetrates the myometrium and causes uterine irritability.

Mrs. Jones, a 65-year-old- home care client, requires a dressing change for her abdominal incision. What is the most appropriate action for the practical nurse to take? 1. Apply sterile gloves before removing the old dressing. 2. Cleanse the surrounding skin and then the incision. 3. Swab the incision for culture and sensitivity. 4. Cleanse the incision proximal to distal.

4. Cleanse the incision proximal to distal. Reason: This is the most appropriate action for the practical nurse to take. The incision should be cleansed in a direction from the least contaminated (top) to most contaminated (bottom).

A client had a prescription to receive 1000ml of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1. Uncaps the distal end of the tubing 2. Uncaps the spike portion of the tubing 3. Opens the roller clamp on the IV tubing 4. Closes the roller clamp on the IV tubing

4. Closes the roller clamp on the IV tubing Reason: The nurse should first clamp the tubing to prevent the solution from running freely through the tubing after it is attached to the IV bag. The nurse should next uncap the proximal(spike) portion of the tubing and attach it to the IV bag. The IV bag is elevated, and the roller clamp is then opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing.

Mr. O'Leary, 81 years old, resides in an assisted-living facility. He requires partial assistance with his personal care. A colleague is providing him with total care and states that it is quicker if staff members provide all the care. What is the practical nurse's best course of action? 1. Advise the colleague that this method of care is inappropriate. 2. Collaborate with the client to institute a plan that is satisfactory. 3. Advise the client that it will be better if the staff members p

4. Collaborate with the client and staff to develop a plan that meets his care needs. Reason: Due to the increased workload for care staff, a mutually agreed-upon solution meets both the client's and staff's need. Involving the client in the planning, timing and types of interventions enhances the client's self-esteem and willingness to assume more independence.

What observation would the practical nurse document to support a nursing diagnosis of risk for depression? 1. Right-sided weakness, anorexia and daily dressing changes. 2. Type 1 diabetes, right-sided weakness and isolation precautions. 3. 74 years of age, impaired mobility and glucometer testing. 4. Decreased appetite, impaired would healing and isolation precautions.

4. Decreased appetite, impaired would healing and isolation precautions. This is a complete list of objective factors that contribute to the nursing diagnosis of risk for depression.

Q5. What manifestation associated with liver failure should the practical nurse report first? 1. Yellowing of sclerae. 2. Decreased appetite. 3. Increased respirations. 4. Decreased consciousness.

4. Decreased consciousness. Reason: Hepatic encephalopathy is a central nervous system manifestation that often leads to coma and death.

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based in this data, which action is most appropriate for the nurse to take initially? 1. Listen to the client's heart sounds. 2. Determine whether the client has a pulse deficit. 3. Instruct the client to use an incentive spirometer. 4. Determine the client's ability to follow verbal commands.

4. Determine the client's ability to follow verbal commands. Reason: Cheynes-Stokes respirations, rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory centre of the pons in the central nervous system such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia.

Mr. Miller's wife tells the practical nurse that, although the surgeon explained the procedure, her husband is still apprehensive about the laparoscopic cholecystectomy surgery. What should the practical nurse do? 1. Inform Mrs. Miller that clients tend to have positive outcome from this surgery. 2. Arrange for the surgeon to meet with Mr. Miller again to discuss his concerns. 3. Explain the surgery and postoperative procedure to Mr. Miller again. 4. Determine why Mr. Miller is apprehensi

4. Determine why Mr. Miller is apprehensive about the surgery. Reason: This provides an opportunity to reinforce information given by the surgeon.

