Midterm N101

80. The dose ordered for the client is 37.5 mg IM. How many milliliters of the medication should the practical nurse administer from a 100-mg/2-ml syringe? a.0.5 ml b.0.75 ml c.1.0 ml d.1.5 ml

b.0.75 ml

84. The practical nurse (PN) is completing an intake and output record for a client who has been restarted on a regular diet after being NPO. The client has the following intake and output during the shift: Intake: 4oz cranberry juice, ½ cup of oatmeal, 2 slices of toast, 80z. of black, decaf coffee, tuna fish sandwich, ½ cup of fruit-gelatin, 1 cup of soup, 60z of 1% milk, 16oz of water. Output: 1300 ml of urine How many milliliters should the PN document as the client's intake?_____________________

ANS: 1380 30ML IN EACH ounce, 240ml in each cup

87. A practical nurse (PN) has been assigned four clients. The nursing assistant is helping with client care. Which assignments are appropriate to delegate to the nursing assistant? (Select all that apply). a. accompany a client being discharged b. collect a urine specimen from a 75-year-old client c. feed a severely disabled teenage client breakfast d. offer sips of water to a postoperative client e. catheterize an elderly client f. administer oral medications

ANS: A,B,D a, b, and d. are within the nursing assistant's scope of practice, the others are not.

86. The practical nurse instructs the client on mixing NPH and regular insulin in the same syringe. Rank the client teaching in the order the client should follow to ensure accurate dosing. _________________ 1. Withdraw the NPH insulin. 2. Withdraw the regular insulin. 3. Remove air bubbles for correct dose. 4. Calculate the combined total volume of insulin. 5. Inject air equal to the NPH insulin volume into the vial. 6. Inject air equal to the regular insulin volume into the vial.

5, 6, 2, 3, 4, 1 3. The first step for the client when mixing NPH and regular insulin is to aspirate air into the syringe equal to the volume of NPH insulin needed, inject the air into the NPH vial and avoid removing NPH insulin at this time. Injecting the air prepares the vial to dispense the correct volume of NPH insulin by displacement. 6 and 2. The nurse instructs the client to perform the same actions on the regular insulin with the same syringe, making sure the correct volume is aspirated and injected into the vial; then the client withdraws the correct volume of regular insulin. 3. The client should remove the air bubbles at this time to ensure the correct dose. 4. The nurse double checks the MAR and the prescription and calculates the total volume of the combined insulins. 1. Finally, the client inserts the needle into the NPH vial, allows the insulin to flow into the syringe containing the regular insulin, and matches unit measurements on the syringe to ensure the correct dose.

85. The physician has ordered furosemide 20 mg stat. The ampule is labeled 40 mg/ml. How many ml. will the practical nurse give?______________________

ANS: 0.5 ml.

83. A client is prescribed hydromorphone (Dilaudid) 10 mg by mouth every 4 hours as needed for pain. The client rates his pain as eight on a one-to-ten scale, so the practical nurse (PN) prepares to administer a dose. The unit has Dilaudid 5mg/5ml on hand. How many milliliters should the PN administer?

Ans=10 ml or 10 formula: 10mg/5mg x 5ml

64. When following standard precautions, the practical nurse's primary responsibility is to: a. wear gloves for all contact with the client b. consider all body substances potential infectious c. place a body substance isolation form on the client's door d. wear gloves and gown whenever caring for the client

b. consider all body substances potential infectious Standard precaution are based on the concept that all body substances are potentially infectious and contact with them should be avoided

40. A practical nurse is caring for a client who weighs 200 lb and is 62 inches. Using the formula for Body Mass Index, what is the BMI for this client? a. 35.05 b. 38.13 c. 36.95 d. 37.18

Wt to Kilo: 200/22=90.9 Height to Meters: 62/39.37=1.57 BMI: 90.9/ (1.57 x 1.57) = 36.95

65. The practical nurse (PN) observes several dark bruised areas on a female teen-age client's back. The client becomes extremely upset and asks the PN not to tell anyone. What response by the PN is best? a. "I have to report what I see to the physician." b. "I won't say anything, but if it happens again you need to call the police" c. "Why don't you just run away?" d. "You have possible internal injuries that could be harmful to your health"

a. "I have to report what I see to the physician." REFLECTS nurses understanding of policy for suspected child abuse

55. The practical nurse (PN) is caring for a female client who is 8 hours post-operation and unable to void. When placing an indwelling catheter, the PN should first advance the catheter how far into the urethra? a. 2 in. (5cm) b. 6 in. (15cm) c. 8 in. (20cm) d. ½ in. (1cm)

a. 2 in. (5cm) THE nurse should advance the catheter 2-3 in. or until urine appears. When urine appears the nurse should advance 1-2 more inches. Male: 6-7 in Female: 2-4 in

30. While selecting medication through the new computerized medication administration system, the practical nurse (PN) notices that the previous nurse removed a narcotic that was ordered for pain for a client, but did not chart that the narcotic was given. The client denies receiving anything for pain. Which action should the PN take first? a. approach the previous nurse to seek clarification about the missing narcotic b. notify the pharmacist that a narcotic is missing c. notify the charge nurse/supervisor that the client did not receive the pain medication d. notify the client that someone else received his pain medication

a. approach the previous nurse to seek clarification about the missing narcotic Asking the nurse is the first step. b and c may occur after clarification has been sought. D is inappropriate

24. The physician orders hourly urine output for a postoperative client. The practical nurse records the following output for 2 consecutive hours: 50ml (8am), 60ml (9am). Based on these findings, what action should the PN take? a. continue to monitor and record hourly urine output b. notify the physician c. irrigate the indwelling urinary catheter d. increase the I.V. infusion rate

a. continue to monitor and record hourly urine output Output is normal so other action is needed. The nurse should report output less than 30 mL/hr for more than 2 hr is a cause of concern. Most adults produce 1,500 - 2000 mL/day of urine Once an adequate amount of urine (150-200 mL) collects in the bladder, stretch receptors in the bladder wall send signal to the brain to indicate the need to urinate. ATI

60. Which nursing action is essential when providing continuous enteral feeding? a. elevating the head of bed at least 30 degrees b. positioning the client on the left side c. warming the formula before administering it d.hanging a full day's-worth of fluid

a. elevating the head of bed at least 30 degrees Raising the HOB minimizes risk for aspiration and allows formula to flow into the client's intestines. Semi-fowlers

34. The practical nurse (PN) is preparing to administer an injection to a client who has been receiving this medication for weeks, when the client says, "My doctor changed this to a pill and I am not going to take that shot again." What action should the PN take first? a. go back to the chart and check for the order b. check the order sheet for the changed order and then speak with the client's physician concerning the order c. talk with the nurse who had previously taken care of the client who is now off duty d. talk with the charge nurse about the advisability of giving an oral rather than injectable medication

a. go back to the chart and check for the order This is done to prevent an error. #2 is not necessary after checking the order; it is the nurse's responsibility to check orders.

