My NCLEX Prep

The nurse is looking at the telemetry monitor and notices a client on the monitor has a flat line. The nurse rushes into the room to check on the client. The first nurse passes another nurse who asks how to help. Which of the following statements by the first nurse is appropriate?

"Grab the crash cart! The client is in asystole" A flat line is called asystole and is a medical emergency requiring a crash cart and the activation of code blue. However, the nurse needs to look at the client before calling a code blue. The nurse must check if the client is responsive, check the leads, pulse, and neuro status of the client to make sure it is a true code blue.

The nurse is admitting a client who states, "When I was pregnant I would get heartburn so bad, I was eating antacids like crazy. I now feel the same way, except I am not pregnant. The antacids aren't helping me and now I have this pain between my shoulder blades." Which part of this statement is most concerning and must be investigated further?

"I have this pain between my shoulder blades" This female client is showing signs of a myocardial infarction. Women often present with atypical symptoms and will often describe a feeling of acid reflux that is actually a heart attack. This client needs an EKG (ECG) immediately to rule out a STEMI

The nurse is caring for a client with a new left leg cast. The client reports increased pain to the affected leg. Which of the following are appropriate nursing interventions for the nurse to implement while caring for this client? Select all that apply. Perform neurovascular checks every 4 hours Administer Morphine 2 mg every 4 hours PRN Apply ice to the client's left leg for one hour Encourage the client to increase ambulation Elevate the client's left leg on two pillows

Administer Morphine 2 mg every 4 hours PRN This helps the client achieve appropriate pain control. Elevate the client's left leg on two pillows This can help with swelling which also helps with pain control. Perform neurovascular checks every 4 hours This client still requires more frequent monitoring of the affected extremity.

Which information should a nurse give to a diabetic client that would best protect against yeast infections? Wear nylon or polyester underwear Use hygienic genital sprays Avoid hot tubs and saunas Take baths with Epsom salt

Avoid hot tubs and saunas

An adult client presents to the emergency department with a chief complaint of heartburn. What is the nurse's immediate priority?

Call for an EKG When a client has complaints of discomfort or pain in the chest area, including heartburn, the client will need an EKG. This client will be simultaneously having vital signs taken and the EKG will be ready shortly after, but calling for the EKG can occur as soon as the healthcare team learns of the chief complaint.

Your client has a known family history of malignant hyperthermia. The nurse knows that which of the following ways would keep the client safe? Select all that apply. Have dantrolene available Identify the location of the malignant hyperthermia cart Have epinephrine available Have chilled IV solutions available Establish a plan with the anesthesia team

Have dantrolene available This is a treatment of malignant hyperthermia. Identify the location of the malignant hyperthermia cart The cart location should be identified in order to ensure it is available and ready if an emergency occurs. Establish a plan with the anesthesia team This is a way to keep the client safe. Have chilled IV solutions available This is a treatment of malignant hyperthermia.

Diuretics are good medications for the management of hypertension because of which of the following mechanisms?

Promote sodium depletion, decreasing intravascular volume Diuretics reduce blood pressure by promoting sodium and water depletion, which decreases intravascular volume.

A client has a family history of myocardial infarction and has been experiencing multiple episodes of chest pain. The client is prescribed a medication to prevent heart attacks. Which of the following medications is appropriate for this condition?

Propranolol This is a beta blocker that is used to treat hypertension, angina, arrhythmias, and heart attacks.

A 58-year-old client suffered a closed head injury and is experiencing abnormal muscle twitching and tremor. The provider has prescribed medication as part of treatment. Which of the following drugs is an example of a dopamine agonist? Phenytoin Ropinirole Pentobarbital Nimodipine

Ropinirole Ropinirole is a type of drug that stimulates nerve receptors in the brain that are normally stimulated by the neurotransmitter dopamine and is actually an anti-Parkinson drug that may be used for the treatment of a closed head injury. It acts as a dopamine agonist and can reduce some of the motor deficits of a closed head injury.

The infusion nurse understands that immunoglobulins are effective against which of the following? Varicella-zoster Disseminated intravascular coagulation Rheumatoid arthritis Cystic fibrosis

Varicella-zoster This is correct. Immunoglobulins are used to treat varicella zoster.