Mrs. Dennis informs the practical nurse that she is not satisfied with the lunch provided and states, "I told the dietitian that I do not have enough to eat." What should the practical nurse so? 1. Reassure Mrs. Dennis that her caloric intake was sufficiently calculated by the dietitian. 2. Explain to Mrs. Dennis that she must follow the nutritional plan developed by the dietitian. 3. Inform the dietitian that Mrs. Dennis is not satisfied with her lunch. 4. Discuss the goal of wellness in

4. Discuss the goal of wellness in order to assist Mrs. Dennis in evaluating her dietary choices. Reason: This option reinforces the partnership between health-care professionals and the client with the common goal of well-being for the client.

Mrs. Turcotte, 74 years old, had a left total hip replacement. The practical nurse notices that Mrs. Turcotte in unsteady when using her walker. What should the practical nurse do? 1. Request further instructions from the orthopedic surgeon. 2. Suggest that the client use a quad cane rather than a walker. 3. Talk to a nurse manager for assistance in developing a plan. 4. Discuss these observation's with the physiotherapist.

4. Discuss these observation's with the physiotherapist. Reason: Physiotherapists are specialists in this area of client care.

What manifestations would indicate that Ms. Moher is in the manic phase? 1. Distractibility, disruptive and fever. 2. IV drug use, elated presentation and distractibility. 3. Medication non-compliance, disruptive behaviour and distractibility. 4. Distractibility, elated presentation and delusion of grandeur.

4. Distractibility, elated presentation and delusion of grandeur. Reason: These are all signs of mania.

Mr. Wildredez, 50 years old, is scheduled for a total hip replacement. Mr. Wildredez tells the practical nurse that he is proud of his 5-year sobriety from both alcohol and opiates and he does not want to receive any pain postoperatively. He has not discussed this with his surgeon or anesthetist. What should the practical nurse do? 1. Arrange for an addictions counsellor to visit his after the surgery to discuss his concerns. 2. Encourage the client to ask for narcotic analgesics and deal wit

4. Document and inform the surgeon and anesthetist of his new information prior to surgery. Reason: The physician must be made aware of new information in relation to client's present health status. The anesthetist would need to know this information to determine the best anesthetic.

A client brought to the emergency department states that he has accidentally been taking two time his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action? 1. Administering an antidote. 2. Drawing a sample for type and crossmatch and transfuse the client. 3. Drawing a sample for an activates partial thromboplastin time (aPTT) level. 4. Drawing a sample for prothrombin t

4. Drawing a sample for prothrombin time (PT) and international normalized ration (INR) Reason: The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. This result will provide information as to how to best treat this client.

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? 1. Soft Custard. 2. Orange juice. 3. Clam chowder. 4. Fat-free beef broth.

4. Fat-free beef broth. Reason: A clear liquid diet consists of foods that are relatively transparent. Soft custard and orange juice would be included in a full liquid diet because they are opaque, not clear.

The practical nurse is caring for a 64-year-old make client who is 3 days postoperative from a partial gastrectomy. Assessment data reveal the following: respiratory rate 16 breaths per minute and shallow, oxygen saturation 93% on room air, abdominal guarding and pain rated as 1 on a scale of 0 to 10. What is the practical nurse's next action? 1. Ambulate the client as per the plan of care. 2. Confirm the client's need for oxygenation. 3. Initiate a referral for physiotherapy. 4. Further exp

4. Further explore the client's pain score. Reason: Based on the data, the client's self-reported pain assessment and actions are inconsistent. Further investigation of the client's pain is necessary.

After performing hand hygiene, what actions should the practical nurse take in preparing to change the client's dressing when the client in on contact isolation precautions? 1. Apply mask, gown and non-sterile gloves and prepare equipment. 2. Apply gown, mask and sterile gloves and prepare equipment. 3. Gather supplies and apply gown and sterile gloves. 4. Gather supplies and apply gown and non-sterile gloves.

4. Gather supplies and apply gown and non-sterile gloves. Reason: This sequence is correct for donning personal protective equipment and gathering supplies prior to entering an isolation room.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which signs/symptoms would be an indication of this electrolyte imbalance? 1. Twitching. 2. Positive Trousseau's sign. 3. Hyperactive bowel sounds. 4. Generalized muscle weakness.

