LARA -SELECT ALL PRACTICE QUESTIONS

The circulating nurse assesses a client's care during the peri-operative period. Which surgery staff action, observed by the nurse, requires follow-up? (Select all that apply.) 1.Surgical nurse #1 removes the hair cap. 2.Surgical nurse #2 shaved the client's hair at the operative site. 3.The surgical assistant's shirt is outside the pants. 4.Surgical nurse #3 reports a cough. 5.The surgeon's face mask fits tightly on the face. 6.Surgical nurse #4 has acrylic nails.

1) CORRECT — A hair cap should be worn by the surgical team members to prevent debris from hair and scalp from invading the surgical site. 2) CORRECT— A client's hair should be clipped, as shaving increases the risk of infection. 3) CORRECT — Shirts and waist drawstrings are tucked inside the pants to prevent accidental contact with sterile areas and to contain skin shedding. 4) CORRECT — Staff with upper respiratory infections, sore throat, and skin infections are sources of pathogens and should not be in the surgical area. 5) INCORRECT — A mask should fit tightly. It decreases the risk of post-operative wound infection by containing microorganisms from the oropharynx and nasopharynx. 6) CORRECT — Artificial fingernails harbor microorganisms and can cause nosocomial infections. Nails are to be short and unpolished.

The nurse reviews a prescription for glimepiride for a client with type 2 diabetes mellitus. Which entry in the client's medication record causes the nurse to question the glimepiride prescription? (Select all that apply.) 1.Propranolol. 2.Gemfibrozil. 3.Ginkgo biloba. 4.Ginseng. 5.Ibuprofen. 6.Valerian.

1) CORRECT — Beta-adrenergic blocking agents may mask symptoms of hypoglycemia, which is a primary adverse effect of oral anti-diabetic agents. 2) CORRECT — Gemfibrozil increases the hypoglycemic effect of sulfonylureas. 3) INCORRECT— Ginkgo biloba does not interact with oral antidiabetic agents. This supplement interacts with anticoagulants. 4) CORRECT — Ginseng increases the hypoglycemic effect of sulfonylureas. 5) CORRECT — Ibuprofen increases the hypoglycemic effect of oral antidiabetic medications. 6) INCORRECT— Valerian does not interact with oral antidiabetic agents, but it does interact with sedative-type medications.

The nurse teaches the parent of an infant with developmental dysplasia of the hip (DDH) about home care. The infant will be discharged with a Pavlik harness. Which parent statement indicates further teaching is needed? (Select all that apply.) 1."I can adjust the harness if it seems too tight or too loose." 2."The straps should be checked every 1 to 2 weeks." 3."I will need to give my baby a sponge bath." 4."It will be hard to keep my baby from moving around." 5."I should put lotion under the harness straps so they won't irritate my baby's skin."

1) CORRECT- A Pavlik harness should be adjusted only by the health care provider to be sure the hips are in correct alignment. 2) INCORRECT- Rapid growth of infants means that the straps should be checked frequently by the health care provider in case adjustments are needed. 3) INCORRECT- This bathing modification is necessary because the Pavlik harness should not be removed by the parents. 4) CORRECT- An infant in a Pavlik harness should be encouraged to move around in age-appropriate ways to facilitate normal growth and development. 5) CORRECT- To prevent irritation of the skin, the parent should put an undershirt on the infant under the chest straps and knee socks under the foot and leg pieces of the harness. Lotions may irritate the infant's skin.

A client diagnosed with a severe sprain of the right ankle must avoid all weight-bearing on the right foot. Which demonstration by the client indicates proper use of the crutches? (Select all that apply.) 1.Elbows are flexed 20 to 30 degrees. 2.Touches down with the right foot. 3.Ensures rubber tips are on both crutches. 4.Bears weight on the armpits. 5.Keeps crutches 14 to 16 inches out to side.

1) CORRECT- Crutches should be measured for client's height. When measured correctly, elbows should be flexed 20 to 30 degrees. 2) INCORRECT- The client must avoid all weight-bearing on the right foot. 3) CORRECT- Rubber tip placement on crutches ensures equipment safety. 4) INCORRECT- Allowing the axillae to bear the weight could result in nerve damage. Weight should be placed on the handpieces instead. 5) INCORRECT- Crutches should be kept 8 to 10 inches out to side.

The nurse provides care for multiple clients requiring central venous pressure (CVP) monitoring. The nurse anticipates an elevated CVP in which client? (Select all that apply.) 1.A client admitted with jugular venous distention (JVD). 2.A client admitted after a motor vehicle accident with a positive Grey Turner sign. 3.A client with an elevated brain natriuretic peptide (BNP) level. 4.A client experiencing a severe anaphylactic reaction to a blood transfusion. 5.A client with a pericardial effusion after cardiac surgery.

1) CORRECT- JVD is a symptom of fluid overload, which would lead to an elevated CVP. 2) INCORRECT- Grey Turner sign is bruising of the flank area and is a sign of retroperitoneal bleeding. A nurse would anticipate that a client who is hemorrhaging would have a decreased CVP. 3) CORRECT- An elevated BNP level (greater than 100 pg/mL [100 ng/L]) is suggestive of heart failure, which would lead to high cardiac filling pressures. This client would be expected to have an elevated CVP level. 4) INCORRECT- A client experiencing an anaphylactic reaction would be in shock. This would cause vasodilation and decreased venous return. The nurse would anticipate a decreased CVP for this client. 5) CORRECT- The pressure from the effusion leads to impaired cardiac filling, which causes fluid accumulation in the venous system. This would manifest as an increased CVP.