28.. An elderly client who underwent a total knee replacement was assigned to a rehabilitation unit. Which of the following duties can the practical nurse (PN) delegate to the nursing assistant? a. go to physical therapy with the client b. change dressings on the surgical wound c. attend rounds with the physician d. perform range-of-motion (ROM) exercises on the affected knee

a. go to physical therapy with the client The PN can delegate going to physical therapy to the nursing assistant b, c, and d are not within the scope and practice of the nursing assistant -Activities of daily living and routine tasks -Right Task -Right circumstances -Right person -Right communication/direction -Right supervision/evaluation

15. The practical nurse would expect which complaint from a client with a fecal impaction? a. liquid or semi-liquid stools b. hard, brown formed stools c. loss of the urge to defecate d. increased appetite

a. liquid or semi-liquid stools Passage of liquid stool occurs d/t seepage of unformed bowel contents around the impacted stool in the rectum. Clients don't pass hard, formed stools b/c of the impaction oil-retention enema: -Lubricate colon & rectum -oil absorbed by feces -stool is softer and easier to pass -instruct pt to retain the enema for as long as possible (1-3 hrs) Tube insertion: -3-4 in (7-10 cm) -hold container 12-18 in above the anus 2 inched with finger S/S: Liquid stool (the stool is leaking around the impacted mass of feces and can be mistaken for diarrhea), abdominal pain/cramping, bloating, passing excessive gas, urge to BM, n/v pg 382

1. A physician in a long-term care facility wrote a medication order that was incorrect. The practical nurse (PN) gave the medication without questioning it. The client died from the overdose. Who is liable? a. the physician and the practical nurse (PN) b. the practical nurse (PN) who gave the medication c. the long-term care facility d. the pharmacist

a. the physician and the practical nurse (PN) Both physician and nurse are held liable for their negligence Unintentional Tort: Negligence: -absence of due care -failure to act in a manner demonstrating the care and knowledge any prudent individual would Ex: Medication errors, patient falls, use of restraints, and proper use of equipment pg. 23 Malpractice: professional negligence 1. Duty: patient - nurse relationship 2. Breach of duty: failure to perform the duty in a reasonable, prudent manner 3. Harm: does not have to be physical 4. The breach of duty was proximate cause of the occurrence of the breach pg 24

82. Which methods does the practical nurse use to identify a client correctly and properly? (Select all that apply.) a.Compare wristband with MAR. b.Ask a staff member to identify. c.Ask the client for client's name. d.Check client identification band. e.Compare room number with MAR. f.Say name; ask client if it is correct.

a.Compare wristband with MAR. c.Ask the client for client's name. d.Check client identification band. a. The nurse compares the wristband with the MAR and verifies the spelling of the client's name and numbers of the medical record number, depending on agency policy. c. The nurse properly identifies a client by asking the client to state and spell the client's name. If the client is unable to do so, the nurse uses other methods to identify the client. d. The client identification band is compared with the MAR. b, e, and f. Asking a staff member, using the room number, and asking the client a yes or no question risk misidentifying the client. Using the room number is especially dangerous because clients are frequently transferred to other rooms or units.

77. The practical nurse (PN) prepares an insulin injection for the client who has diabetes mellitus. Which does the PN implement for insulin administration? a.Gives regular insulin within 15 to 30 minutes of meals b.Stores sealed, unused insulin vials at room temperature c.Examines vials of NPH insulin for abnormal cloudiness d.Administers NPH insulin for sliding-scale insulin dosing

a.Gives regular insulin within 15 to 30 minutes of meals a. The nurse administers regular insulin subcutaneously within 15 to 30 minutes of the client's meal because it starts to work in 30 minutes to 1 hour; thus, the client eats around the same time as the insulin administration to avoid severe hyperglycemia (occurs if client eats and does not take insulin) or hypoglycemia (does not eat and takes insulin). b. Sealed, unused insulin is generally stored in a refrigerator to prevent decomposition. c. NPH insulin has a cloudy appearance. d. Regular insulin is used for sliding-scale insulin and as needed insulin.

7. The practical nurse (PN) must delegate care to the nursing assistant. Care of which of the following clients can be delegated to the nursing assistant? a. newly admitted total knee replacement client b. cerebral vascular accident client being transferred to a skilled nursing floor c. terminally ill client with continuous morphine infusing d. preoperative client with suspected colon cancer

b. cerebral vascular accident client being transferred to a skilled nursing floor A nursing assistant can assist with transport of a client. A, c, and d would require supervision by a licensed nurse. ATI: pg 25

70. The practical nurse (PN) is teaching the client to self-administer insulin. The client is 5 feet tall and weighs 197 pounds. Which does the PN include in client teaching? a.Insert the needle into abdominal tissue at 90-degree angle. b.Include an air space when drawing up the prescribed dose. c.Aspirate before injecting to ensure needle is not in a vessel. d.Instruct client to use an insulin syringe with a 1-inch needle.

a.Insert the needle into abdominal tissue at 90-degree angle. a. The nurse instructs the client to insert the needle at a 90-degree angle to inject insulin into subcutaneous tissue because the client is obese and likely to have excessive abdominal adipose tissue. The 5/8-inch needle is long enough to reach subcutaneous tissue for proper administration of insulin but not long enough to reach muscle. b. The nurse instructs the client to remove all air bubbles from the syringe before administering the insulin. c. Aspiration is unnecessary for subcutaneous injections because the tissue is avascular. Never massage. d. A 1-inch needle is unnecessary because a 5/8-inch needle reaches the same subcutaneous tissue in this client as a 1-inch needle. SubQ: -1/2 - 5/8 in -25 - 28 G -29 - 30 G insulin -drug absorption is slower due to no blood supply -outer aspects of upper arms, thighs, abdomen and scapula -no more than 1 mL each site

61. While preparing a client for a diagnostic colonoscopy, the practical nurse teaches him how to use a prepackaged enema. Which statement by the client indicates teaching was understood? a. "I will administer the enema while sitting on the toilet." b. "I will administer the enema while lying on my left side with my right knee flexed" c. "I will administer the enema while lying on my right side with my left knee flexed." d. "I will administer the enema while lying on my back with both knees flexed."

b. "I will administer the enema while lying on my left side with my right knee flexed" lying on the left side allows the enema to flow downward by gravity along the natural curve of the colon.