4. Generalized muscle weakness. Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, hyperactive bowel sounds are signs of hypocalcemia.

A client is having problems with blood clotting. Which food items should the nurse encourage the client to eat? 1. Legume. 2. Citrus fruits. 3. Vegetable oils. 4. Green, leafy vegetables.

4. Green, leafy vegetables. Reason: Green, leafy vegetables are high in vitamin K, which acts as a catalyst for facilitating blood-clotting factors. Legumes are high in folic acid and thiamine. Citrus fruits are high in vitamin C, which helps with wound healing. Vegetable oil is his in vitamin E, which acts as an antioxidant.

Which of the following would indicate that Tom, a 17 year old with genital herpes, requires health teaching? 1. He can tell when the infection in going to start again. 2. He knows that even if he cannot see the sores, the condition is still there. 3. He indicates that he must wash his hands after urinating. 4. Her verbalizes that he does not need to wear a condom in the absence of sore.

4. Her verbalizes that he does not need to wear a condom in the absence of sore. Reason: Herpes can still be active during the absence of sores and thus transmitted to others.

Mr. Jordon, 95 years old, resides in a long-term care facility and has indicated that he wishes to be resuscitated with full life-saving measures. Mr. Jordon's condition begins to deteriorate and he is in need of cardiopulmonary resuscitation. The nurse-in-charge tells the practical nurse to delay cardiopulmonary resuscitation. What should the practical nurse do when Mr. Jordan experiences an arrest? 1. Delay initiation of cardiopulmonary resuscitation. 2. Notify family of client's deteriorat

4. Immediately implement cardiopulmonary resuscitation. Reason: The treatment plan is a full code and needs to be implemented stat.

Christine says that she has cared for children before and can look after her newborn. How should the practical nurse best identify her learning needs? 1. Ask Christine to write out a list of questions to identify her needs regarding care for her newborn. 2. Wait for Christine's friends to leave and then ask her what her priorities are in regard to postpartum. 3. Ask Christine's friends to leave and then give her some pamphlets and videos. 4. Incorporate teaching in small segments while ob

4. Incorporate teaching in small segments while observing Christine handle and interact with her newborn. Reason: The amount of postpartum teaching that is required is overwhelming to many new mothers. Breaking it into smaller segments makes it easier to retain.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long term use? 1. Gurgling respirations. 2. Increased blood pressure. 3. Decreased hematocrit level. 4. Increased specific gravity of the urine.

4. Increased specific gravity of the urine. Reason: Clients taking diuretics on a long term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine.

The practical nurse finds Mr. Shoenthal, 85 years old, lying on the floor. He is conscious. What should the practical nurse do first? 1. Call for help to get the client and use a mechanical lift to get him up. 2. Bring a stretcher to the client and use a mechanical lift to get him up. 3. Assist the client onto a chair and immediately check his vital signs. 4. Keep the client immobile until a full assessment is completed.

4. Keep the client immobile until a full assessment is completed. Reason: The client should be assessed prior to moving him.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin(aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed? 1. Discontinuing the heparin infusion. 2. Increasing the rate of the heparin infusion. 3. Decreasing the rate of the heparin infusion. 4. Leaving the rate of the heparin infusion as is.

4. Leaving the rate of the heparin infusion as is. Reason: The normal aPTT varies between 28 seconds and 35 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal.

Mr. Browning, 60 years old, has gastroenteritis. Which action is most appropriate for the practical nurse to take when updating Mr. Browning's intake and output record? 1. Recording the number of times Mr. Browning voids. 2. Estimating Mr. Browning's water loss due to perspiration. 3. Weighing Mr. Browning to determine fluid loss. 4. Measuring Mr. Browning's urinary output and liquid stool.

