Final Questions (ch)

A patient is prescribed meloxicam for rheumatoid arthritis. This drug has a long half-life of 51 hours. Which prescription would the nurse be sure to clarify with the health care provider before giving the medication? 1. Meloxicam 7.5 to 15 mg/day 2. Meloxicam 15 mg/day before breakfast 3. Meloxicam 7.5 mg every 4 hours as needed for pain 4. Meloxicam 7.5 mg/day as needed

3. Meloxicam 7.5 mg every 4 hours as needed for pain

Which finding by the clinic nurse about a client who has been taking adalimumab to treat psoriasis is most indicative of a need for a change in therapy? 1. Temperature 100.9°F (38.3°C) 2. Patches of scaly skin on chest 3. Erythema on sun-exposed areas of skin 4. Client report of worsening depression

1. Temperature 100.9°F (38.3°C)

The charge nurse in the labor and delivery unit needs to assign two patients to one of the RNs because of a staffing shortage. Normally the unit has nursepatient ratio of 1:1. Which two patients should the charge nurse assign to the RN? 1. A 30-year-old gravida 1, para 0 (G1P0) woman, 40 weeks, 2 cm/90% effaced/-1 station 2. A 25-year-old G3P2 woman, 38 weeks, 8 cm/100% effaced/0 station 3. A 26-year-old G1P1 woman who delivered via normal vaginal delivery 15 minutes ago 4. A 17-year-old G1P0 woman with premature rupture of membranes, no labor at 35 weeks 5. A 40-year-old G6P5 woman with contractions at 28 weeks who has not yet been evaluated by the health care provider

1. A 30-year-old gravida 1, para 0 (G1P0) woman, 40 weeks, 2 cm/90% effaced/-1 station 4. A 17-year-old G1P0 woman with premature rupture of membranes, no labor at 35 weeks

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions, with 1 being the most critical and 4 being the least. 1. A patient who is taking trifluoperazine and has a temperature of 103.6°F (39.8°C) with tachycardia, muscular rigidity, and dysphagia 2. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity 3. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions 4. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; white blood cell count is 2000/mm3 (2.0 × 10 9 /L)

1. A patient who is taking trifluoperazine and has a temperature of 103.6°F (39.8°C) with tachycardia, muscular rigidity, and dysphagia 4. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; white blood cell count is 2000/mm3 (2.0 × 10 9 /L) 3. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions 2. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity

Which actions should the nurse assign to the experienced LPN/LVN for the care of a patient with hypothyroidism? Select all that apply. 1. Assessing and recording the rate and depth of respirations 2. Auscultating lung sounds every 4 hours 3. Creating an individualized nursing care plan for the patient 4. Administering sedation medications every 6 hours 5. Checking blood pressure, heart rate, and respirations every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort

1. Assessing and recording the rate and depth of respirations 2. Auscultating lung sounds every 4 hours 5. Checking blood pressure, heart rate, and respirations every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort

A male patient must undergo intermittent catheterization. The nurse is preparing to insert a catheter to assess the patient for postvoid residual. Place the steps for intermittent catheterization in the correct order. 1. Assist the patient to the bathroom and ask the patient to attempt to void. 2. Retract the foreskin and hold the penis at a 60- to 90-degree angle. 3. Open the catheterization kit and put on sterile gloves. 4. Lubricate the catheter and insert it through the meatus of the penis. 5. Position the patient supine in bed or with the head slightly elevated. 6. Drain all the urine present in the bladder into a container. 7. Cleanse the glans penis starting at the meatus and working outward. 8. Remove the catheter, clean the penis, and measure the amount of urine returned.

1. Assist the patient to the bathroom and ask the patient to attempt to void. 5. Position the patient supine in bed or with the head slightly elevated. 3. Open the catheterization kit and put on sterile gloves. 2. Retract the foreskin and hold the penis at a 60- to 90-degree angle. 7. Cleanse the glans penis starting at the meatus and working outward. 4. Lubricate the catheter and insert it through the meatus of the penis. 6. Drain all the urine present in the bladder into a container. 8. Remove the catheter, clean the penis, and measure the amount of urine returned.