A nurse is working with a client who is recovering from a shoulder injury. The client is unable to move the right shoulder without pain. The nurse is considering that the client will need physical therapy treatment. Which alternative best describes the concept of direct access in referring someone to physical therapy?

The client does not need a provider referral to participate in physical therapy Clients who need physical therapy may receive a referral from a healthcare provider based on their condition and need for services. Direct access refers to a situation in which a client seeks physical therapy without a referral or order from a healthcare provider. Depending on the client's insurance plan, there may be direct access to physical therapy without the need to wait for a provider referral to start services.

The provider diagnoses a client with Marfan syndrome. The client asks the nurse what this means. Which of the following is the best response by the nurse? "It is an epithelial tissue disorder" "It is a smooth muscle disorder" "It is a connective tissue disorder" "It is a skeletal muscle disorder"

"It is a connective tissue disorder" Marfan syndrome is a connective tissue disorder that affects the heart, eyes, blood vessels and bones. People with Marfan syndrome are generally very tall and thin.

A client is being admitted to the hospital and will be started on telemetry because of his cardiac condition. The client asks the nurse, "What should I do if one of these stickers falls off?" Which response from the nurse is correct?

"Notify the nurse to put it back on correctly" A client being monitored with a telemetry box in the hospital is able to be monitored from a remote location in the building. The client wears electrodes attached to wires that are often connected wirelessly to the telemetry unit. The nurse should instruct the client to avoid trying to replace the electrodes if they fall off because the nurse is trained on the proper placement and should be the one to replace them rather than the client.

A nurse is helping a nursing student to understand aminoglycosides and how to identify which drugs belong to this class. The nurse is correct in saying that aminoglycosides tend to have which of the following suffix? -lol -azole -pril -mycin

-mycin Aminoglycosides have the -mycin suffix. -azole Aminoglycosides have the -mycin suffix. and "azole" are antifungals. -pril Aminoglycosides have the -mycin suffix. and "-pril" are ACE inhibitors. -lol Aminoglycosides have the -mycin suffix. "lol" are beta-blockers,

A nurse is measuring the PR interval on an EKG. In order for the measurements to be within the parameters of normal sinus rhythm, the PR interval would need to be between which of the following seconds?

0.12-0.2 The PR interval needs to be between 0.12-0.2 seconds. The PR interval is the time from the onset of the P wave to the start of the QRS complex. The normal PR interval is between 0.12-0.2 seconds in duration (three to five small squares).

A 9-year old child is brought to the emergency room in anaphylactic shock. Which of the following medication orders would be the most appropriate for this child? 25 mg Diphenhydramine IM 50 mg Diphenhydramine PO 0.5 mg of 1:10,000 Epinephrine IV 0.3 mg of 1:1,000 Epinephrine IM

0.3 mg of 1:1,000 Epinephrine IM Epinephrine 1:1,000 concentration should be given IM during an anaphylactic reaction. 0.3 mg is an appropriate dose for a 9 year old.

A nurse is measuring systemic vascular resistance for a client with hypovolemic shock. The client has a central catheter and his mean arterial pressure (MAP) is 100 mmHg. His central venous pressure is 0 mmHg and his cardiac output is 8.0 L/min. Calculate this client's systemic vascular resistance (SVR).

1000 dyn×s/cm5 Systemic vascular resistance is calculated when the nurse knows the clients mean arterial pressure, the central venous pressure, and the cardiac output. The formula is: SVR = 80*(MAP-CVP) /CO. Therefore: SVR = 80*(100-0) /8 = 1,000

Which best describes a normal hemoglobin level for a 4-year-old child? 18 g/dL 20 g/dL 16 g/dL 12 g/dL

12 g/dL Hemoglobin concentration indicates the amount of oxygen-carrying hemoglobin molecules in the red blood cells. The normal level varies between gender and age for different clients. A normal hemoglobin level for a 4-year-old child averages 12.5

The nurse is reviewing a client's lab results. Which result for phenytoin would the nurse correctly interpret as being within the therapeutic range? 37 mcg/mL 1.4 mcg/mL 15 mcg/mL 0.2 mcg/mL

15 mcg/mL The therapeutic range of phenytoin (Dilantin) is 10-20 mcg/mL.