4. Measuring Mr. Browning's urinary output and liquid stool. Reason: Urinary output and liquid stool should be included in the recording of intake and output for a client with gastroenteritis; this will help monitor for dehydration.

The practical nurse observes two colleagues arguing about client assignments. What should the practical nurse do? 1. Direct them to draw up a schedule that has an equal number of clients. 2. Let them resolve the situation and bring a new schedule to the next team meeting. 3. Meet with them individually so their personal issues can be addressed. 4. Mediate a session with both of them to discuss alternative scheduling.

4. Mediate a session with both of them to discuss alternative scheduling. Reason: This is a people-centred approach. Health workers are given control and participate in the decision making. Basic principle for conflict management include demonstrating respect for all parties, avoiding blaming, allowing discussion and exploring alternative solutions.

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches. Reason: Photography is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value? 1. ST elevation. 2. Peaked P waves. 3. Prominent U waves. 4. Narrow, peaked T waves.

4. Narrow, peaked T waves. Reason: A serum potassium level of 5.4 mEw/L is indicative of hyperkalemia. Cardia changes include a wide, flat P wave, a prolonged PR interval, a widened QRS complex, and narrow peaked T waves.

A 66-year-old male is soon to be discharged from a psychiatric facility and has made several statements about killing his girlfriend. What should the practical nurse do? 1. Advise his girlfriend that she should not visit the client. 2. Protect the client's rights by maintaining confidentiality. 3. Inform the girlfriend of the client's threatening statements. 4. Notify the physician so that appropriate action can be taken.

4. Notify the physician so that appropriate action can be taken. Reason: When a client presents a serious danger of violence, it is the practical nurse's duty to report this to the physician or psychiatrist first.

Mrs. Nicholson asks the practical nurse to assist in arranging a religious ceremony for her in the nursing home. What should the practical nurse do to support Mrs. Nicholson? 1. Suggest that she call her religious leader to arrange the religious ceremony. 2. Call her daughter and inform her of her mother's request. 3. Inform her that the religious ceremony should be performed in a place of worship. 4. Offer to assist her in contacting someone to make the arrangements.

4. Offer to assist her in contacting someone to make the arrangements. Reason: This meets and respects Mrs. Nicholson's religious needs and empowers her.

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus. Which method should be used to monitor the client for crepitus? 1. Auscultating the posterior breath sounds. 2. Asking the client about pain upon inspiration. 3. Placing the hands over the rib area and observing expansion. 4. Palpating the skin around the chest and neck for a crackling sensation.

4. Palpating the skin around the chest and neck for a crackling sensation. Reason: Air caught under the skin in the subcutaneous tissues is known as crepitus of subcutaneous emphysema. It presents as a "Puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. It can be monitored by palpating, and it feels like bubble wrap when palpated.

Ms. Karch reports that her abdominal pain in increasing. Her vital signs are T 39.8C, HR 110, RR 24 and BP 100/60. Her lung fields are clear on auscultation. What should the practical nurse do next. 1. Obtain blood for a complete blood count and cultures. 2. Notify the physician of the assessment finding. 3. Administer acetaminophen (Tylenol) as prescribed for the pain and fever. 4. Perform an abdominal assessment and pain scale.

4. Perform an abdominal assessment and pain scale. Reason: The client shows signs of peritonitis and sepsis, a common complication of diverticulitis. Further assessment of her abdominal status is needed.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000mm. the nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client's medical record.

4. Place the normal report in the client's medical record. Reason: A normal platelet count ranges from 150,000mm to 400,000mm. The nurse should placate report contains the normal laboratory value in the client's medical record.

The nurse is caring for a client with leukaemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to notes in this client if hyponatremia is present? 1. Intense thirst. 2. Slow bounding pulse. 3. Dry mucous membranes. 4. Postural blood pressure changes.