The nurse has received orders to initiate phototherapy on a 36-hour-old newborn with an elevated bilirubin level. What instructions should the nurse give the student nurse who is assisting in the care of the infant? Select all that apply. 1. Cover the infant's eyes with a mask. 2. Monitor the infant's temperature closely. 3. Keep the infant NPO during the treatment. 4. Apply ointment to the infant's skin before light exposure. 5. Offer the infant sterile water feedings during the treatment

1. Cover the infant's eyes with a mask. 2. Monitor the infant's temperature closely.

A 24-year-old gravida 1, para 0 patient, who is receiving oxytocin, is in labor at 41 weeks gestation. Which are appropriate nursing actions in the presence of late fetal heart rate decelerations? Select all that apply. 1. Discontinue the oxytocin. 2. Decrease the maintenance IV fluid rate. 3. Administer oxygen to the mother by mask. 4. Place the woman in high Fowler position. 5. Notify the health care provider.

1. Discontinue the oxytocin. 3. Administer oxygen to the mother by mask 5. Notify the health care provider.

The RN supervising a senior nursing student is discussing methods for preventing acute kidney injury (AKI). Which points would the RN be sure to include in this discussion? Select all that apply. 1. Encourage patients to avoid dehydration by drinking adequate fluids. 2. Instruct patients to drink extra fluids during periods of strenuous exercise. 3. Immediately report a urine output of less than 2 mL/kg/hr. 4. Record intake and output and weigh patients daily. 5. Question any prescriptions for potentially nephrotoxic drugs. 6. Monitor laboratory values that reflect kidney function

1. Encourage patients to avoid dehydration by drinking adequate fluids. 2. Instruct patients to drink extra fluids during periods of strenuous exercise. 4. Record intake and output and weigh patients daily. 6. Monitor laboratory values that reflect kidney function

Which personal protective equipment will the nurse need when planning a dressing change for a client with a methicillin-resistant Staphylococcus aureus-infected skin wound? Select all that apply. 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. Booties

1. Gown 2. Gloves

Which information will the nurse include when teaching a group of 20-yearold women about emergency contraception with levonorgestrel (the morning-after pill)? Select all that apply. 1. Heavier menstrual bleeding is a common side effect of this medication regimen. 2. Emergency contraception requires a prescription from a licensed health care provider. 3. Even if pregnancy occurs after using emergency contraception, risk for complications is low. 4. Because nausea and vomiting may occur, an antiemetic may be used before levonorgestrel. 5. The medication must be taken within the first 24 hours after unprotected intercourse to be effective.

1. Heavier menstrual bleeding is a common side effect of this medication regimen. 3. Even if pregnancy occurs after using emergency contraception, risk for complications is low 4. Because nausea and vomiting may occur, an antiemetic may be used before levonorgestrel.

The nurse is caring for an 81-year-old adult with type 2 diabetes, hypertension, and peripheral vascular disease. Which admission assessment findings increase the patient's risk for development of hyperglycemic-hyperosmolar syndrome (HHS)? Select all that apply. 1. Hydrochlorothiazide (HCTZ) prescribed to control her blood pressure 2. Weight gain of 6 lb (2.7 kg) over the past month 3. Avoids consuming liquids in the evening 4. Blood pressure of 168/94 mm Hg 5. Urine output of 50 to 75 mL/hr 6. Glucose greater than 600 mg/dL (33.3 mmol/L)

1. Hydrochlorothiazide (HCTZ) prescribed to control her blood pressure 3. Avoids consuming liquids in the evening 6. Glucose greater than 600 mg/dL (33.3 mmol/L)

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which patient care actions should the nurse delegate to the experienced unlicensed assistive personnel? Select all that apply. 1. Monitor and record strict intake and output. 2. Provide the patient with ice chips when requested. 3. Remind the patient about his or her fluid restriction. 4. Weigh the patient every morning using the same scale. 5. Report a weight gain of 2.2 lb (1 kg) to the nurse. 6. Provide mouth care allowing the patient to swallow the rinses.

1. Monitor and record strict intake and output. 3. Remind the patient about his or her fluid restriction. 4. Weigh the patient every morning using the same scale. 5. Report a weight gain of 2.2 lb (1 kg) to the nurse.