A nurse is assisting with the placement of a pulmonary artery (PA) catheter to monitor a client's hemodynamic status and prevent cardiogenic shock. During placement of the catheter, the physician initially moves the tip of the catheter through the superior vena cava, into the right atrium, and then into the right ventricle while the nurse watches the monitor. While the catheter tip is in the right atrium, the nurse would expect to see systolic pressures of:

2 to 6 mmHg Central hemodynamic monitoring is done by inserting a catheter and threading it through the superior vena cava, into the right atrium, and then into the right ventricle to the pulmonary artery. While the catheter is passed through the superior vena cava and into the right atrium, the normal systolic pressure should be between 2 and 6 mmHg

The nurse is talking with new parents about the different reflexes. The mother wants to know when they should expect their baby to lose the Babinski reflex. Which of the following is an appropriate answer for the nurse to give? 8-10 months 6-7 months 2 years 5-6 months

2 years The Babinski reflex involves the baby's toes fanning out when the lateral side of the foot is stroked upward. This reflex disappears by about 2 years but can disappear as early as 12 months.

A nurse is preparing to give a dose of insulin subcutaneously to a client. Which of the following needle sizes is most appropriate for this injection? 25-gauge 18-gauge 21-gauge 29-gauge

29-gauge A subcutaneous injection requires a small gauge needle, as the injection will go through the skin and into the subcutaneous fat, but it does not need to penetrate the muscle. An example of a needle size used for a subcutaneous injection would be a 29-31-gauge needle.

The nurse is assessing a client in the urgent care clinic who is complaining of burning with urination. The urinalysis shows that the client has a urinary tract infection (UTI). Which of the following medications is an appropriate medication to treat this client's UTI? Captopril Clopidogrel Cimetidine Cephalexin

Cephalexin This is an anti-infective medication used for skin infections, pneumonia, UTIs, and otitis media

A nurse assistant tells the nurse that four of the clients had complaints when morning vitals were being done. Of the following four client complaints, which is the priority for the nurse to see first? 58-year-old female with heart burn 24-year-old with abdominal pain 37-year-old with urinary retention 24-year-old with anxiety

58-year-old female with heart burn Women often present with atypical symptoms of a heart attack and usually think they are having acid reflux. This client needs an ECG immediately to rule out a STEMI. All other clients are stable at this time.

Which describes a warning signal of Munchausen syndrome by proxy? A child's health improves when he is in the hospital but then worsens after he goes home A child must take medications for the treatment of allergies A child has poor hygiene and dirty clothes A child develops cancer when no one else in the family has had it

A child's health improves when he is in the hospital but then worsens after he goes home Munchausen syndrome is a form of mental illness in which a person causes himself to become sick or develops fake symptoms of illness. Munchausen syndrome by proxy is a form of child abuse in which a caregiver makes a child sick on purpose. It can be difficult to identify true situations in which Munchausen's by proxy is present but some signs to look for include the child getting better after treatment in the hospital but then getting worse again after going home, the child having a significant number of absences from school or social functions, and evidence of substances in the child's blood or urine.

The nurse just received reports on the following four clients. Which client should the nurse see first? 1) A client who was admitted for sepsis with vasopressors infusing 2) A client who was admitted for respiratory distress with normal saline infusing and a respiratory rate of 20 3) A client who was admitted for a non-ST elevated MI (NSTEMI) with heparin infusing 4) A client who was admitted for a urinary tract infection with antibiotics infusing.

A client who was admitted for sepsis with vasopressors infusing When prioritizing client care, the nurse prioritizes airway, breathing, and circulation first. The client with sepsis and a vasopressor infusing has a circulation issue, and is most unstable of the group due to the instability of blood pressure. This client should be seen first.

A client tells the nurse that he cannot take Percocet because he thinks he has an increased risk of having an allergic reaction to the drug. Which of the following factors are associated with an increased risk of having an allergic reaction to this drug? Select all that apply.

A family history of reaction to acetaminophen Percocet (oxycodone and acetaminophen) has acetaminophen as part of its drug ingredients. A previous reaction to acetaminophen within his family suggests this client is at a higher risk for an allergic reaction. Prior reaction to Norco Percocet (oxycodone and acetaminophen) is an oral opioid in the same family as Norco. Therefore, a prior reaction to Norco would suggest this client is at a higher risk for an allergic reaction if they were to take Percocet.