4. Postural blood pressure changes. Reason: Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia.

A client with diabetes mellitus has a glucosylated hemoglobin A1C level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client bout the need for which measure? 1. Avoiding infection. 2. Talking in adequate fluids. 3. Preventing and recognizing hypoglycaemia. 4. Preventing and recognizing hyperglycaemia.

4. Preventing and recognizing hyperglycaemia. Reason: The normal reference range for glycosylated hemoglobin A1C is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose.

Mr. Kasius, 21 years old, is diagnosed with genital herpes. The practical nurse learns that a friend is contemplating beginning a sexual relationship with Mr. Kasius. What should the practical nurse do? 1. Maintain client confidentiality and avoid saying anything. 2. Tell the friend that she should consult with Mr. Kasius' physician first. 3. Tell the friend that Mr. Kasius has genital herpes. 4. Provide Mr. Kasius with information related to sexual health.

4. Provide Mr. Kasius with information related to sexual health. Reason: The practical nurse should provide health education to the client in order to facilitate his understanding of the risks associated with genital herpes.

Mrs. Green, 43 years old, has a new colostomy. She will not look at the colostomy site and refuses to participate in self-care. How can the practical nurse best assist Mrs. green? 1. Refer the client to the wound and stony support team. 2. Designate a family member to assume care of colostomy. 3. Encourage the family to convince the client to look at her colostomy. 4. Provide the client an opportunity to discuss her feelings about the colostomy.

4. Provide the client an opportunity to discuss her feelings about the colostomy. Reason: The client needs to express her perception of this significant change in her body appearance.

The practical nurse is preparing Carrie, a 17-year-old postpartum client, and her newborn for discharge home. Although Carrie denies abuse by her partner, she admits that he "Get jealous easily" and has hit her "once or twice". What is the practical nurse's priority action? 1. Encourage Carrie to call the hospital social worker. 2. Tell Carrie that abuse is a reportable offence. 3. Notify the police of the possible abuse. 4. Reassure Carrie that she is not alone in experiencing domestic vi

4. Reassure Carrie that she is not alone in experiencing domestic violence. Reason: Women often believe that they are alone in experiencing domestic violence and are reluctant to discuss it. Reassuring Carrie will demonstrate acceptance and a willingness to assist her.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing funeral arrangements.

4. Remain with the family member without discussing funeral arrangements. Reason: The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member.

Mr. Wise, 63 years old, has been admitted with a diagnosis of myocardial infarction (MI). Two hours after admission, he asks the practical nurse if he can go outside to smoke. What should the practical nurse do? 1. Obtain a nicotine patch for the client. 2. Educate the client about the risk factors of smoking with a heart condition. 3. Advise the client of the hospital's no smoking policy. 4. Remind the client that the physician's ordered in bedrest.

4. Remind the client that the physician's ordered in bedrest. Reason: Initially, he will be on bedrest with a gradual increase in exercise according to client's tolerance.

Mr. Carrington, 78 years old, lives in a long-term care facility. He has a T of 38C taken orally. What should the practical nurse do? 1. Call the physician and obtain an order for acetaminophen(Tylenol). 2. Call the client's family to inform them that he is not feeling well. 3. Check the client's chart for his wishes concerning transfer to acute care. 4. Remove excess blankets and place a cool cloth on the client's forehead.

4. Remove excess blankets and place a cool cloth on the client's forehead. Reason: Smoking, mouth breathing, oral intake and outside factors can influence temperature readings. The elderly population can have impaired thermoregulation.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor.

4. Report the information to a nursing supervisor. Reason: Nurse practice acts require reporting the suspicion of impaired nurses. Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This needs to be reported to the nursing supervisor, who will then report to the board of nursing.

The nurse arrives at work and is told to report (float) to the paediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? 1. Call the hospital lawyer. 2. Call the nursing supervisor. 3. Refuse to float to the paediatric unit. 4. Report to the pediatric unit and identify task that can be safely performed.