After receiving report for a client who underwent surgery for reconstruction of the left ankle, the nurse observes the client pulling at the ankle dressing and stating, "Where am I? How did I get home so quickly?" Which action by the nurse is most appropriate? (Select all that apply.) 1.Reorient the client to place and time. 2.Assess for the location, type, and quality of pain. 3.Apply soft restraints to the client's wrists. 4.Instruct the client to be quiet and calm. 5.Assign an unlicensed assistive personnel (UAP) to sit with the client. View Explanation

1) CORRECT- Reorienting the client to the proper date and time of day may help the client with any confusion or delirium. Alternatives to restraints should be used first. An alternative is placing a clock and calendar in the room, which can help facilitate the proper orientation for the client. 2) CORRECT- Extreme pain can cause delirium and agitation. Therefore, asking the client to state where the main source of pain is located, along with the type and quality, is a priority for the nurse. Managing the client's pain should be done before considering restraining the client. 3) INCORRECT- Applying wrist restraints to a client is not therapeutic. Alternatives to restraints should be attempted first. In addition, properly identifying postoperative delirium must be evaluated and it must be treated without restraints. 4) INCORRECT- Telling the client to be calm and quiet may not be realistic immediately after surgery. An alternative is facilitating conversation with the client and properly addressing the client's needs for hydration, pain control, and toileting. 5) CORRECT- An alternative to restraints is having a nursing team staff member remain with the client. A "sitter" or similar program where trained hospital staff remain with a confused client for safety reasons has proven effective and does keep clients safe and free of restraints.

While making hourly rounds, the nurse notices a fire in a trash can in a client's room. Upon inspection, the client is not in the room. Which intervention does the nurse initiate first to manage the fire? (Select all that apply.) 1.Activate the fire alarm. 2.Use blankets and pillows to extinguish the fire. 3.Close the door to the room. 4.Locate the client to determine how the fire started. 5.Evacuate all clients from the unit. ( trick Q= the key word ALL)

1) CORRECT- Since the client is not in the room, the nurse needs to activate the nearest fire alarm. 2) INCORRECT- The nurse should not use blankets and pillows to extinguish the fire as this may cause the fire to grow. 3) CORRECT- Closing the door to the room will decrease oxygen flow available to fuel the fire and slow its growth. This is an appropriate action for the nurse to take. 4) INCORRECT- The nurse needs to focus on extinguishing and containing the fire. After the fire has been extinguished, the nurse should locate the client. 5) INCORRECT- The focus is to contain and extinguish the fire. Evacuation of clients who are in immediate danger should occur first. However, evacuation of the entire unit is the last resort and is done only if efforts to contain the fire fail.

The nurse in the post-anesthesia care unit (PACU) cares for a client following a bronchoscopy and mediastinoscopy for lung biopsy. Which assessment is important for the nurse to perform before offering the client oral fluids? (Select all that apply.) 1.Level of consciousness. 2.Presence of cough reflex. 3.Drainage on mediastinal dressing. 4.Pulse oximeter reading. 5.Urinary output.

1) CORRECT- The client's level of consciousness should be assessed to ensure that the client is alert enough to avoid aspiration. 2) CORRECT- Due to the local anesthetic used in a bronchoscopy, once the cough reflex returns, the nurse should assess the client's ability to orally manage and safely swallow using a few ice chips before providing liquids. 3) INCORRECT- Ensuring that the client is not excessively bleeding from the mediastinal puncture site is important, but this information is not related to the client's ability to swallow liquids safely. 4) INCORRECT- Ensuring that the client is appropriately oxygenated is an important component of postoperative care. However, it is not specific to the client's ability to swallow liquids safely. 5) INCORRECT- Ensuring adequate urinary output is an important component of postoperative care. However, it is not specific to the client's ability to swallow liquids safely.

The nurse provides care for a client who experienced a pulmonary embolism. The client is receiving a continuous heparin infusion. Which instruction will the nurse provide to the unlicensed assistive personnel (UAP) assisting with the care? (Select all that apply.) 1.Use an electric razor to shave the client's face. 2.When performing mouth care, check the client's gums and mucosa for red spots. 3.Note any bruising seen while assisting the client with morning care. 4.Take and record the client's rectal temperature every 4 hours. 5.Tell the nurse if the client reports cold, painful, or blue feet. 6.When assisting the client to reposition, use a lift sheet. View Explanation

1) CORRECT- The nurse has provided the correct instruction to the UAP in relation to safety for a client on an anticoagulant. 2) INCORRECT- While mouth care is within the UAP's scope of practice, assessment is not. 3) INCORRECT- While morning care is within the UAP's scope of practice, assessment is not. 4) INCORRECT- Rectal temperatures should be avoided in clients at risk for bleeding. 5) CORRECT- The UAP should report concerning client reports to the nurse. 6) CORRECT- This is an appropriate instruction and within the UAP's scope of practice.