. A client comes to the emergency department and reports nausea, vomiting, colicky abdominal pain, fever, and tachycardia. The health care provider informs the nurse that the client probably has a strangulated intestinal obstruction with perforation. What diagnostic testing and interventions does the nurse anticipate for this emergency condition? Select all that apply. 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics

1. Preparation for surgery 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics

After a radical prostatectomy, a client is ready to be discharged. Which nursing action included in the discharge plan should be assigned to an experienced LPN/LVN? 1. Reinforcing the client's need to check his temperature daily 2. Teaching the client how to care for his retention catheter 3. Documenting a discharge assessment in the client's chart 4. Instructing the client about the prescribed narcotic analgesic

1. Reinforcing the client's need to check his temperature daily

According to The Joint Commission, hospitals are required to form emergency management committees to periodically exercise the disaster operations plan. Hospital administration has selected various health care providers (HCPs) to join the committee. Members from which other key departments should be included? Select all that apply. 1. Security and communications 2. Nursing and unlicensed assistive personnel 3. Laboratory and diagnostic services 4. Medical and information technology 5. Maintenance and engineering 6. Physical therapy and occupational therapy

1. Security and communications 2. Nursing and unlicensed assistive personnel 3. Laboratory and diagnostic services 4. Medical and information technology 5. Maintenance and engineering

The RN is caring for a patient with diabetes admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would the nurse include in a teaching plan for the patient and family before discharge? Select all that apply. 1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL (3.3 mmol/L). 2. Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or ¼ cup (60 mL) of fruit juice. 3. Retest blood glucose in 30 minutes. 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. 6. If the patient has severe hypoglycemia, does not respond to treatment, and is unconscious, transport to the emergency department (ED).

1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL (3.3 mmol/L). 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. 6. If the patient has severe hypoglycemia, does not respond to treatment, and is unconscious, transport to the emergency department (ED).

Which of the following should the nurse be sure to assess before and after giving amlodipine to treat high blood pressure? Select all that apply. 1. Swelling in ankles or feet 2. Heart rate 3. Oral temperature 4. Blood pressure 5. Lung sounds 6. Weight 7. Respiratory rate

1. Swelling in ankles or feet 2. Heart rate 4. Blood pressure 5. Lung sounds 6. Weight

The home health nurse sees that the client is taking cimetidine. What question is the nurse most likely to ask to evaluate the efficacy of the therapy? 1. "Are you still having problems with constipation?" 2. "Has the medication helped to relieve the acid indigestion?" 3. "Did the medication relieve the nausea and vomiting?" 4. "Do you feel like your appetite has improved?"

2. "Has the medication helped to relieve the acid indigestion?"

The RN is the preceptor for a senior nursing student who will teach a patient with diabetes about self-care during sick days. For which statement by the student must the RN intervene? 1. "When you are sick, be sure to monitor your blood glucose at least every 4 hours." 2. "Test your urine for ketones whenever your blood glucose level is less than 240 mg/dL (13.3 mmol/L)." 3. "To prevent dehydration, drink 8 ounces (236 mL) of sugar-free liquid every hour while you are awake." 4. "Continue to eat your meals and snacks at the usual times."

2. "Test your urine for ketones whenever your blood glucose level is less than 240 mg/dL (13.3 mmol/L)."

Which pediatric pain patient should be assigned to a newly graduated RN? 1. An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose 2. A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures 3. A child who is receiving palliative end-of-life care; the child is receiving opioids around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. A child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful

2. A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures

Which actions can the school nurse delegate to an experienced unlicensed assistive personnel (UAP) who is working with a 7-year-old child with type 1 diabetes in an elementary school? Select all that apply. 1. Obtaining information about the child's usual insulin use from the parents 2. Administering oral glucose tablets when blood glucose level falls below 60 mg/dL (3.3 mmol/L) 3. Teaching the child about what foods have high carbohydrate levels 4. Obtaining blood glucose readings using the child's blood glucose monitor 5. Reminding the child to have a snack after the physical education class 6. Assessing the child's knowledge level about his or her type 1 diabetes

2. Administering oral glucose tablets when blood glucose level falls below 60 mg/dL (3.3 mmol/L) 4. Obtaining blood glucose readings using the child's blood glucose monitor 5. Reminding the child to have a snack after the physical education class

The nurse is working in the triage area of an emergency department, and the following four clients approach the triage desk at the same time. List the order in which the nurse will assess these clients. 1. An ambulatory, dazed 25-year-old man with a bandaged head wound 2. An irritable newborn with a fever, petechiae, and nuchal rigidity 3. A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. A 50-year-old woman with moderate abdominal pain and occasional vomiting.