4. Report to the pediatric unit and identify task that can be safely performed. Reason: Floating in an acceptable legal practice used by hospitals to solve staffing shortages. Legally the nurse can not refuse to float unless a union contract guarantees that the nurse can only work in a specified area or the nurse can prove a lack of knowledge in that department.

Q13. Mrs. Burke states that she has has some episodes of diarrhea as well as constipation. What action should the practical nurse take first? 1. Prepare to perform a digital rectal exam. 2. Consult the dietitian to increase Mrs. Burke's fibre intake and add prune juice to her diet. 3. Place an incontinence product on Mrs. Burke. 4. Review with Mrs. Burke her bowel elimination pattern and ask for her last documented bowel movement.

4. Review with Mrs. Burke her bowel elimination pattern and ask for her last documented bowel movement. Reason: This is the most appropriate action because it is necessary to complete an assessment in order to determine her current bowel function.

Mrs. Turjanica, 42 years old, recently had a mastectomy. She is relieved that all the cancer was removed, but is at times depressed over her loss. Which conclusion should the practical nurse make about Mrs. Turjanica's emotional state? 1. She is displaying signs of maladaptation. 2. She needs to be left alone to come to terms with her surgery. 3. She is not coping well and needs more time to adjust. 4. She is adjusting as would be expected.

4. She is adjusting as would be expected. Reason: It is normal for the client to experience mixed feelings about the outcome of a mastectomy. Her responses are consistent with those expected following a loss.

The nurse has been instructed to remove an intravenous(IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? 1. Band-aid 2. Alcohol swab 3. Betadine swab 4. Sterile 2x2 gauze

4. Sterile 2x2 gauze Reason: A dry, sterile dressing such as sterile 2x2 gauze is used to apply pressure to the site while the catheter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A band-aid may be used to cover the site after hemostasis has occurred. An alcohol swab or butadiene would irritate the opened puncture site and would not stop the blood flow.

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position? 1. High fowler's position. 2. supine with no head elevation. 3. Left lateral (Side-lying) Position. 4. Supine with head elevation no greater than 30 degrees.

4. Supine with head elevation no greater than 30 degrees. Reason: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period to prevent arterial occlusion or bleeding and hematoma.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows.

4. Supine, with the residual limb supported with pillows. Reason: The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture.

The nurse is preparing to assist the health care provider to test the extra ocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done? 1. Testing using the Ishihara chart. 2. Testing using a Snellen eye chart. 3. Testing the corneal light reflexes. 4. Testing the six cardinal positions of gaze.

4. Testing the six cardinal positions of gaze. Reason: Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze.

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100F orally. The nurse reports the findings to the registered nurse(RN) and anticipates that which action will take place? 1. The transfusion will begin as prescribed. 2. The transfusion will begin after the administration of an antihistamine. 3. The transfusion will begin after the administration of 650mg of acetaminophen. 4. The blood will be held, and the primary health care provider(PHCP) will be

4. The blood will be held, and the primary health care provider(PHCP) will be notified. Reason: If the client has a temperature of 100F or more, the unit of blood should be held unit the primary health care provider is notified and has the opportunity to give further prescriptions. Th other options are incorrect actions.

The nurse is reviewing the health records of assigned clients the nurse should plan care knowing that which client is at risk for a potassium deficit? 1. The client with Addison's disease. 2. The client with metabolic acidosis. 3. The client with intestinal obstruction. 4. The client receiving nasogastric suction.

4. The client receiving nasogastric suction. Reason: Potassium-rich gastrointestinal fluids are lost through GI suction, which places the client at risk for hypokalemia.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least risk for the development of third-spacing? 1. The client with sepsis. 2. The client with cirrhosis. 3. The client with kidney failure. 4. The client with diabetes mellitus.

4. The client with diabetes mellitus. Reason: Fluid that shifts into the interstitial space and remains there is referred to as third space fluid. Common sites of third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac.