The nurse supervises care provided to a client who requires an indwelling urinary catheter. The nurse will intervene if which action is observed? (Select all that apply.) 1.The urinary drainage bag is placed on the floor. 2.After insertion, the exposed catheter is wiped clean during routine perineal care. 3.The catheter tubing is secured to the bed frame. 4.Clean technique is used by the novice nurse during insertion. 5.Pale yellow urine is noted in the collection bag after insertion.

1) CORRECT- The urinary drainage bag should be placed in a dependent position, but it should never be placed on the floor, as this can increase the risk of catheter-associated urinary tract infection. 2) INCORRECT- Routine perineal care, including cleaning of the catheter, is indicated to prevent catheter-associated urinary tract infection. 3) CORRECT- The tubing should be secured to the client's body, not the bed frame. Securing the tubing to the bed frame will cause pulling on the catheter. 4) CORRECT- Sterile technique is required during catheter insertion to prevent contamination of the urinary tract with pathogens. 5) INCORRECT- Pale yellow urine indicates good hydration. The nurse would be concerned about a catheter-associated urinary tract infection if urine output was cloudy.

The nurse provides care for a client who is prescribed levothyroxine. Which client statements indicate to the nurse a correct understanding of the medication therapy? (Select all that apply.) 1."I will feel more energetic when this medication works. " 2."My blood TSH level will increase with this medication. " 3."I will take this medication on an empty stomach when I wake up. " 4."This medication contains both T3 and T4 hormones. " 5."This medication replaces the hormone I don 't produce. "

1) CORRECT— Levothyroxine increases metabolism and cellular energy, which will likely cause the client to have more energy. This statement indicates a correct understanding of the medication therapy. 2) INCORRECT - Serum TSH levels will decrease with medication effectiveness. If the client has normal thyroid function as a result of the levothyroxine, the thyroid-stimulating hormone will decrease because it is not receiving negative feedback to cause it to increase. 3) CORRECT— Food in the stomach may affect absorption of this medication. This statement indicates a correct understanding of the medication therapy. 4) INCORRECT - Levothyroxine is a synthetic thyroid hormone, replacing T4 only. 5) CORRECT— Levothyroxine is a synthetic thyroid hormone that replaces the client 's lack of endogenous hormone. This statement indicates a correct understanding of the medication therapy.

The nurse prepares to teach a client newly diagnosed with lactase deficiency. Which points will the nurse include in the teaching? (Select all that apply.) 1.Avoid nondairy creamers along with cream. 2.Drink a commercial product where lactose has been preconverted to absorbable sugars. 3.Consume yogurt that contains bacterial lactases. 4.Understand that lactase converts lactose, the sugar in milk, into simpler sugars. 5.Obtain calcium through other dietary sources, such as green leafy vegetables.

1) INCORRECT - The nurse should teach the client with lactase deficiency to use nondairy creamers, which are lactose-free, instead of cream. 2) CORRECT— The nurse should encourage the client to drink a commercial product, such as Lactaid, in which the lactose has been preconverted into other absorbable sugars. 3) CORRECT— Lactase enzyme preparations are available, without prescription, to improve milk tolerance. Yogurt containing bacterial lactase is another option that may be tolerated. 4) CORRECT— The nurse should explain that lactose is a digestive enzyme that converts lactose, the sugar in milk, into simpler sugars. 5) CORRECT— The nurse should advise the client to obtain calcium through other sources, such as green leafy vegetables, dates, prunes, canned sardines and salmon with bones, egg yolks, whole grains, dried peas, beans, and calcium supplements.

The nurse provides care for a client who requires neurological checks every 2 hours. The nurse identifies which components as part of the Glasgow Coma Scale (GCS)? (Select all that apply.) 1.Eye-opening response — partially. 2.Best motor response — unsteady gait. 3.Best verbal response — confused. 4.Eye-opening response — none. 5.Best verbal response — incomprehensible sounds. 6.Best motor response — localizes pain.

1) INCORRECT - This is not a component of the GCS. 2) INCORRECT - This is not a component of the GCS. 3) CORRECT - The client would score a 4 on best verbal response. 4) CORRECT - The client would score a 1 on eye-opening response. 5) CORRECT - The client would score a 2 on best verbal response. 6) CORRECT - The client would score a 5 on best motor response.

A client preparing to begin hemodialysis has received dietary guidelines to follow. Which food, if selected by the client, indicates correct understanding of the diet? (Select all that apply.) 1.Oranges and nectarines. 2.Brie cheese and sherbet. 3.Tomatoes and avocados. 4.Cream of wheat and white rice. 5.Peanut butter and whole wheat bread.

1) INCORRECT- Fruits that are high in potassium, such as oranges and nectarines, should be limited or avoided. Star fruit (carambola) must be avoided at all times. 2) CORRECT- While dairy foods generally are high in phosphorus, dairy foods low in phosphorus that can be consumed in limited amounts include brie cheese and sherbet. Other low-phosphorus options include cream cheese, margarine, and ricotta cheese. 3) INCORRECT- Vegetables higher in potassium, such as tomatoes and avocados, should be limited or avoided. Others to avoid or limit include potatoes, beets, and asparagus. 4) CORRECT- Grains, cereals, and breads are good calorie sources for a client on hemodialysis, unless limited calorie intake is indicated. However, note that whole grain and high-fiber foods (e.g., whole wheat bread, bran cereal, brown rice) are high in phosphorus and should be avoided. 5) INCORRECT- Peanut butter is high in both potassium and phosphorus, and it should be limited or avoided. Whole grain and high-fiber foods are high in phosphorus and should be limited or avoided.