2. An irritable newborn with a fever, petechiae, and nuchal rigidity 1. An ambulatory, dazed 25-year-old man with a bandaged head wound 4. A 50-year-old woman with moderate abdominal pain and occasional vomiting. 3. A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity

For clients coming to the ambulatory care gastrointestinal clinic, which task would be most appropriate to assign to an LPN/LVN? 1. Teaching a client self-care measures for an ulcer 2. Assisting the health care provider to incise and drain a pilonidal cyst 3. Evaluating a client's response to sitz baths for an anorectal abscess 4. Describing the basic pathophysiology of an anal fistula to a client

2. Assisting the health care provider to incise and drain a pilonidal cyst

A newborn infant is diagnosed with tracheoesophageal fistula. Which nursing interventions should be implemented in the preoperative period? Select all that apply. 1. Provide small frequent feedings. 2. Elevate the head of the bed. 3. Prepare a tracheostomy tray. 4. Set up suctioning. 5. Administer IV antibiotics.

2. Elevate the head of the bed. 4. Set up suctioning. 5. Administer IV antibiotics.

A patient with diabetes has hot, dry skin; rapid and deep respirations; and a fruity odor to his breath. The charge nurse observes a newly graduated RN performing all the following patient tasks. Which action requires that the charge nurse intervene immediately? 1. Checking the patient's fingerstick glucose level 2. Encouraging the patient to drink orange juice 3. Checking the patient's order for sliding-scale insulin dosing 4. Assessing the patient's vital signs every 15 minutes

2. Encouraging the patient to drink orange juice

The nurse responds to a call for help from the emergency department waiting room. An older adult client is lying on the floor. List the order in which the nurse must carry out the following actions. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct unlicensed assistive personnel to get the crash cart.

2. Establish unresponsiveness. 1. Perform the chin lift or jaw thrust maneuver. 4. Call for help and activate the code team. 3. Initiate cardiopulmonary resuscitation (CPR).

The nurse is preparing a care plan for a patient with Cushing disease. Which abnormal laboratory values would the nurse expect? Select all that apply. 1. Increased serum calcium level 2. Increased salivary cortisol level 3. Increased urinary cortisol level 4. Decreased serum glucose level 5. Decreased sodium level 6. Increased serum cortisol level

2. Increased salivary cortisol level 3. Increased urinary cortisol level 6. Increased serum cortisol level

A client who has just returned to the surgical unit after a transurethral resection of the prostate (TURP) reports acute bladder spasms. In which order will the nurse perform these prescribed actions? 1. Administer acetaminophen/oxycodone 325 mg/5 mg. 2. Irrigate the retention catheter with 30 to 50 mL of sterile normal saline. 3. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours. 4. Offer the client oral fluids to at least 2500 to 3000 mL/da

2. Irrigate the retention catheter with 30 to 50 mL of sterile normal saline. 1. Administer acetaminophen/oxycodone 325 mg/5 mg. 3. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours. 4. Offer the client oral fluids to at least 2500 to 3000 mL/day

The LPN/LVN is assigned to provide care for a patient with pheochromocytoma. Which physical assessment technique should the RN instruct the LPN/LVN to avoid? 1. Listening for abdominal bowel sounds in all four quadrants 2. Palpating the abdomen in all four quadrants 3. Checking the blood pressure every hour 4. Assessing the mucous membranes for hydration status

2. Palpating the abdomen in all four quadrants

The RN is teaching a patient how to perform intermittent self-catheterization for a long-term problem with incomplete bladder emptying. Which are important points for teaching this technique? Select all that apply. 1. Always use sterile techniques. 2. Proper hand washing and cleaning of the catheter reduce the risk for infection. 3. A small lumen and good lubrication of the catheter prevent urethral trauma. 4. A regular schedule for bladder emptying prevents distention and mucosal trauma. 5. The social work department can help you with the purchase of sterile supplies.

2. Proper hand washing and cleaning of the catheter reduce the risk for infection. 3. A small lumen and good lubrication of the catheter prevent urethral trauma. 4. A regular schedule for bladder emptying prevents distention and mucosal trauma.