36. The practical nurse is caring for a small child who has been febrile for the last few days. Which of the following statements by the mother would indicate the need for further teaching? a. "When we get home, I can take his temperature by placing the thermometer under his tongue." b. "If he has a fever, I will give him aspirin to help bring it down." c. "I shouldn't take his temperature right after he has been drinking his milk." d. "If his temperature is 100° F, then I will need to call the physician."

b. "If he has a fever, I will give him aspirin to help bring it down." A statement about giving aspirin to a small child would indicate a problem and the need for further teaching. *Children should not be given aspirin due to the risks of Reye's syndrome. 97 - 99.6 F (36.1-37.5 C) Hyperthermia: 105 F (40.5 C) - destroy normal body cells Hypothermia: 93.2 F (34 C) -Death is a risk pg 283 1. Constant: remain elevated, little fluctuation 2. Intermittent: Rise and fall 3. Remittent: temp does not return normal

68. The provider prescribes aluminum hydroxide gel 2 ounces. The practical nurse (PN) has aluminum hydroxide in 30-ml containers in the client's medication drawer. How many containers does the PN administer to the client? a. 1 b. 2 c. ½ d. 1½

b. 2 The nurse administers two containers at 30 ml per container because 1 ounce = 30 ml. The prescription calls for aluminum hydroxide 60 ml, so to administer 60 ml the nurse needs two containers

29. While assessing a patient's lower extremities, the practical nurse (PN) notes edema around the feet and ankles. When the area is depressed, it last for more than 1 minute before the shape returns. The PN would document this edema as: a. 4+ pitting edema b. 3+ pitting edema c. 2+ pitting edema d. 1+ pitting edema

b. 3+ pitting edema pg 334 4+ Severe (8mm): pitting edema is very deep pitting, very edematous and distorted extremity, with depression lasting as long as 2 to 5 minutes. 3+ Moderate (6mm): pitting edema is noticeably deep pitting, full and edematous extremity, with depression lasting more than 1 minute 2+ Mild (4mm): pitting edema is somewhat pitting edema, no marked change in shape of the extremity, and depression disappears in 10-15 seconds. 1+ Trace (2mm): pitting edema is slight pitting, no visible change in the shape of the extremity and depression disappears rapidly. ATI: pg 162

19. A practical nurse (PN) is inserting an indwelling urinary catheter into the urethra of a male client. As the PN inflates the balloon, the client complains of discomfort. What is the most appropriate nursing action? a. Remove the syringe from the balloon; discomfort is normal and temporary. b. Aspirate the fluid, advance the catheter farther, and reinflate the balloon. c. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon. d. Aspirate the fluid, remove the catheter, and reinsert a new catheter.

b. Aspirate the fluid, advance the catheter farther, and reinflate the balloon. If the balloon is malpositioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther to provide sufficient space to inflate the balloon. The catheter's balloon is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. report of fullness in the bladder area, check for kinks and sediments in the tubing There is no need to remove the catheter and reinsert a new one. Make sure collection bag is at the level below bladder to avoid reflux. Pain when the balloon is inflated is not normal or temporary

48. A client is admitted to the hospital with a sacral wound that has a foul odor, purulent drainage, and necrotic tissue in the center. It measures 4 cm in circumference by 2 cm deep. What is the most appropriate nursing diagnosis? a. Risk for infection b. Impaired skin integrity c. Chronic pain d. Impaired peripheral circulation

b. Impaired skin integrity The collected data all show that there is an impaired skin integrity

2. A client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. A practical nurse (PN) notes that the client has abdominal distention as well. The PN reviews the nutritional content on the label of the can to see if it contains which of the following ingredients? a. Maltose b. Lactose c. Sucrose d. Fructose

b. Lactose Several tube feeding formulas contain lactose. A client with an unreported history of lactose intolerance would develop symptoms such as these in response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose-free formula should be prescribed by the physician. This will resolve the client's symptoms and promote adequate nutrition for the client. Simple Carbs Disaccharides: Maltose: Malted grain products Lactose: Milk Sucrose: Table sugar, sugarcane, powdered and brown sugar, fruits Monosaccharides: Glucose: dextrose, corn syrup Fructose: Fruits, honey, high fructose corn syrup Galactose: Milk Polysaccharides: Complex carbs Starch Glycogen Dietary fiber pg 527

3. A practical nurse (PN) is assigned to care for a client receiving enteral feedings. The PN plans care knowing that which of the following is of highest priority for this client? a. Imbalanced nutrition b. Risk for aspiration c. Risk for deficient fluid volume d. Risk for diarrhea

b. Risk for aspiration Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Options 1 and 4 may be appropriate but are not the highest priority. Option 3 is not likely to occur in this client.

42. Which reaction is a normal response to a corneal sensitivity test? a. seeing a flash of light b. blinking c. pupil dilation d. pupil contraction

b. blinking the normal response is blinking Sensitivity of the cornea is a protective mechanism Trigeminal nerve (V) carries sensory fibers for the cornea

44. A geriatric client is admitted to the hospital after fainting while gardening on a hot summer day. What is the priority nursing diagnosis for this client? a. activity intolerance b. hyperthermia c. disturbed thought process d. risk for falls

b. hyperthermia With age the ability to regulate temperature diminishes, putting these patients at risk for hyperthermia. Since hyperthermia can be life-threatening, has the highest priority.

10. The practical nurse is caring for a client with a history of falls. What is the priority nursing action? a. placing the call light within reach b. keeping the bed in the lowest, locked position c. instructing the client not to get out of bed without permission d. keeping the bedpan available so the client does not have to get out of bed

b. keeping the bed in the lowest, locked position Having the bed in lowest position and locked is the priority

57. The practical nurse (PN) sees and unauthorized person reading the client's medical record outside the client's room. What action would be best for the PN to take? a. approach the individual and request the client's chart b. notify the nursing superviser and approach the client c. contact security immediately d. document the incident on an incident report

b. notify the nursing superviser and approach the client Approaching the person alone isn't sufficient, notifying the superviser first is most appropriate with this brief of confidentiality.

33.The practical nurse (PN) notes the client has difficulty breathing in the supine position and the patient admits that he sleeps in a recliner at home. What action should the PN take next? a. notify the physician of respiratory disease b. obtain a pulse oximeter reading on the client c. document the client's history of emphysema d. instruct the client to lay supine, then auscultate the lungs

b. obtain a pulse oximeter reading on the client The nurse should next assess the arterial oxygen saturation via pulse oximetry to complete data collection. Client should not be instructed to lay supine if the client demonstrates respiratory distress.