NOT A SELECT ALL A client admitted to the cardiac care unit after a myocardial infarction develops shortness of breath, tachycardia, and a cough with frothy, pink-tinged sputum. Which breath sound will the nurse expect when assessing this client? 1.Vesicular. 2.Bronchial. 3.Course rales. 4.Diminished breath sounds.

1) INCORRECT - Vesicular, or normal, breath sounds are not expected for the client with an MI who develops heart failure. 2) INCORRECT - Bronchial breath sounds are tubular, hollow sounds which are heard when auscultating over the large airways. This is not anticipated based on the current data. 3) CORRECT - Course rales are expected with the pulmonary edema that accompanies a myocardial infarction. 4) INCORRECT - Diminished breath sounds are not consistent with the pulmonary edema that is expected with a myocardial infarction. Think Like a Nurse: Clinical Decision-Making The nurse uses knowledge of anatomy and physiology along with an understanding of the pathophysiology associated with the client's diagnosis. The nurse should conclude the client recovering from a myocardial infarction is at risk for developing heart failure. This is because of the damage to the cardiac tissue weakening the ability of the ventricles to pump blood effectively. Heart failure development will depend upon the location and extent of cardiac tissue ischemia. In heart failure, fluid is backed up in the vascular system and may enter the lungs. Fluid that enters the lungs will cause the client to develop pink-tinged sputum as evidence of pulmonary edema, and the breath sounds will reflect fluid in the lungs. Content Refresher When caring for a client post-myocardial infarction (MI), the nurse should assess vital signs and lung sounds. Examine the client in supine, sitting, and in left lateral recumbent positions. Utilize a systematic approach to listen to the lungs, from side to side and top to bottom. The nurse should expect to hear rhonchi. Promote adequate oxygenation, administer supplemental oxygen as prescribed, and position the client upright to support effective ventilation. Obtain a 12-lead EKG; repeat testing as prescribed. Administer prescribed medications, which may include nitroglycerin, morphine, clotting inhibitors, antihypertensive agents, and thrombolytic agents. Teach effective strategies such as deep-breathing to reduce anxiety.

The nurse provides care to a client diagnosed with Paget disease. Which findings are anticipated by the nurse as characteristic of this disorder? (Select all that apply.) 1.A vitamin D deficiency. 2.An elevated serum alkaline phosphatase. 3.A pathologic fracture. 4.A loss of total bone mass and substance. 5.An abnormal remodeling and resorption of bone.

1) INCORRECT - Vitamin D deficiency is seen in osteomalacia that causes generalized bone decalcification with bone deformity. 2) CORRECT - An elevated serum alkaline phosphatase level occurs in advanced forms of the disease. 3) CORRECT - Pathologic fractures are the most common complication of the disease. \ 4) INCORRECT - Loss of total bone mass and substance is seen in osteoporosis. 5) CORRECT - Abnormal remodeling and resorption of bone occurs, and the new bone is larger, disorganized, and structurally weaker.

A client who experienced a stroke with residual mobility deficits has entered a residential rehabilitation program. Which action does the nurse take to promote personal hygiene? (Select all that apply.) 1.Give the client a bed bath daily to maintain cleanliness. 2.Teach the client about the use of handrails in the bathroom. 3.Show the client and family how to use the shower chair. 4.Have the family bathe the client every other day as needed. 5.Provide the client with wet wipes for handwashing.

1) INCORRECT- Clients should maintain as much independence as possible. 2) CORRECT- Limited mobility places the client at risk for falls. Handrails are provided to ensure safety in the bathroom. 3) CORRECT- Clients with limited mobility may safely shower if provided with a shower chair and handrails. 4) INCORRECT- Having the family assume responsibility for client bathing removes the client's efforts to be independent in some activities. 5) CORRECT- Because of limited mobility, the client may be unable to wash the hands as frequently or as easily as desired or needed. Providing wet wipes allows for on-demand handwashing.

An infant diagnosed with failure to thrive has been prescribed enteral feedings via a nasogastric (NG) tube. Which intervention does the nurse include in the plan of care? (Select all that apply.) 1.Reinsert the tube daily. 2.Weigh the infant daily. 3.Flush the tube once per shift. 4.Irrigate the tube with 100 mL water. 5.Allow the infant to suck a pacifier.

1) INCORRECT- Daily reinsertion of the NG tube is unnecessary and may cause significant irritation to the nasal passages. 2) CORRECT- Daily weights are the best indicator of fluid balance in infants and also will determine adequacy of enteral feeding. 3) CORRECT- Patency of the tube may be maintained with flushing. 4) INCORRECT- It is not necessary to irrigate the NG tube, and 100 mL is an excessive volume for an infant. 5) CORRECT- Sucking a pacifier will help the infant associate sucking with a feeling of satiation.

An infant diagnosed with failure to thrive has been prescribed enteral feedings via a nasogastric (NG) tube. Which intervention does the nurse include in the plan of care? (Select all that apply.) 1.Reinsert the tube daily. 2.Weigh the infant daily. 3.Flush the tube once per shift. 4.Irrigate the tube with 100 mL water. 5.Allow the infant to suck a pacifier.