. A patient needs clonazepam 0.25 mg PO. The pharmacy delivers lorazepam 2-mg tablets. A nursing student asks the nurse if clonazepam and lorazepam are interchangeable or if they are the same drug. Place the following steps in the correct sequence so that the nurse can teach the nursing student how to prevent medication errors. 1. Advise the pharmacy of any corrections as appropriate. 2. Recognize that "look-alike, sound-alike" drugs increase the chances of error. 3. Consult a medication book to verify the purpose of the drugs and generic and brand names. 4. Check the original medication order to verify what was prescribed. 5. Write an incident report, as appropriate, if a system error is occurring. 6. Call the health care provider (HCP) for clarification of the order as appropriate

2. Recognize that "look-alike, sound-alike" drugs increase the chances of error. 4. Check the original medication order to verify what was prescribed. 3. Consult a medication book to verify the purpose of the drugs and generic and brand names. 6. Call the health care provider (HCP) for clarification of the order as appropriate 1. Advise the pharmacy of any corrections as appropriate. 5. Write an incident report, as appropriate, if a system error is occurring.

. The RN team leader has assigned the LPN/LVN to administer clopidogrel 75 mg orally to a patient with a diagnosis of myocardial infarction. The patient also has an antacid prescribed for a diagnosis of gastric reflux. What must the LPN/LVN remember when administering these drugs? Select all that apply. 1. Clopidogrel can interfere with absorption of the antacid. 2. The antacid can interfere with absorption of clopidogrel. 3. Clopidogrel can be given with a meal to prevent nausea or upset stomach. 4. Clopidogrel should be given 1 hour after giving the antacid. 5. Clopidogrel and the antacid are compatible and can be given together. 6. Clopidogrel can be given one hour before the antacid.

2. The antacid can interfere with absorption of clopidogrel. 3. Clopidogrel can be given with a meal to prevent nausea or upset stomach. 6. Clopidogrel can be given one hour before the antacid.

A 36-year-old gravida 1, para 0 patient has received an epidural anesthetic. Her cervix is 6 cm dilated. Her blood pressure is currently 60/38 mm Hg. Which would be appropriate priority nursing actions? Select all that apply. 1. Place the patient in high Fowler position. 2. Turn the patient to a lateral position. 3. Notify the anesthesiologist. 4. Prepare for emergency cesarean section. 5. Decrease the IV fluid rate.

2. Turn the patient to a lateral position. 3. Notify the anesthesiologist.

. The nurse is working on a medical unit staffed with LPNs/LVNs and unlicensed assistive personnel (UAP) when a client with stage IV ovarian cancer and recurrent ascites is admitted for paracentesis. Which activity is best to assign to an experienced LPN/LVN? 1. Obtaining a paracentesis tray from the central supply area 2. Completing the short-stay client admission form 3. Measuring vital signs every 15 minutes after the procedure 4. Providing discharge instructions after the procedure

3. Measuring vital signs every 15 minutes after the procedure

The postpartum nurse has just taken report from the night nurse. Place the following patients in the order in which they should be seen by the oncoming nurse. 1. A 32-year-old woman gravida 1, para 1 (G1P1) day 2 after normal spontaneous vaginal delivery who is tearful because the baby has been up all night crying and not nursing well 2. A 22-year-old G3P3 6 hours after normal spontaneous vaginal delivery who has expressed a wish to speak with a social worker about giving up her baby for adoption 3. A 16-year-old G1P1 day one postpartum with blood pressure of 160/90 mm Hg who is complaining of a headache 4. A 26-year-old G2P2 day 1 after cesarean section with temperature of 100.5°F (38.1°C)

3. A 16-year-old G1P1 day one postpartum with blood pressure of 160/90 mm Hg who is complaining of a headache 1. A 32-year-old woman gravida 1, para 1 (G1P1) day 2 after normal spontaneous vaginal delivery who is tearful because the baby has been up all night crying and not nursing well 2. A 22-year-old G3P3 6 hours after normal spontaneous vaginal delivery who has expressed a wish to speak with a social worker about giving up her baby for adoption 4. A 26-year-old G2P2 day 1 after cesarean section with temperature of 100.5°F (38.1°C)

The charge nurse must rearrange room assignments to admit a new patient. Which two patients would be best suited to be roommates? 1. A 58-year-old patient with urothelial cancer receiving multiagent chemotherapy 2. A 63-year-old patient with kidney stones who has just undergone open ureterolithotomy 3. A 24-year-old patient with acute pyelonephritis and severe flank pain 4. A 76-year-old patient with urge incontinence and a urinary tract infection (UTI)