A client has an order for oral diphenhydramine (Benadryl) to be taken by mouth twice daily. Which of the following principles would the nurse consider when administering oral medications? Select all that apply

A patient who gags before taking the drug should be given the whole capsule in applesauce If the client gags and the nurse is concerned that they will have trouble taking a pill, an option is to "float" the pill in yogurt or applesauce to assist with swallowing, provided the client's diet allows. Enteric-coated medications should be swallowed whole For oral medication, the client should swallow the pills whole with fluid and should not chew or crush medications, particularly enteric coated medications. Extended-release capsules or tablets should not be crushed before administration When administering medication in this manner, the client should swallow the pills whole and should not chew or crush medications, particularly those classified as extended release. Oral medications are the most common drug forms Oral medications are the most common form of drug administration.

A nurse is talking with a client about starting a new type of medication. The nurse reviews the absolute contraindications for the medication. Which describes the differences between absolute and relative contraindications? Select all that apply.

A relative contraindication means that a drug should be used with caution Some drugs have contraindications that are classified as being either absolute or relative contraindications. Relative contraindications describe those cases in which a drug should be used with caution, but if the benefits outweigh the risks, the client could still take the drug. Alternatively, an absolute contraindication describes a situation in which life-threatening complications can develop and the client should avoid the drug at all costs. An absolute contraindication could cause life-threatening complications An absolute contraindication describes a situation in which life-threatening complications can develop and the client should avoid the drug at all costs. An absolute contraindication should be avoided at all costs An absolute contraindication describes a situation in which life-threatening complications can develop and the client should avoid the drug at all costs.

The nurse is caring for a client with jaundice. The provider orders labs. Which of the following labs would the nurse NOT expect to be ordered? ABG ALT ALP AST

ABG Arterial blood gas is a lab to detect the oxygenation capacity of the blood and the acid-base balance. These values are not related to the liver function.

A pregnant client with a history of a GI bleed is on the unit in preterm labor. Which of the following orders should the nurse question?

Administer PO Indomethacin Indomethacin is a NSAID. This should not be given to a client with a bleeding history because it will increase their risk. The provider should choose a different tocolytic.

A client is demonstrating signs of low cardiac output, and is bradycardic. Which of the following nursing interventions is appropriate?

Administer atropine as ordered Atropine will increase pulse rate, which is necessary for the client who has symptomatically low cardiac output and bradycardia, because this will help increase cardiac output.

The nurse is caring for a client who was admitted to the ICU in a state of septic shock. The client requires oxygen by nasal cannula to maintain blood oxygenation levels and needs hemodynamic monitoring. Which of the following describes the best method of providing nutritional support for this client?

Administering enteral nutrition through a feeding tube or oral feedings A client in a state of septic shock should still receive nutrition therapy. Studies have shown that enteral nutrition, such as through a feeding tube or through oral feedings, is most appropriate and can be beneficial because it maintains gut function and can actually reduce the inflammatory response to sepsis. Some clients do require parenteral nutrition if they have become malnourished, but the first line of treatment for nutrition maintenance in septic shock is enteral nutrition.

A nurse is caring for a newborn on the pospartum unit. When should the newborn metabolic screening be completed? Right after birth After 24 hours After a successful feeding When the infant has voided and stooled

After 24 hours It needs to be done after 24 hours when several good feedings have occurred since we are looking for metabolic disorders. The lab will not accept a screening prior to 24 hours and if it is done too early they will require a repeat.

The nurse is caring for a client with asthma who requests a respiratory treatment at bedtime. The client takes albuterol at home, but has orders for additional respiratory drugs in the hospital. Which of the following medications is most appropriate for this client? Ipratropium Albuterol Theophylline Fluticasone

Albuterol This inhaled drug causes restlessness and difficulty sleeping when a client first begins to take it, but these symptoms disappear completely after a few weeks of use. Since this client takes albuterol at home, this is the best option.

A nurse is working with a client who takes kava for control of anxiety. The nurse should counsel the client to avoid which other kinds of drugs when taking kava? Select all that apply.