1) INCORRECT- Daily reinsertion of the NG tube is unnecessary and may cause significant irritation to the nasal passages. 2) CORRECT- Daily weights are the best indicator of fluid balance in infants and also will determine adequacy of enteral feeding. 3) CORRECT- Patency of the tube may be maintained with flushing. 4) INCORRECT- It is not necessary to irrigate the NG tube, and 100 mL is an excessive volume for an infant. 5) CORRECT- Sucking a pacifier will help the infant associate sucking with a feeling of satiation.

The nurse in the post-anesthesia care unit (PACU) provides care for an adult client who had repair of an abdominal aortic aneurysm. Which assessment finding may indicate unexpected bleeding? (Select all that apply.) 1.Extremities pink and warm. 2.Arterial blood pressure 84/56 mm Hg. 3.Bilateral pedal pulses +1. 4.Capillary refill 4 seconds. 5.Heart rate 84 beats per minute.

1) INCORRECT- Extremity warmth and pink color indicate adequate perfusion. 2) CORRECT- Decreased blood pressure is indicative of hypovolemic shock associated with blood loss. 3) CORRECT- Decreased strength of distal pulses suggests poor perfusion associated with hypovolemia. 4) CORRECT- Ideally, capillary refill time of less than 3 seconds would indicate adequate perfusion. 5) INCORRECT- The heart rate is within normal limits.

The clinic nurse has taught parents about safe sleep for their young infants. Which statement by a parent indicates teaching is successful? (Select all that apply.) 1."Our baby sleeps most comfortably on his tummy." 2."Our baby's thick, soft comforter will help him sleep." 3."We will place our baby on his back for naps and at bedtime." 4."Our baby's bassinette will stay in our bedroom for a few more months." 5."We will add rice cereal to the bedtime bottle to help him sleep."

1) INCORRECT- It is recommended that infants be placed supine for sleep. 2) INCORRECT- Infants should not sleep with pillows or comforters. 3) CORRECT- Infant supine sleeping is associated with a decreased risk of sudden infant death syndrome (SIDS). 4) CORRECT- The safest place for infants to sleep is in their own bed. 5) INCORRECT- Adding rice cereal to the young infant's bottle is not recommended, nor has it been demonstrated to assist with sleeping through the night.

The nurse has completed an educational conference on the appropriate handling of infectious and hazardous materials. Which action by the nurse indicates an understanding of the topic presented? (Select all that apply.) 1.Recap needles, then place them in the sharps disposal box. 2.Place soiled linens on the floor, then carry to the nearest linen disposal bin. 3.Place used syringes with needles directly into the sharps disposal box. 4.Use personal protective equipment when preparing IV chemotherapeutic agents. 5.Remove personal protective equipment immediately upon exiting an isolation room.

1) INCORRECT- Needles should never be recapped as doing so increases the risk of needle stick and transmission of disease. 2) INCORRECT- Placing soiled linens on the floor increases contamination of both the linens and the floor. 3) CORRECT- The safest disposal of needles involves direct placement into the sharps disposal box without recapping. 4) CORRECT- In order to protect the nurse from potential exposure, gown and gloves are used appropriately when preparing, administering, and discarding IV chemotherapeutic agents. 5) INCORRECT- Personal protective equipment is removed just prior to exiting the isolation room.

The nurse provides care for several clients who have urinary issues. Which client will the nurse refer to the health care provider for immediate follow-up? (Select all that apply.) 1.A pregnant client with bilateral varicose veins whose postvoid residual is 50 mL. 2.A preoperative client scheduled for urethral sling surgery in 4 hours who reports leaking urine when sneezing. 3.A sexually active adolescent diagnosed with a urinary tract infection (UTI) who received sulfamethoxazole-trimethoprim 30 minutes ago reports a strong urge to urinate. 4.A client 2 days post right kidney transplant with vital signs HR 88 beats/minute, BP 100/58 mm Hg, R 16 breaths/minute, T 103.1°F (39.5°C). 5.A client 4 hours post transurethral resection of the prostate (TURP) procedure, receiving continuous bladder irrigation, with pink urinary drainage and occasional small clots noted. 6.A multigravida client with a pessary in place who reports trouble passing urine.

1) INCORRECT- Postvoid residuals of 50 to 100 mL are generally considered within normal range. 2) INCORRECT- Leaking urine upon sneezing is a classic symptom of stress incontinence and is likely the reason the client is undergoing urethral sling surgery. 3) INCORRECT- A frequent, urgent need to urinate is a common symptom of urinary tract infection. Additionally, the antibiotic given has not yet had time to take effect. 4) CORRECT- A fever post-transplant could be a sign of infection or organ rejection. 5) INCORRECT- Pink urinary drainage and occasional small clots are expected findings shortly after surgery. 6) CORRECT- A pessary, a prosthetic device to treat pelvic organ prolapse, should not affect the client's ability to urinate. This client should have a follow-up evaluation.