3. A 24-year-old patient with acute pyelonephritis and severe flank pain 4. A 76-year-old patient with urge incontinence and a urinary tract infection (UTI)

The nurse is caring for the following patients with endocrine disorders. Which patient must the nurse assess first? 1. A 21-year-old patient with diabetes insipidus whose urine output overnight was 2000 mL 2. A 55-year-old patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who is demanding that the unlicensed assistive personnel refill his water pitcher 3. A 65-year-old patient with Addison disease whose morning potassium level is 6.2 mEq/L (6.2 mmol/L) 4. A 48-year-old patient with Cushing disease with a weight gain of 1.5 lb (0.7 kg) over the past 4 days

3. A 65-year-old patient with Addison disease whose morning potassium level is 6.2 mEq/L (6.2 mmol/L)

The nurse is performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps in the order in which each should be accomplished. 1. Apply silver sulfadiazine ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. Débride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing.

3. Administer morphine sulfate 10 mg IV. 4. Débride the wound of eschar using gauze sponges. 2. Obtain specimens for aerobic and anaerobic wound cultures. 1. Apply silver sulfadiazine ointment. 5. Cover the wound with a sterile gauze dressing.

An older man was admitted for palliative care of terminal pancreatic cancer. His wife stated, "We don't want hospice; he wants treatment." The patient requested discharge and home health visits. Several hours after discharge, the man committed suicide with a gun. Which people should participate in a root cause analysis of this sentinel event? Select all that apply. 1. The wife and all immediate family members 2. Only the health care provider (HCP) who discharged the patient 3. Any nurse who cared for the patient during hospitalization 4. The case manager who arranged home visits for the patient 5. Only the nurse who discharged the patient 6. All HCPs who were involved in the care of the patient

3. Any nurse who cared for the patient during hospitalization 4. The case manager who arranged home visits for the patient 6. All HCPs who were involved in the care of the patient

The nurse is caring for a client who is on the cardiac monitor because of these symptoms: syncope, dizziness, and intermittent episodes of palpitations. Below is a display of what the nurse sees on the cardiac monitor. What should the nurse do first? 1. Call the Rapid Response Team. 2. Obtain the automated external defibrillator. 3. Assess the client and take vital signs. 4. Check the adherence of the gel pads on the chest.

3. Assess the client and take vital signs.

The nurse is creating a care plan for older adult patients with incontinence. For which patient will a bladder-training program be an appropriate intervention? 1. Patient with functional incontinence caused by mental status changes 2. Patient with stress incontinence due to weakened bladder neck support 3. Patient with urge incontinence and abnormal detrusor muscle contractions 4. Patient with transient incontinence related to loss of cognitive function

3. Patient with urge incontinence and abnormal detrusor muscle contractions

While transferring a dirty laundry bag, an unlicensed assistive personnel (UAP) sustains a puncture wound to the finger from a contaminated needle. The unit has several clients with hepatitis and acquired immunodeficiency syndrome; the needle source is unknown. Place the following instructions, for the UAP, in the correct order of priority 1. Have blood test(s) performed per protocol. 2. Complete and file an incident report. 3. Perform a thorough aseptic hand washing. 4. Report to the occupational health nurse. 5. Follow up for laboratory results and counseling. 6. Begin prophylactic drug therapy

3. Perform a thorough aseptic hand washing. 4. Report to the occupational health nurse. 1. Have blood test(s) performed per protocol 6. Begin prophylactic drug therapy 2. Complete and file an incident report. 5. Follow up for laboratory results and counseling.

Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by emergency department staff in the event of a biochemical incident. 1. Report to public health department or Centers for Disease Control and Prevention per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol

3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 2. Decontaminate the affected individuals in a separate area. 5. Perform triage according to protocol 1. Report to public health department or Centers for Disease Control and Prevention per protocol.

The nurse is reviewing the principle of "least restrictive" interventions with the staff. Place the following interventions in the correct order, with 1 being the least restrictive and 6 being the most restrictive. 1. Escort the patient to a quiet room for a time out. 2. Restrain the patient's arms and legs with soft cloth restraints. 3. Verbally instruct the patient to stop the unacceptable behavior (i.e., yelling, arguing) and move to another part of the day room. 4. Accompany the patient out into the garden courtyard. 5. Restrain the patient's upper extremities with wrist restraints. 6. Place the patient in isolation room with psychiatric nursing assistant observing.