62. A client is admitted to the facility with a productive cough, night sweats and a fever. What action is most important in the initial plan of care? a. monitoring the client's temperature every 8 hours b. placing the client in isolation c. monitoring the fluid intake and output d. wearing gloves during all client contact

b. placing the client in isolation Client is exhibiting signs of a respiratory infection, possibly TB so Airborne isolation is the priority. gloves are need only when in contact with body fluids & mucus membranes. Bacterial infection s/s: blood tinged, dry, purulent, cough, night sweats, wt loss, anorexia

25. A female client who had pelvic surgery two weeks ago is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following would the practical nurse recognize as a major contributing factor? a. history of increased aspirin use b. recent pelvic surgery c. an active daily walking program d. a history of diabetes

b. recent pelvic surgery History of recent surgery is a risk factor for DVT. Diabetes is generally associated with peripheral vascular disease -A DVT is the formation of a blood clot within the deep veins. It's a type of venous thromboembolism (VTE). Unfortunately, a deep vein thrombosis can break off and turn into a pulmonary embolism (another type of VTE). S/S: calf pain and cramping, redness, unilateral swelling, warmth of surrounding skin, and positive Homan's Sign (dorsiflexion pain), *SOB and chest pain=PE Need doppler NO hot pads, TED/SCD (Hoses can dislodge clot) massage. Interventions: -Only warm and moist pads. -Bed rest (do not walk) -Elevate the leg Interventions: when resolve (after clot) C: calf exercise and isometrics H: hydration A:Ambulation N: No long sitting (car rides, airplanes) T: TED/SCD when clot resolves (stockings should be removed once every shift to monitor for circulation and inspect skin) *thrombosis/embolism

22. The ear canal of an adult: a. slants upward b. slants downward c. is horizontal d. slants backward

b. slants downward -Slants downward in an adult -Slants upward in a younger child. Tympanic Temp: Pull ear up and back = Adult Pull ear down and back = child younger than 3 y/o) *Tympanic shares blood supply with Hypothalamus, good source for obtaining core-temp

17. A client with a history of heart failure is at risk for fluid volume excess. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status? a. measuring and recording fluid intake and output b. weighing the client at the same time each day c. assessing vital signs every 4 hours d. checking the lungs for crackles each shift

b. weighing the client at the same time each day Excess fluid volume leads to rapid weight gain-2.2lbs per liter retained. Weighing the client at the same time provides more objective data that measuring intake/output b/c there might be errors

11. The provider prescribes a sublingual medication and the pharmacy sends it in oral form. Which should the practical nurse implement? a.Administer the identical drug orally. b.Call pharmacy for sublingual formulation. c.Withhold drug and notify the provider. d.Calculate oral equivalent dose for client.

b.Call pharmacy for sublingual formulation. b. The nurse can administer the sublingual medication in sublingual form only; changing the route of administration is practicing medicine and is outside the scope of practice for the nurse. The nurse owes a duty to the client to obtain the sublingual form for administration. a. The nurse cannot administer the oral medication, even if it is the identical drug, because it is the wrong route and violates a client medication right. c. Withholding the medication until the provider is notified is risky and unnecessary because the nurse can ask the pharmacy to send the correct form of the medication. If the pharmacy does not carry the prescribed form, then the nurse should contact the provider. d. Many medications come in several forms; thus, determining an equivalent dose of a medication in another form is possible; however, the nurse needs a prescription for both forms of the medication to administer the oral form. 1. Right patient 2. Right time 3. Right route 4. Right Dose 5. Right medication 6. Right Documentation

23. Which statement reflects appropriate documentation in the medical record of a hospitalized client a. "Small pressure ulcer noted on the leg." b. "Client seems to be mad at the physician." c. "Client's skin is moist and cool." d. "Client had a good day."

c. "Client's skin is moist and cool." Documentation should include data that was collected. Documentation of a leg ulcer should include exact size and location.

67. The practical nurse (PN) administers the client's medication and, within 30 minutes, the client has bilateral wheezing, large red blotches on the face, and is anxious and dizzy. Which action should the PN take? a.Encourage the client to drink plenty of fluids. b.Direct a colleague to contact the provider stat. c.Check the MAR for an antihistamine as needed. d.Document potential client allergy to medication.

b.Direct a colleague to contact the provider stat. The client has clinical indicators of a moderate to severe hypersensitivity reaction, most likely related to the medication. The wheezing increases the risk of impairing the client's airway and the blood pressure can be low already, as evidenced by client dizziness. The nurse should stay with the client and wait for emergency equipment, supplies, and personnel to assist. In the meantime, the nurse should plan to support the client's airway, breathing, and circulation.

69. The client with chronic obstructive pulmonary disease uses a metered-dose inhaler (MDI). Which instructions should the practical nurse (PN) provide the client on administering glucocorticoids by MDI? a.Administer two puffs of medication in rapid succession. b.Maintain firm seal with lips around inhaler's mouthpiece. c.Dispense glucocorticoid 30 seconds after a bronchodilator. d.Press MDI after breathing in and out deeply.

b.Maintain firm seal with lips around inhaler's mouthpiece. -maintain a firm seal around mouthpiece of the MDI -take a bronchodilator before any subsequent medications administrated by an MDI such as a glucocorticoid -glucocorticoid is the most critical medication -Although the bronchodilator is important to open the airway, the glucocorticoid is the most critical medication to deliver deep into the lungs for its anti-inflammatory effect. The client opens the airways with the bronchodilator and then is able to deliver the glucocorticoid deep within the lungs. a. A MDI delivers medication by inhalation and does not lend itself to delivering two puffs in rapid succession because a short wait is usually required for the medication to reach deeper parts of the lung. Not only is it difficult to activate the MDI quickly, but the client may not have the ventilatory capacity to quickly inhale two puffs. c. When administering a glucocorticoid after a bronchodilator, the nurse waits 5 minutes to give the bronchodilator time to work and then administers the second agent. d. To use an MDI, the nurse instructs the client to exhale and then inhale slowly and deeply to drive the inhalation medication into the lungs.

73. The practical nurse (PN) evaluates the client's ability to self-administer subcutaneous enoxaparin (Lovenox). Which action by the client demonstrates the need for further client teaching? a.Injects at a 45-degree angle. b.Massages area after injection. c.Administers without aspirating. d.Injects 3 inches from umbilicus.

b.Massages area after injection. b. The nurse wants the client to avoid massaging the injection site after administering enoxaparin (Lovenox) to prevent the formation of large hematomas and to decrease the risk of additional bleeding and tissue damage. The nurse instructs the client to inject the enoxaparin and to withdraw the needle without massaging the site afterward. If the client massages the area to dispel pain or discomfort, the client reports this to the nurse or provider because it is an unusual finding. a, c, and d. The client demonstrates good injection technique with injections at 45 degrees, avoiding aspiration, and injecting at least 2 inches away from the umbilicus.