A client recently diagnosed with thyroid cancer returns to the unit after a thyroidectomy. Which finding concerns the nurse? (Select all that apply.) 1.The LPN/LVN places a tracheostomy set at the bedside. 2.The client reports a feeling of fullness around the dressing. 3.The client reports spasms in the hands. 4.The LPN/LVN places a small, soft pillow under the head. 5.The client's VS are: BP 150/96 mm Hg, P 152 beats/min, RR 22 breaths/min, T 101.9°F (38.8°C).

1) INCORRECT- Potential edema and hematoma formation can compress the trachea, resulting in respiratory distress. An emergent artificial airway insertion is required. 2) CORRECT- This indicates possible hemorrhage at the surgical site. 3) CORRECT- Spasms in the hands after a thyroidectomy indicate decreased calcium levels, causing hyper-irritability of the nerves. 4) INCORRECT- This will facilitate proper neck alignment, which decreases tension on the surgical site. 5) CORRECT- These clinical findings are indicative of a life-threatening crisis known as thyroid storm. While rare, thyroid storm is a potential postoperative complication of a thyroidectomy.

A client diagnosed with cancer undergoes brachytherapy with a temporary iridium-192 implant. An LPN/LVN assists with care for the client in the hospital. Which action by the LPN/LVN causes the nurse to intervene and provide additional teaching? (Select all that apply.) 1.The LPN/LVN advises the client that a pregnant family member should not visit while receiving treatment. 2.The LPN/LVN brings the client's daily medications an hour prior to a scheduled respiratory treatment. 3.The LPN/LVN dons protective clothing before entering the client's room. 4.The LPN/LVN uses standard precautions when handling the client's meal tray following the meal. 5.The LPN/LVN advises the unlicensed assistive personnel (UAP) that the client should be placed in a single-occupancy room.

1) INCORRECT- Pregnant women and young children should avoid exposure to the client while internal radiation treatment is in progress. This is an appropriate action. 2) CORRECT- Clients undergoing internal radiation treatments should have their care and treatments clustered as much as possible to reduce unnecessary exposure to staff members. The nurse should intervene and provide teaching to the LPN/LVN. 3) INCORRECT- Exposure to potential radiation should be as low as reasonably achievable. The LPN/LVN and other staff should wear appropriate protective clothing while caring for the client. This is an appropriate action. 4) INCORRECT- This is an appropriate action. Standard precautions should be used when handling articles that have been in the client's room and in contact with the client. 5) INCORRECT- This is an appropriate action. Clients undergoing internal radiation treatments should not share a room with another client to avoid unnecessary exposure to radiation.

A client who has been confined to bed for several weeks begins to show early signs of a pressure injury on the heel. Which action does the nurse take? (Select all that apply.) 1.Place a sheepskin cloth under the heels. 2.Keep the feet in ankle-foot splints throughout the day. 3.Place a rolled towel under the calf. 4.Have the client wear socks when moving in bed. 5.Massage the heel every 2 hours. 6.Apply lotion to the ankles three times a day.

1) INCORRECT- Sheepskins reduce but do not remove pressure. The heel must be kept off the bed. 2) INCORRECT- Ankle-foot splints will not reduce pressure on the heels. 3) CORRECT- Placing a rolled towel or pillow under the calf will raise the heel off the bed and allow healing. Do not place the device under the Achilles tendon because it can cause injury. 4) CORRECT- Wearing socks while moving in bed reduces further injury from friction. 5) INCORRECT- Massaging a damaged area can increase tissue breakdown. 6) INCORRECT- Lotion will not aid in the healing of a heel pressure injury. Elimination of pressure from the bed is best.

A client diagnosed with chronic kidney disease is informed that hemodialysis must be started immediately. The client becomes extremely upset and begins to cry. Considering the client's medical diagnosis and emotional state, which statement does the nurse make? (Select all that apply.) 1."Do not worry. We will refer you to the best hemodialysis team." 2."Hemodialysis is only temporary." 3."I am just going to sit here with you for a while." 4."There are many positive things to look forward to." 5."Hemodialysis will greatly improve your health in the coming days." 6."I am here if you want someone to talk to."

1) INCORRECT- The client is in the early stages of trying to cope with the diagnosis and the required treatment. The priority is to assess the client's emotional state and assist with lowering the client's level of anxiety. This statement is non-therapeutic because it is false reassurance and has a dismissive tone for the client's current state. 2) INCORRECT- This statement is false reassurance. There is no guarantee that the client will only need hemodialysis temporarily. 3) CORRECT- This statement shows compassion and concern and will help the nurse establish therapeutic communication with the client. The client likely is in shock over hearing the diagnosis and the required treatment. Because the client is in a high state of anxiety, it is therapeutic for the nurse to offer support by sitting near the client until the client is ready to talk. Stating that the nurse will just sit near the client communicates the nurse's intention and will make the client feel that the nurse is not invading the client's personal space. 4) INCORRECT- This statement diverts attention from what the client is currently going through and has a dismissive tone. 5) INCORRECT- This statement may be perceived as false reassurance, as "greatly-improved health" is not a guarantee. 6) CORRECT- This statement offers the nurse's presence without being overwhelming for the client. Because the client needs more time to cope with the diagnosis and the required treatment, it is therapeutic for the nurse to offer support by staying near the client until the client is ready to talk. Stating that the nurse will be nearby for the client informs the client of the nurse's intention and will avoid the client getting anxious about the nurse's presence.

he nurse provides care for clients on a medical-surgical unit. Which information, if obtained by the nurse, should be reported to the health care provider immediately? (Select all that apply.) 1.A client with a systolic blood pressure of 180 mm Hg has a standing order for PRN labetalol. 2.A client reports new onset calf pain 2 days after total knee arthroplasty. 3.A client receiving metformin reports weakness, unusual sleepiness, and muscle cramping. 4.A client being treated for hypertension and diabetes mellitus appears sluggish and confused. 5.A client diagnosed with acute kidney injury has a serum potassium level of 4.7 mEq/L (4.7 mmol/L). 6.A client admitted with ulcerative colitis reports passage of bloody diarrhea.