3. Verbally instruct the patient to stop the unacceptable behavior (i.e., yelling, arguing) and move to another part of the day room. 4. Accompany the patient out into the garden courtyard. 1. Escort the patient to a quiet room for a time out. 6. Place the patient in isolation room with psychiatric nursing assistant observing. 5. Restrain the patient's upper extremities with wrist restraints. 2. Restrain the patient's arms and legs with soft cloth restraints.

After receiving the change-of-shift report, in which order will the nurse assess these assigned clients? 1. A 22-year-old client who has questions about how to care for the drains placed in her breast reconstruction incision 2. An anxious 44-year-old client who is scheduled to be discharged today after undergoing a total vaginal hysterectomy 3. A 69-year-old client who reports level 5 pain (on a scale of 0 to 10) after undergoing perineal prostatectomy 2 days ago 4. A usually oriented 78-year-old client who has new-onset confusion after having a bilateral orchiectomy the previous day

4. A usually oriented 78-year-old client who has new-onset confusion after having a bilateral orchiectomy the previous day 3. A 69-year-old client who reports level 5 pain (on a scale of 0 to 10) after undergoing perineal prostate 2 days ago 2. An anxious 44-year-old client who is scheduled to be discharged today after undergoing a total vaginal hysterectomy 1. A 22-year-old client who has questions about how to care for the drains placed in her breast reconstruction incision

The nurse is instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would the nurse be sure to include when instructing the student about thyroid palpation? 1. Always stand to the side of the patient. 2. Instruct the patient not to swallow. 3. Palpate using one hand and then the other. 4. Always palpate the thyroid gland gently.

4. Always palpate the thyroid gland gently.

In which order will the nurse take these actions which are needed for a client seen in the family medicine clinic and diagnosed with impetigo? 1. Obtain specimen for culture. 2. Apply topical antibiotic ointment. 3. Give the client a hand hygiene handout. 4. Clean off the crust from the lesion. 5. Apply a sterile dressing to the wound

4. Clean off the crust from the lesion. 1. Obtain specimen for culture. 2. Apply topical antibiotic ointment. 5. Apply a sterile dressing to the wound 3. Give the client a hand hygiene handout.

The nurse in the labor and delivery unit is caring for a 25-year-old gravida 3, para 2 patient in active labor. The nurse has identified late fetal heart decelerations and decreased variability in the fetal heart rate and notified the health care provider (HCP) on call, who thinks that the pattern is acceptable. What would be the priority action at this time? 1. Advise the patient that a different HCP will be called because the first HCP's response was not adequate. 2. Discuss the concerns with another labor and delivery nurse. 3. Document the conversation with the HCP accurately, including the HCP's interpretation and recommendation, and continue close observation of the fetal heart rate. 4. Go up the chain of command and communicate the assessment of the fetal heart rate findings clearly to the next appropriate HCP.

4. Go up the chain of command and communicate the assessment of the fetal heart rate findings clearly to the next appropriate HCP.

The nurse is working in a small rural community hospital. There is a fire in a local church, and six injured clients have arrived at the hospital. Many others are expected to arrive soon, and other hospitals are 5 hours away. Using disaster triage principles, place the following six clients in the order in which they should receive medical attention, with 1 being the first to receive attention and 6 being the last to receive attention. 1. A 52-year-old man in full cardiac arrest who has been receiving cardiopulmonary resuscitation (CPR) continuously for the past 60 minutes 2. A firefighter who is showing combative behavior and has respiratory stridor 3. A 60-year-old woman with full-thickness burns to the hands and forearms 4. A teenager with a crushed leg that is very swollen; he is anxious and has tachycardia 5. A 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 6. A 12-year-old child with wheezing and very labored respirations unrelieved by an asthma inhaler

6. A 12-year-old child with wheezing and very labored respirations unrelieved by an asthma inhaler 2. A firefighter who is showing combative behavior and has respiratory stridor 4. A teenager with a crushed leg that is very swollen; he is anxious and has tachycardia 3. A 60-year-old woman with full-thickness burns to the hands and forearms 5. A 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 1. A 52-year-old man in full cardiac arrest who has been receiving cardiopulmonary resuscitation (CPR) continuously for the past 60 minutes