The nurse reviews electrolyte values and notes a sodium level of 130 mEg/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition? 1. The client with watery diarrhea. 2. The client with diabetes insidious. 3. The client with an inadequate daily water intake. 4. The client with the syndrome of inappropriate secretion of antidiuretic hormone.

4. The client with the syndrome of inappropriate secretion of antidiuretic hormone. Reason: Hyponatremia is a serum sodium level less than 135 mEq/L (135 mmol/L). Hyponatremia can occur secondary to syndrome of inappropriate secretion of antidiuretic hormone. The client with an inadequate daily water intake, watery diarrhea, or diabetes insidious is at risk for hypernatremia.

A Hispanic American mother brings her child to the clinic for an examination. Which is most important when garthering data about the child? 1. Avoiding eye contact. 2. Using body language only. 3. Avoiding speaking to the child. 4. Touching the child during the examination.

4. Touching the child during the examination. Reason: In the Hispanic American culture, eye behaviour is significant. it is believed that the "Bad/evil eye" can be given to a child if a person looks at and admires a child without touching the child.

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the practical correctly interpret these findings? 1. Bacteremia 2. Fluid overload. 3. Hypovolemic shock. 4. Transfusion reaction.

4. Transfusion reaction. Reason: The signs and symptoms exhibit by the client are consistent with a transfusion reaction. With bacteria, the client would have a fever, which is not part of the clinical picture presented. With fluid overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask the friend who accompanied the client to ask the emergency

4. Transport the client to the operation department immediately without obtaining an informed consent. Reason: Generally there are only two instances in which the informed consent of an adult client is not needed. When an emergency is present and delaying treatment or when the client waives the right to give informed consent.

Mr. Lewis, 21 years old, returns to the emergency Department 24 hours following a cast application for a close reduction of a fractured right radius. Which manifestation would be the priority concern? 1. Itchiness under the cast. 2. Heaviness in right shoulder. 3. Warmth of fingers. 4. Unrelieved pain in lower arm.

4. Unrelieved pain in lower arm. Reason: An increase in pain is most problematic and indicative of onset of compartment syndrome.

The physician has left orders for Mrs. Morrow to receive 2 units of packed cells. Each unit is to be administered over a 5-hour period. What should the practical nurse do when processing this order? 1. Flag the order to be given immediately. 2. Notify the nurse-in-charge. 3. Process the order as written. 4. Verify the time frame.

4. Verify the time frame. Reason: The time frame needs to be clarified because the blood is to be administered within 4 hours. Do not let the unit of blood hang for more than 4 hours due to the risk of bacterial growth.

What is blood pressure?

Blood pressure is the force of the blood pushing against the sides of the vessel wall.

Hydrogen and the body.

Hydrogen determines the pH of the body, which must be maintained in a narrow range.

What is malignant pain?

Malignant pain is changes in the pathological process created by tumour cells. The pain is induced by tissue necrosis or stretching of an organ by the growing tumour.

Examples of neuropathic pain?

Nerve trama-spinal cord injury. Infectious diseases- Herpes or HIV. Medications- Chemotherapy, antiretroviral therapy.

How is nociceptive pain caused?

Nociceptive pain is caused by tissue injury. Usually localized. Can be described as aching or throbbing.

Where are nociceptors located?

Nociceptors are located in the skin, connective tissue, muscles, and thoracic, abdominal, and pelvic viscera.

What causes referred pain?

Referred pain originates in one location but is felt at another site. Both sites share the same spinal nerve and the brain can have a hard time differentiating the point of origin.

How is somatic pain caused?

Somatic pain can be superficial, derived from skin surface and subcutaneous tissues, or deep derived from joints, tendons, muscles, or bone.

What is systole pressure?

Systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole.

How is visceral pain caused?

Visceral pain originates from the larger interior organs. The pain can stem from direct injury to the organ or from stretching the organ as a result of tumour, ischemia, distention, or serve contraction.