39. Which of the following should the practical nurse use to document medication administration? a.Erase each medication from the MAR immediately after administration. b.Record time administered and nurse's name at once after administration. c.Record medication administration time, route, and dosage at end of shift. d.Delegate recording administration time and the nurse's name in the MAR.

b.Record time administered and nurse's name at once after administration The nurse records the nurse's name and administration time immediately after medication administration to maintain an up-to-date and accurate client medical record. If the nurse plans the event but it did not occur, the nurse cannot document the event because documentation records events, statements, tests, etc., that have occurred. In addition, documentation follows medication administration in a logical order; the nurse assesses the client first, administers the medication if indicated, documents the assessment with the administration, and performs postadministration assessments.

14. When visiting a client, the priest asks to read the chart. Which is the best nursing response? a. "You will have to obtain permission from the client." b. "Are you a certified hospital chaplain?" c. "The chart is a confidential record." d. "I will have to check with the physician."

c. "The chart is a confidential record." Info on the chart is only viewable by the client, physician and hospital. It is a breach of confidentiality to provide info to anyone else

18. The practical nurse measures the client's temperature at 102oF. What is the equivalent Centigrade temperature? a. 39oC b. 47oC c. 38.9oC d. 40.1oC

c. 38.9oC F: 1.8 (C) + 32 = 102.02 C: F - 32 / 1.8 = 38.88

32. Which does the practical nurse (PN) use as anatomical landmarks for the ventrogluteal injection site? a. Greater trochanter and knee b. Acromion process, scapula, and axilla c. Anterosuperior iliac spine and iliac crest d. Posterior superior iliac spine and iliac crest

c. Anterosuperior iliac spine and iliac crest -lay client on left side -palpate the head of the femur and the anterior superior iliac spine with the left hand -Place heel of the right hand on the greater trochanter with thumb pointing to the groin and index finger toward the anterior superior iliac spine. -Extend middle finger back to the iliac crest toward the buttocks, creating a V -between index finger and middle finger is the injection site. Middle of the V-pelvic girdle pg 471

56. The practical nurse (PN) is caring for a client who had an above-the-knee amputation. The client refuses to look at the stump. When the PN attempts to discuss the surgery, the client says he doesn't want to discuss it. He also refused to let his family visit. Which nursing diagnosis best describes the client's problem? a. Hopelessness b. Powerlessness c. Disturbed body image d. Knowledge deficit

c. Disturbed body image Disturbed body image includes a negative perception of self that makes healthful functioning difficult

58. A client with chronic renal failure is admitted with a HR of 122, respirations 32, BP 190/110, neck vein distention, and crackles heard upon lung auscultation. Which nursing diagnosis takes the highest priority? a. Fear b. Urinary retention c. Excess fluid volume d. Risk for ineffective airway clearance

c. Excess fluid volume The client has signs of excessive fluid volume and this could be life threatening.

8. A practical nurse (PN) 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 200 mL. What action should the PN take? a. Administer the feeding. b. Flush the tubing with 30 mL of water. c. Hold the feeding. d. Elevate the head of the bed to 90 degrees and administer the feeding.

c. Hold the feeding. When 200 mL of residual formula is obtained, the feeding is held and the physician is notified because it is an indication that the feeding is not being absorbed. Usually, if the residual is less than 100 mL, the feeding is administered ATI: *Gastric residual exceeds 250 mL for each two consecutive assessments 1.Withhold feeding 2.Notify provider 3. Keep the client in Semi-fowler's 4. Recheck residual in 1 hour pg 324 large-volume aspirates indicate delayed gastric emptying and place the client at risk for aspiration. Always check the physician's orders and agency policy regarding residual amounts. Elevating the head of the bed to 90 degrees and flushing the tubing are not appropriate actions pg: 557-564 ATI: pg 321

79. The practical nurse (PN) is in the client's room before a scheduled angiogram. The client informs the PN that she had taken her diazepam (Valium) 40 minutes before signing the consent and really does not understand what the physician will be doing. She further states she will have the procedure done anyway. What should the PN do? a. Nothing, the client has verbalized she does not object to the procedure b. Explain the procedure, risks, benefits and alternatives. c. Notify the physician immediately d. Have the client resign another consent form

c. Notify the physician immediately It's the nurse's responsibility to inform the physician when a client has consented when incompetent, as an informed consent is not legal when incompetent

38. The practical nurse (PN) is caring for an older adult who is on a vasodilator and antihypertensives. The PN should monitor the client for which condition? a. Hypertension b. Dysrhythmias c. Orthostatic hypotension d. Respiratory difficulties

c. Orthostatic hypotension Older adults are more susceptible to a drop in blood pressure related to inactivity. Antihypertensives increase the risk of orthostatic hypotension, particularly when the patient rises after a period of bed rest.

27. When documenting assessment findings, which of the following are examples of objective data? a. Chest pain and headache b. Leg pain and calf tenderness c. Redness and swelling of feet d. Dizziness and headache

c. Redness and swelling of feet Correct (c): Redness and swelling are both observed signs of objective data. Incorrect (a): These examples are subjective data that would be expressed by the patient. Incorrect (b): These examples are subjective data that would be expressed by the patient.

37. A practical nurse is caring for a client that has been admitted with syncope (fainting). The physician orders the client to be tested for orthostatic hypotension. Which is the best description of how the practical nurse should perform this test? a. Take a B/P standing, followed by sitting, then lying b. Take a B/P sitting, followed by lying, then standing c. Take a B/P lying, followed by sitting, then standing d. Take a B/P lying, followed by standing, then sitting

c. Take a B/P lying, followed by sitting, then standing Orthostatic hypotension is seen when there is a drop of 25 mm Hg systolic and a drop of 10 mm Hg diastolic when moving from lying to sitting, or from sitting to standing. 1. obtain supine in each arm, select arm with highest reading 2. Sit: after 1-3 mins obtain BP 3. Stand: obtain BP Symptoms: weakness, dizziness, lightheadedness, feeling faint, or sudden pallor pg 299

16.Which requires the practical nurse (PN) to notify the registered nurse (RN) immediately? a. decrease in the client's blood pressure from 160/90 to 140/84 b. complaint of pain that rates 7 on a scale of 1-10 c. apical pulse of 90 beats/minute with a radial pulse of 70 beats/minute d. respiration rate that has increased from 14 breaths/minute to 20/breaths minute

c. apical pulse of 90 beats/minute with a radial pulse of 70 beats/minute Indicates a pulse deficit which signifies an irregular heartbeat and might lead to a decrease in cardiac output. Irregular - Uneven time intervals between beats. Apical pulse/Point of Maximal Impulse (PMI) - Angle of Louis -Fourth or Fifth intercostal space - medial left midclavicular line (below left nipple line) 7.6 cm (about 3 in) to the left of the sternum - Apex