1) INCORRECT- The client's blood pressure is elevated significantly, but the client is eligible to receive a dose of labetalol—a beta blocker medication—to lower the blood pressure. The nurse would not need to contact the provider unless the systolic blood pressure did not respond to the labetalol. 2) CORRECT- New onset calf pain could indicate a deep vein thrombosis. This potential complication should be reported to the health care provider immediately. A deep vein thrombosis can be life-threatening if the clot dislodges and travels to the lung, causing a pulmonary embolism. 3) CORRECT- This client is reporting symptoms of lactic acidosis, which is a life-threatening adverse reaction to metformin. These symptoms need to be reported to the health care provider immediately. 4) CORRECT- Confusion is not an expected symptom in a client with hypertension and diabetes mellitus. It could be an indicator of an acute condition in this client, such as hypoglycemia, infection, or stroke. These symptoms should be reported to the health care provider immediately. 5) INCORRECT- Clients with acute kidney injury are at risk for hyperkalemia, which can lead to life-threatening cardiovascular complications. However, the potassium level is within the normal range of 3.5-5 mEq/L (3.5-5 mmol/L) and does not need to be reported to the health care provider. 6) INCORRECT- Bloody diarrhea is an expected finding in a client with ulcerative colitis and does not require immediate reporting to the health care provider.

The nurse provides care for a middle-age adult diagnosed with prostate cancer who is receiving brachytherapy. Which intervention is appropriate when caring for this client? (Select all that apply.) 1.Sitting with the client during meal times. 2.Assigning the client to a private room. 3.Posting notices about radiation safety precautions. 4.Assigning this client to a nurse who is pregnant. 5.Limiting visitors to 30-minute sessions.

1) INCORRECT- There is no indication that this intervention is necessary, as it places the nurse at increased radiation exposure risk. 2) CORRECT- This protects other clients from being unnecessarily exposed to the radiation. 3) CORRECT- This will alert the health care team members to take appropriate precautions when interacting with this client. 4) INCORRECT- Assigning a nurse who is pregnant to care for this client places the fetus at increased radiation exposure risk. 5) CORRECT- This action limits the visitor's exposure to radiation while allowing the visitor to offer emotional support to the loved one.

An older adult client diagnosed with malnutrition is being discharged to home. When reviewing discharge instructions, which menu does the nurse suggest this client follow? (Select all that apply.) 1.Spinach salad, low-fat yogurt, cookie, and sweet tea. 2.Two hard-boiled eggs, turkey sausage, blueberry whole milk yogurt, and apple juice. 3.Turkey casserole with croissant, baked carrots, canned fruit, and whole milk. 4.Lentil chili, whole grain crackers, banana, and water. 5.Scrambled egg whites, blueberries, apple, and grapefruit juice.

1) INCORRECT- This menu is not appropriate for a client diagnosed with malnutrition because it is not very high in calories or protein. 2) CORRECT- This menu is well-balanced and high in calories and protein. This is a good choice for a client diagnosed with malnutrition. 3) CORRECT- This menu is well-balanced and high in calories and protein. This is a good choice for a client diagnosed with malnutrition. 4) INCORRECT- Overall, this menu is not very high in protein or calories and therefore is not the best option for a client diagnosed with malnutrition. 5) INCORRECT- This is a good low-calorie option, but a client with malnutrition needs foods that are high in calories and protein.

The nurse instructs a client recovering from acute pancreatitis on actions to reduce further inflammation. Which client statement indicates to the nurse that teaching is effective? select all that apply 1. I will avoid all alcoholic beverages 2. I will drink plenty of water and limit caffeinated beverages 3. I will avoid strict dieting as a means to lose excess weight 4. I will increase the intake of fat in my diet 5. I will cut the amount of my cigarette smoking in half

1, 2, 3 Alcohol intake is a major cause for the development of acute pancreatitis; duodenal edema leads to spasms at the sphincter of Oddi, which results when alcohol is ingested; the client recovering from acute pancreatitis should avoid all alcohol since this could cause further damage to the pancreas Caffeine stimulates the production of gastric and pancreatic secretions, which could cause pain in the client recovering from acute pancreatitis; because of this, caffeine should be limited; it is very important for the client to be well hydrated after an episode of pancreatitis Dieting should be avoided in the client recovering from acute pancreatitis because rapid weight loss places the client at risk for another attack; the client should be instructed to ingest frequent small meals throughout the day

The nurse instructs a client prescribed hydralazine as tx for HTN. Which client statements indicate to the nurse that the teaching is effective? select all that apply 1. I will take my hydralazine w/my breakfast 2. I will call my HCP before taking ibuprofen 3. I need to have my blood drawn twice a week 4. I will feel hungry while on this medication 5. I will sit on the edge of my bed for 2 minutes before I get out of bed