Alcohol Kava has a mild sedative effect, so it should not be combined with other substances that produce the same effect. Kava is a type of herbal supplement that some clients may take to control anxiety and stress. Sleeping pills Since kava has a mild sedative effect, it should not be combined with sleeping pills. Xanax Kava has been reported to increase the adverse effects of the central nervous system when taken with Xanax.

A nurse is taking care of a client with chronic controlled atrial flutter and knows that which of the following medications is the priority? Diuretics Anticonvulsants Anticoagulants Antihypertensives

Anticoagulants The client must take an anticoagulant to decrease the risk of a stroke that is increased with atrial flutter because blood flow is not moving through effectively.

A nurse is caring for a client who has cut their hand with a kitchen knife. The client is bleeding through the kitchen towel that is wrapped around their hand and reports 8/10 pain. What is the priority nursing intervention for this client? Apply pressure with a fresh bandage Prepare for the provider to suture the wound Administer 2 mg Morphine as ordered Rinse the wound out thoroughly with sterile saline

Apply pressure with a fresh bandage The priority at this time is to control the bleeding. If the client is still actively bleeding, this must be controlled before any wound irrigation or suturing would occur. Once pressure is held and bleeding is controlled, THEN pain can be addressed. The purpose of the fresh bandage is to be able to judge the bleeding rate - if the towel is saturated, it's difficult to tell how much or how fast the client is bleeding.

Upon admission to the hospital, a nurse asks a client about allergies. Which statement by the nurse best describes how the nurse would assess for a latex allergy in the client? Have you ever had a skin rash after being exposed to adhesive tape? Do your hands hurt if you wear latex gloves? Are you allergic to bananas or avocados? Have you ever had a hypersensitivity reaction?

Are you allergic to bananas or avocados? Assessment of allergies is an important component of an intake assessment for clients when they are admitted to the healthcare facility. The nurse screens the client to determine which allergy alerts to put in the client's record, as well as on a wristband for the client to wear at all times. To assess a latex allergy, the nurse can ask if the client experiences a skin rash when exposed to common products containing latex, or if they are allergic to foods that contain the same protein as latex, such as bananas, avocados, or chestnuts.

A nurse in the Emergency Department is admitting a client with an asthma exacerbation, headache, and fever of 101.4 F. Which of the following medication orders should the nurse question?

Aspirin Aspirin use is discouraged in asthma as it can contribute to exacerbations. Therefore in this scenario it would not be appropriate.

The nurse is caring for a client and notes the rhythm pictured on the client's telemetry monitor. Which of the following actions is a priority?

Assist the client to perform a vagal maneuver This client is in SVT, or supraventricular tachycardia. This means the heart is beating too fast, which lowers the client's cardiac output. A vagal maneuver can be effective to treat SVT because the action stimulates the vagal nerve. To help the client perform a vagal maneuver, the nurse will instruct the client to cough or bear down.

The labor and delivery nurse is caring for a newborn. The nurse knows that phytonadione should be given when? Immediately after delivery At one hour of life Prior to discharge 30 minutes after delivery

At one hour of life Phytonadione is vitamin K. A newborn should be with mom for the first hour after delivery, and then given the vitamin K injection.

The nurse is assessing a client in the urgent care clinic who is complaining of burning with urination. The urinalysis shows that the client has a urinary tract infection (UTI). Which of the following medications is an appropriate medication to treat this client's UTI? Cephalexin Cimetidine Captopril Clopidogrel

Cephalexin This is an anti-infective medication used for skin infections, pneumonia, UTIs, and otitis media.

An 87-year-old client is connected to both telemetry and the continuous pulse oximetry. The pulse oximeter shows no pulse, but the telemetry monitor shows a rhythm. The nurse verifies that the finger probe on the pulse oximeter is reading correctly and it is, but the nurse is not able to palpate a pulse on the client. Which of the following should the nurse do next?

Begin CPR The nurse should immediately begin CPR to pump the blood through the heart to keep perfusing the organs.

An 18-year-old client is seen at the healthcare center with swelling of the hands and face. The client is diagnosed with acromegaly. The nurse knows that this condition is typically caused by which of the following? An overproduction of the stress hormone cortisol Excess secretion of parathyroidhormone after diagnosis of thyroid nodules A genetic condition that develops as a chromosomal abnormality Benign tumors on the pituitary that cause excess secretion of growth hormone

Benign tumors on the pituitary that cause excess secretion of growth hormone A client with acromegaly produces too much growth hormone as a result of small tumors that develop on the pituitary gland. The condition causes excess growth of tissue, resulting in enlarged hands, feet, and facial structures.