31. When auscultating the chest, the practical nurse (PN) hears crackles in both lower lobes. What action should the PN take next? a. listen again with the stethoscope over the clothes b. notify the physician c. ask the client to cough, then re-listen d. document the finding

c. ask the client to cough, then re-listen Whenever adventitious breath sounds are heard, the nurse should instruct the client to cough and then re-listen to see if it clears Normal Lung sounds: -Bronchial -Bronchiovesicular -Vesicular *Systemically auscultate the apices and posterior, lateral, and anterior chest. (Zigzag approach) -listen to a full inspiration-expiration cycle each time you move your stethoscope -Anterior first: right to left -posterior last: left to right Crackles: Fine, medium, or coarse * not cleared when coughing

5. The practical nurse (PN) notices that a client is unable to eat without assistance. Which action is most appropriate for the PN? a. stop and assist the client with his meal b. ask the charge nurse to assist the client with his meal c. ask the nursing assistant to help the client with his meal d. notify dietary that the client cannot eat

c. ask the nursing assistant to help the client with his meal Delegating the feeding to the nurse's assistant is most appropriate Delegate to AP's -Activities of daily living (ADL's) -Routine tasks ATI: pg 25

12. Which of the following outcome criteria would be most effective when caring for a client with a nursing diagnosis of ineffective airway clearance? a. respiratory rate of 24 breaths/minute b. presence of congestion on x-ray c. breath sounds clear on auscultation d. continued use of oxygen when necessary

c. breath sounds clear on auscultation The expected outcome is clear breath sounds. all other indicate continued respiratory difficulty.

43. When testing a client's pupils for accommodation, the practical nurse should interpret which findings as normal? a. constriction and divergence b. dilation and convergence c. constriction and convergence d. dilation and divergence

c. constriction and convergence -Pupils would constrict and converge equally on an object. -Pupils dilate in darkness. -Divergence is never normal P: Pupils clear E: Equal and between 3 -7 mm in diameter R: round RL: Reactive to light both directly and consensually when you direct light into one pupil and then the other A: Accommodation of the pupils when they dilate to look at an object far away and then converge (turn eyes inward) and constrict to focus on a near object ATI: pg 145

53. When leaving the isolation room the practical nurse should remove which protective equipment first? a. cap b. gown c. gloves d. mask

c. gloves Gloves are considered the most contaminated and should be removed first. Removing other equipment before gloves could contaminate skin and hair. Don: -Gown -mask -face Sheild/goggle -gloves Doffing: -gloves -goggles/face shield -gown -mask

21. The practical nurse must evaluate skin turgor of an elderly client. While doing so, which fact should the PN remember? a. overhydration causes the skin to tent b. dehydration causes the skin to be edematous and spongy c. inelastic skin turgor is a normal part of aging d. normal skin turgor is moist and boggy

c. inelastic skin turgor is a normal part of aging inelastic skin turgor is a normal part of aging Turgor: elasticity of skin caused by the outward pressure of cells, and interstitial fluid Normal: warm, dry and smooth with good turgor Skin Tenting: delay in skin return to its usual place Poor turgor: dehydration or aging, increase risk for skin breakdown. Assess skin turgor: back of hand, sternum, forearm, or abdomen Increase in skin turgor: over hydration: Edema, smooth, taut, shiny skin that cannot be grasped and raised. pg 327

45. Why shouldn't the practical nurse palpate both carotid arteries at the same time? a. the pulse rate will be inaccurate b. it may cause transient hypertension c. it may impair cerebral circulation d. it may cause severe tachycardia

c. it may impair cerebral circulation Palpate one at a time to prevent possible bradycardia and impairment of cerebral circulation

59. A client requests something to treat his constipation. The client has a physician's order for a laxative to be administered every other day as needed. Which assessment finding by the practical nurse indicates the need to notify the registered nurse before administering the laxative? a. incontinence of liquid stool b. complaints of abdominal fullness c. presence of blood in the client's stool d. abdominal distention

c. presence of blood in the client's stool

63. Which client requires further data collection by the practical nurse? a. the client whose blood pressure is 142/78 mm Hg b. the client whose apical pulse rate is 84 beats/min. c. the client who's restless d. the client whose respiratory rate is 22 breaths/min.

c. the client who's restless Restlessness is an early sign of hypoxia

46. A client who's scheduled for open-heart surgery in two days has been having circulation problems in his legs and feet, so the physician orders antiembolism stockings. The practical nurse is teaching the client about this treatment. What information should the PN give the client about the purpose of antiembolism stockings. a. to decreased arterial blood circulation to the legs and feet b. to decrease venous blood circulation from the legs and feet c. to reduce or prevent edema in the legs and feet d. to maintain warmth in the legs

c. to reduce or prevent edema in the legs and feet Antiembolism stockings are designed to prevent/reduce edema by promoting venous return. They do this by increasing arterial and venous blood circulation to the legs and feet

9. A newly licensed practical nurse (PN) may practice: a. independently in a hospital setting. b. with an experienced LPN/LVN. c. under the supervision of a physician or RN. d. as a sole practitioner in a clinic setting

c. under the supervision of a physician or RN. An LPN/LVN practices under the supervision of a physician, dentist, OD, or RN.

76. Which client does the practical nurse (PN) determine has the highest risk for a bleeding disorder during heparin therapy? a.A 10-year-old client who has viral infection 2.A female client who gave birth 6 weeks ago c.A male client who takes naproxen (Naprosyn) d.A 60-year-old client who has a nephrolithiasis

c.A male client who takes naproxen (Naprosyn) c. The male client who takes naproxen (Naprosyn) has the highest risk of a bleeding disorder complicating heparin therapy because naproxen is a nonsteroidal anti-inflammatory agent with known risk factors for bleeding, especially gastrointestinal bleeding. b. The client who gave birth 6 weeks ago probably has the second highest risk; however, at 6 weeks post partum, involution is usually complete, so hemorrhaging from the uterus is unlikely. a. and d. The remaining clients with a viral infection and a nephrolithiasis have a lower risk of bleeding while on heparin.