1, 2, 5 Hydralazine should be taken w/food to increase bioavailability of the medication OTC medications should be avoided when taking hydralazine unless otherwise directed by the HCP Orthostatic hypotension is a possible adverse effect of hydralazine; the client should be instructed to sit on the edge of the bed prior to standing to prevent this effect

The nurse teaches a client dx w/Cushing syndrome about the disease process. Which client statements indicate to the nurse that teaching is effective? select all that apply 1. my dx helps explain why my bones are weak 2. I need to increase my daily caloric intake 3. my HCP may prescribe a diuretic for me 4. I need to avoid people who have infections 5. I may have to take potassium supplements 6. I feel weak because the syndrome makes my blood glucose low

1, 3, 4, 5 Cushing syndrome results from chronic exposure to excess corticosteroids; excess corticosteroids adversely affect the bone structure, leading to weakening Edema of the lower extremities is common in Cushing syndrome; a potassium-sparing diuretic may be prescribed The client is at risk for an infection r/t lowered resistance to stress and suppression of immune system caused by excessive corticosteroids Hypokalemia commonly occurs in Cushing syndrome; potassium supplements are often prescribed

A newborn receives phototherapy for hyperbilirubinemia. Which finding on day 2 is a cause for concern? select all that apply 1. the parent removes the eye covers when taking the newborn out to feed 2. the newborn is sleepy and lacks interest in breastfeeding 3. the newborn has had one stool since starting phototherapy yesterday 4. the newborn awakens and cries prior to the scheduled feeding time 5. the newborn's temperature is 100 F

2, 3, 5 The newborn may be becoming more lethargic, indicating non-improvement in the hyperbilirubinemia despite phototherapy Unconjugated bilirubin that is successfully excreted in the stools results in frequent, loose, green stools; because the newborn has had only one stool since phototherapy was initiated, this is cause for concern Phototherapy can cause changes in the client's temperature; the lights can increase insensible water loss and lead to dehydration; in addition, a change in temperature can contribute to a hypermetabolic state

The nurse provides care to a client who has just undergone cardiac catheterization. The nurse is concerned by which assessment finding? select all that apply 1. the area around the insertion site has a bluish discoloration 2. the client has difficulty swallowing ice chips and water 3. the client reports nausea and sleepiness 4. the area around the insertion site is swollen and tender 5. the client reports feeling anxious and SOB

2, 4, 5 Potential complications of cardiac catheterization include CVS; s/s of CVS include neurologic changes, such as swallowing difficulties, slurred speech, and weakness in the extremities Complications cardiac catheterization include formation of a hematoma at the catheter insertion site; manifestations of a hematoma include swelling (or a lump) at the insertion site, as well as pain and tenderness at the site Potential complications associated w/cardiac catheterization include pulmonary embolism; s/s of pulmonary embolism include anxiety and SOB

An infant w/an unrepaired congenital heart defect has been prescribed digoxin for HF. Which assessment finding indicates the medication is having the desired effect? select all that apply 1. potassium level 2.92. HR 72 bpm 3. clear breath sounds 4. normal sinus rhythm 5. easy work of breathing

3, 4, 5 As HF improves, pulmonary congestion resolves When levels are therapeutic and the medication is effective, arrhythmias are controlledW/increased cardiac contractility, HF is lessened, resulting in improvements in SOB

A client diagnosed with cirrhosis of the liver reports, "I cannot catch my breath." Which finding does the nurse report to the health care provider? (Select all that apply.) 1.Palpable swelling on bilateral ankles. 2.Blood pressure of 165/90 mm Hg. 3.Auscultation of crackles in the lung fields. 4.Bulging jugular vein. 5.A weight gain of 2 kg (4.4 lb) in 24 hours. 6.Blood urea nitrogen (BUN) level is 7 mg/dL (2.5 mmol/L).

ALL OF THE ANSWERS ARE CORRECT!!! 1) CORRECT- Edema, especially in the lower extremities, is a clinical sign of fluid volume excess. 2) CORRECT- Hypertension due to expansion of extracellular fluid is a sign of fluid volume excess. 3) CORRECT- Crackles noted on auscultation are manifestations of fluid volume excess. 4) CORRECT- Jugular vein distention is a clinical manifestation of fluid volume excess. 5) CORRECT- A weight gain of 2 kg in 24 hours signifies about 2 liters of excess fluid. 6) CORRECT- As a result of plasma dilution, BUN levels may be decreased in clients who have fluid volume excess. A normal BUN level is 10 to 20 mg/dL (3.57 to 7.14 mmol/L).

Arrange the steps for donning the prosthetic device in order

The nurse may offer pain medication to allow for comfortable prosthesis placement. Lubricant decreases friction, thus making it easier to place the prosthetic device. The liner must be rolled up against the end of the residual limb prior to prosthetic placement. This acts as a barrier between the skin and the hard plastic of the device. Wrinkles increase pressure points, thus increasing the risk for skin breakdown. The suspension sleeve creates a tight seal between the residual limb and the prosthetic limb. Expelling air creates a vacuum seal between the residual and prosthetic limb.