A client presents to the emergency department with chest pain and difficulty breathing. The provider orders an ECG and the client is diagnosed with a STEMI. Based on the nurse's knowledge of this condition, the nurse would expect what type of treatment for this client? Select all that apply.

Beta adrenergic blocker therapy Beta blockers are given as part of the treatment regimen for acute myocardial infarction. They reduce myocardial oxygen demand, and have antiarrythmic properties. Percutaneous coronary intervention A STEMI (ST elevated myocardial infarction) is a type of heart attack that demonstrates certain changes on the ECG. This type of myocardial infarction is more severe than a non-ST elevated myocardial infarction. The client would require rapid coronary intervention, such as with cardiac catheterization. Regardless of the type of MI, when the client presents to the emergency department the team will give a chewable aspirin (if not given by emergency medical staff in the ambulance), oxygen, and sublingual nitrates, as well as morphine for pain. Fibrinolytic administration The client may be administered fibrinolytics to break up a clot in the coronary artery.

A 56-year-old client is being seen at the primary care clinic for follow-up after having chest pain. The client tells the nurse, "I think I had a heart attack yesterday but it could have just been chest pain. It still hurts some, though." The provider orders a troponin level and an ECG. Which response from the nurse is most appropriate?

Both the ECG and troponin levels may be abnormal, even if the heart attack was yesterday A client may experience a heart attack but may not necessarily know if it was an actual myocardial infarction or simply angina. The outcome may not be obvious right away, but laboratory levels can be drawn that will demonstrate changes in cardiac enzymes showing if the client actually suffered damage to the heart muscle. The troponin levels may remain abnormal for up to ten days after a heart attack. Additionally, an ECG may also demonstrate changes as part of the fully evolved post-myocardial stage, which occurs within hours to days after a heart attack.

A nurse is assigned to a 6-month-old diagnosed with a large ventricular septal defect and is being treated for signs of heart failure. The nurse knows to expect which of the following orders to help decrease pulmonary and systemic vascular resistance?

Captopril Captopril is an ACE inhibitor that causes vasodilation, which decreases pulmonary and systemic vascular restriction.

The nurse is caring for a client with a history of congestive heart failure (CHF). While reviewing his medications with the nurse, the client asks for help identifying which medication is for CHF. The nurse knows that which of the following medication is used to treat this condition? Cephalexin Cimetidine Captopril Clopidogrel

Captopril This is an ACE inhibitor that is commonly prescribed for hypertension and CHF.

A 44-year-old client is recovering in the hospital following a myocardial infarction. The client asks the nurse about participation in cardiac rehabilitation. Which of the following is an accurate explanation of cardiac rehabilitation?

Cardiac rehabilitation can help you to improve activity levels and exercise tolerance after a heart attack Cardiac rehabilitation is available for clients with many different types of cardiac conditions, including following treatment of an MI. Cardiac rehabilitation helps to strengthen the client's heart by increasing exercise tolerance. The program also helps the client regarding other issues that may occur following treatment of heart disease, such as counseling for dietary problems, help with stress levels, and care of psychosocial issues.

The nurse receives a client in the emergency room with an obvious deformity of the left leg. What is the first thing the nurse should do? Check a pedal pulse Get an X-Ray Ask the client to wiggle their toes Check a capillary refill

Check a pedal pulse This client is at risk for losing blood flow distally to the deformity, so checking a pedal pulse is the priority.

The nurse is caring for a client who has a broken femur. The client calls to report chest pain. What is the first thing the nurse should do?

Check a pulse oximetry A fat embolism is a risk with long-bone fractures such as a femur. This fat particle will move through the bloodstream and become lodged in the heart or lungs, causing chest pain. After checking the pulse oximetry, the nurse will notify the provider and get an EKG (ECG).