35.The practical nurse instructs a nursing assistant on the appropriate methods for taking a blood pressure. Which statement, if made by the nursing assistant indicates understanding of the teaching? a. "Apply the cuff approximately 2 inches below the antecubital fossa." b. "If unable to get a reading the first time, immediately reinflate the cuff." c. "Assess the pulse with the bell of the stethoscope." d. "Apply the cuff snugly."

d. "Apply the cuff snugly." -The cuff should be applied 2 inches above the antecubital fossa and secured snugly. -The pulse should be assessed with the diaphragm of the stethoscope. If unable to get a reading the first time, the cuff should be deflated completely and reinflated after several minutes. pg 301

52.A client with newly diagnosed breast cancer asks the practical nurse "Why me? What have I done to deserve this?" Which response by the PN would be most appropriate? a. "Were you doing your monthly Self Breast Exam?" b. "I believe a cure will be found soon" c. "You seem upset. Let's talk about something more upbeat" d. "Would you like to talk about this?"

d. "Would you like to talk about this?" Offering to talk about the client's feelings validates them and allows the client to express them and is therapeutic

4. A practical nurse (PN) is preparing to administer a feeding to the client receiving enteral nutrition through a nasogastric tube. The PN performs which of the following as the priority nursing action? a. Measuring intake and output b. Weighing the client c. Adding blue food coloring to the enteral formula d. Determining tube placement

d. Determining tube placement Initiating a tube feeding before checking tube placement can lead to serious complications, such as aspiration. Options 1 and 2 are part of the total plan of care for a client on enteral feeding. Option 3 may be instituted for a client who has been identified as a high risk for aspiration. Option 4 is the priority nursing action. -Aspirate gently to collect gastric contents, use of blue LITMUS paper to check the acidity of aspirate testing pH (1-4), assess odor, color, and consistency -CXR the most accurate. -if placement is not in stomach advance it 5 cm (2in), repeat placement check most RELIABLE method for a small-bore feeding tube is an abdominal x-ray pg 377

13. A client receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings knowing that these signs are indicative of which complication of TPN therapy? a. Hyperglycemia b. Air embolism c. Sepsis d. Fluid overload

d. Fluid overload TPN: given through a large central vein pg 565 The client's signs and symptoms are consistent with fluid overload. ATI: 344 The increased intravascular volume increases the blood pressure, while the pulse rate increases as the heart tries to pump the extra fluid volume. -Tachycardia -boudning pulses -hypertension -tachypnea -increased central venous pressure -confusion -wt gain -edema -distended neck vien A fever would be present in sepsis. S/S air embolus: confusion, pallor, lightheadedness, tachycardia, tachypnea, hypotension, anxiety, and unresponsiveness. S/S Hyperglycemia: Polyuria, polydipsia, and polyphagia

49. Using Maslow's hierarchy of needs, which nursing diagnosis has the highest priority? a. Deficient knowledge b. Acute pain c. Risk for impaired skin integrity d. Imbalanced nutrition

d. Imbalanced nutrition The lack of nutrition falls in the base of Maslow's, therefore being of the highest importance. knowledge and pain falls under safety and security Risk for is not a main priority but a result of another problem 1.Physiologic: nutrition, elimination, oxygenation, sexuality 2.Safety and Security: Stability, protection, security, freedom from fear and anxiety 3. Love and Belongings: Affection, acceptance by peers and community 4. Esteem: Self-respect, self-confidence, feelings of self-worth 5. Self-actualization: Full use of individual talents pg 13.

66. What task can the practical nurse appropriately delegate to the nursing assistant? a. obtaining vital signs from a client who has just returned from surgery b. feeding a client for the first time after he has experienced a stroke c. administering feedings through a nasogastric tube d. encouraging a client to drink fluids

d. encouraging a client to drink fluids The nurse can delegate the task of encouraging fluids because it doesn't involve an unstable client or require nursing assessment or judgement.

26.. To avoid an erroneously low systolic blood pressure because of failure to recognize and auscultatory gap, which action should the practical nurse take? a. have the client lie down while taking his blood pressure b. inflate the cuff to at least 200 mm Hg. c. take blood pressure reading in both arms d. inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable

d. inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable The nurse should rapidly inflate the cuff until she can no longer palpate the radial pulse and then inflate the cuff until it rises 30 more mmHg -apply cuff 1-2 in above anetcubital space -Cuff should be 40% of the circumference -note point radial pulse is obliterated -deflate and rest 1 min -reinflate 30mmHg above radial artery was obliterated. -release pressure 2-3 mmHg per sec Cuff to small: higher inaccurate reading Cuff to big: lower inaccurate reading. pg 302

47. A practical nurse (PN) discovers that a stat dose of potassium chloride that was prescribed by the physician was never given. What action should the PN take? a. request the medication from the pharmacy and administer it as soon as possible b. ask the client if the medication is still needed c. document the incident according to facility policy d. notify the charge nurse so she can notify the physician of the missed dose

d. notify the charge nurse so she can notify the physician of the missed dose The charge nurse should be notified first of the error, so she can notify the physician, who may request labs be drawn or that the medication be given. Then the incident can be documented

6.A practical nurse (PN) is checking for correct placement of a nasogastric (NG) tube. The nurse aspirates the stomach contents and checks the contents for pH. Which of the following pH values indicates correct placement of the tube? a. pH of 7.5 b. pH of 7.35 c. pH of 7.0 d. pH of 4.0

d. pH of 4.0 If the NG tube is in the stomach, the pH of the contents will be acidic. Option 1 indicates an alkaline pH. Option 2 indicates a neutral pH. Option 3 indicates a slightly acidic pH. -secondary measure of verification -pH 1-4 -grassy green fluid -off white or tan with water pH: more than 6 intestinal fluid: contains bile, golden yellow or brownish green pH: more than 6 clear fluid: Respiratory

50. A nursing assistant caring for a client who is diagnosed with Clostridium difficile asks the practical nurse (PN), "How can I keep from catching this disease from the client?" What information should the PN give the nursing assistant? a. place the client on protective isolation b. practice neutropenic precautions c. place the client in a negative pressure room d. practice contact isolation

d. practice contact isolation Staff should practice contact precautions-wear gowns and gloves for C. diff. 1.Airborne: Negative pressure, N95 -chicken pox (varicella) -Disseminated Herpes Zoster -Measles (Rubeola) -TB 2. Droplet: Surgical Mask -3 feet, private room is possible, bacterial, viral 3. Contact: -Gloves and Gown, Disposable equipment -GI, Resp, Skin, Wound infection -Colonized Multi-resistant bacteria

51. Which action would be contraindicated for a client who develops a temperature of 102oF (38.9oC)? a. monitoring temperature every 2 hours b. increasing fluid intake c. covering the client with a light blanket d. providing a low-calorie diet

d. providing a low-calorie diet A client with a fever has an increased basal metabolism rate, requiring additional calories in the diet. -reduce external coverings -keep clothes and linens dry -Monitor at least q4hrs or prn -Administer medication -increase rest periods -encourage fluids -encourage oral hygiene -Encourage increase calorie intake

81. While working at a local health clinic, a young woman informed the practical nurse (PN) that she is engaged to be married to one of the client's. The PN knows the client is HIV positive. The PN is legally obligated to: a. inform the young woman of the fiancé's HIV status b. recommend that the friend be tested for HIV antibodies c. advise the friend to postpone the marriage indefinitely d. safeguard information in the fiancé's health record

d. safeguard information in the fiancé's health record The nurse is responsible for safeguarding the client's health history

41. The practical nurse is collecting data on the client who may be in the early stages of dehydration. The PN recognizes which symptom(s) as early indication of dehydration? a. coma or seizures b. sunken eyeballs and poor skin turgor c. increased heart rate with hypertension d. thirst or confusion

d. thirst or confusion Early signs: -thirst -irritability -confusion and dizziness -headache Late signs: -increased HR w/ HTN -sunken eyeballs -poor skin turgor -seizures -coma Measurable (sensible) 1. urine 2. vomit 3. diarrhea Unmeasurable (insensible) 1. respiration 2. sweating (diaphoresis) V-vomiting P-poop (diarrhea) P-pee (urine) S-sweating (diaphoresis) D-DKA (polyuria) & diuretics R-Restriction in fluid intake I-increased ventilation (hyperventilation) E-diaphoresis D-Diabetes insipidus Interventions: -daily wt (best indicator) -IV fluids: isotonic or hypotonic fluids -teach: daily wts & BP -Evaluate causes (VPPS) -Reposition slowly *urine specific gravity greater than 1.030 *sodium greater than 145 mEq/L

75. The practical nurse (PN) reconstitutes a powdered medication in a vial. The label on the vial states 1.5 ml of diluent yields 200,000 U/ml of the medication. The client has an order for 150,000 U of the medication. How much does the PN administer? a.0.5 ml b.1.0 ml c.1.5 ml d.0.75 ml

d.0.75 ml

78. Which angle should the practical nurse (PN) use to administer an IM injection for a client who is 5 feet 6 inches tall and weighs 140 pounds? a.15 degrees b.45 degrees c.60 degrees d.90 degrees

d.90 degrees d. The nurse administers an IM injection at a 90-degree angle to the surface to ensure injecting the medication into the muscle. a, b, and c. An angle less than 90 degrees increases the risk of injecting the medication into subcutaneous tissue.

54.The practical nurse (PN) needs to administer a rectal suppository to the client for constipation. Which should the PN delegate to the nursing assistant (UAP)? a.Insert the suppository into client's rectum. b.Notify client's provider of suppository results. c.Document the administration of a suppository. d.Assist client to bathroom for a bowel movement.

d.Assist client to bathroom for a bowel movement. d. The nurse asks the UAP to help the client to the bathroom after receiving a suppository because the assistant is trained to perform the task. a. Usually assistants lack the training and education to administer medication unless the UAP receives specialized training as a medication technician. b. and c. The nurse notifies the provider of results and documents the medication because these tasks are within the nurse's scope of practice.

71. The practical nurse (PN) instructs the client with diabetes mellitus about subcutaneous insulin administration. Which should the PN include in client teaching? a.Remember that NPH insulin peaks within 15 minutes. b.Prepare for hyperglycemia 2 hours after taking insulin. c.Keep insulin refrigerated after administering the first dose. d.Eat right after taking regular insulin to avoid hypoglycemia.

d.Eat right after taking regular insulin to avoid hypoglycemia. d. Regular insulin peaks in 15 to 30 minutes after subcutaneous administration, so the client needs to eat right after administering the insulin to prevent a hypoglycemic emergency. Once it is administered, the insulin begins to drive glucose into the cells, resulting in a lower blood sugar; thus, if the client does not eat to sustain the blood sugar, the client becomes hypoglycemic. may be given IV bag or IV push a. NPH, an intermediate-acting insulin, peaks 2 to 6 hours after subcutaneous administration. Never given IV b. Because insulin drives glucose into the cells, the blood sugar is more likely to drop after insulin administration than to increase. c. The nurse teaches the client to store insulin at room temperature as long as the client is the only person using the insulin vial. Nursing interventions -Give food during PEAKS -Draw clear to cloudy (draw regular than NPH)

20. The practical nurse (PN) administers acetaminophen (Tylenol) 650 mg per rectum. Which should the PN implement to correctly administer a rectal suppository properly? a.Assist client to right lateral position and flex left leg. b.Perform preadministration digital rectal examination. c.Wash hands and apply sterile gloves before procedure. d. Insert the suppository 4 inches into the client's rectum.

d.Insert the suppository 4 inches into the client's rectum. pg 447 ATI: pg 264 d. The nurse inserts the suppository about 4 inches into the client's rectum to clear the rectal sphincters because the sphincters help to keep the medication in the client's rectum. *instruct client to remain flat or sim's for 5 mins after insertion to retain the suppository a. The nurse assists the client into the left lateral position to take advantage of normal anatomy of the descending colon; this curvature in the colon helps to sequester the medication, contain it in the client, and increase its effectiveness. b. The nurse avoids performing a digital examination before inserting a suppository because it is not indicated. c. Washing hands is always a reasonable nursing action; however, clean gloves are sufficient for this procedure because the nurse wants to avoid contamination from the rectum.

72. The practical nurse (PN) prepares to administer an irritating medication by the Z-track technique. Which does the PN use to administer this IM injection properly? a.Insert needle and pull skin 1 to 2 inches laterally before injection. b.Have client lie in supine position to prevent medication leakage. c.Wait 10 seconds and release skin before withdrawing the syringe. d.Pull client's skin about 1 ½ inches laterally before inserting needle.

d.Pull client's skin about 1 ½ inches laterally before inserting needle. -The nurse pulls skin tightly in lateral direction 1 to 1 ½ inches to the side to prepare the seal for the medication -Hold the skin taut with the non dominant hand. -Aspirate: inject 90 degree angle -When the skin is released after the needle is withdrawn, it assumes its original place and helps to contain the medication. -The nurse retracts the client's skin and then inserts the needle. -The nurse waits 10 seconds but withdraws the needle and then releases the skin. -reduces discomfort and leakage of the medication into tissue IM: -1 - 1 1/2 in -20 - 22 G

74. The practical nurse (PN) needs to administer an IM injection to a client who is 7 months old. Which is the best site for the PN to use for the injection? a.Deltoid b.Dorsogluteal c.Ventrogluteal d.Vastus lateralis

d.Vastus lateralis d. The preferred IM injection site for clients under the age of 12 months is the vastus lateralis muscle because it is a relatively large muscle mass without major nerves and blood vessels, has a consistent layer of fat, and has a good safety record. a. The deltoid is suitable for well-developed children and adolescents with use of a 5/8 -inch needle. b. The dorsogluteal site is contraindicated because of the major anatomical structures it contains. This is no longer preferred c. The ventrogluteal site is a safe site for injections with all age groups; however, the vastus lateralis is preferred site for infants. IM Sites: -Deltoid: (3-5 cm: 1-2 in) below acromion process -Ventrogluteal: iliac crest and greater trochanter: V -Vastus lateralis: preferred site younger than 3 y/o, free of nerve and blood vessels. Anterior lateral thigh