What laboratory levels would need to be monitored in a client taking growth hormones? Blood gas analysis Cholesterol levels Hemoglobin levels White blood count

Cholesterol levels Human growth hormone is often given to pediatric clients with chronic kidney disease, because CKD can cause less than normal growth in children. While growth hormone often works to correct growth abnormalities, it has been shown to affect cholesterol levels. A client who takes regular growth hormone injections will need to have routine cholesterol level testing.

A nurse wants to implement evidence-based practice into developing new standards of care for the clients on the unit. Evidence-based practice consists of the integration between research evidence, client values and preferences, and which of the following? Patient care outcomes A complete search of literature The cause of the client's condition Clinical expertise

Clinical expertise Evidence-based practice is described as the use of information gained from research and from clinical expertise to make decisions about providing client care. A nurse can look up information from research studies to find evidence but can also consult with clinical experts who have practiced specific methods and who know the pros and cons of working within certain parameters. For instance, when researching a particular topic to implement using evidence-based practice, a nurse could look up information in current research journals and could consult with a professional who has clinical experience in the particular topic area.

During shift report, the oncoming nurse is told that an assigned client has atelectasis. The nurse knows this could be caused by which of the following? Select all that apply. Intubation during general anesthesia Deep vein thrombosis Collapsed lung Brain aneurysm Ventricular tachycardia

Collapsed lung A person with a collapsed lung will have atelectasis in the affected area. Intubation during general anesthesia When a client is intubated, a machine breathes for the client. Normally a person's diaphragm contracts, which increases the space in the chest cavity and causes air to enter the lungs. When intubated, a machine forces air into the lungs, which is the opposite mechanism for lung inflation than normal, and can cause a certain measure of obstruction. Clients who are intubated nearly always have some amount of atelectasis afterward.

A client is admitted by the nurse for alcohol detox and drinks a pint of vodka each day. The last drink was 8 am this morning. Which of the following orders should the nurse implement upon admission? Select all that apply.

Continous cardiac monitoring telemetry The client should be on telemetry to monitor the heart while hospitalized for alcohol withdrawal because the heart rate and rhythm may vary. Remember, clients that come in with alcohol withdrawal have an electrolyte imbalance, which affects the heart. Banana bag IV A banana bag should be infused in the client withdrawing from alcohol to address electrolyte imbalances and prevent further damage to the body. Alcohol withdrawal protocol The alcohol withdrawal protocol should be initiated to ensure that the appropriate care is provided to the client.

The nurse is reviewing the following rhythm and knows that which of the following is the priority nursing intervention for this rhythm?

Continue to monitor the client It is a normal sinus rhythm (NSR) and there is no need for further interventions.

A nurse is caring for a client in a cardiac telemetry unit and notes the client's EKG strip above. The client's blood pressure is 118/78. What action should the nurse take?

Continue with the current plan of care The client's EKG rhythm shows normal sinus rhythm, and since the client's blood pressure is within normal limits, there is no need to intervene at this time.

A nurse is working with a 68-year-old client with cardiac dysrhythmias who has cool skin, poor pulses, and mental status changes. Which of the following conditions is this client most likely experiencing?

Decreased cardiac output Cardiac dysrhythmias can lead to decreased cardiac output if they are significant enough. Signs of decreased cardiac output include decreased peripheral pulses, exercise intolerance, cool extremities, hypotension, and cerebral changes ranging from anxiety/irritability and restlessness to confusion. The nurse should report any changes to the provider to ensure proper treatment for the client's condition.

The nurse is assessing a client with atrial fibrillation and notes weak, thready pulses, cool extremities, and complaints of fatigue. Which of the following is occurring?

Decreased cardiac output This client is demonstrating signs of decreased cardiac output. Decreased cardiac output means that a low amount of blood is being pumped by the heart, so the tissues are starved for oxygen. Signs and symptoms of low cardiac output include diminished pulses, weak, thready pulses, hypotension, cool extremities and fatigue.

Tachycardia affects perfusion of the myocardium in which of the following ways? Affects perfusion only if there is a partial coronary artery blockage Decreases perfusion Increases perfusion Does not affect perfusion

Decreases perfusion Tachycardia decreases perfusion because there is decreased diastolic time, resulting in less blood flow to the coronary circulation.

A nurse is getting an EKG on a client when one of the wires breaks open. Which of the following actions should the nurse take?

Disconnect the machine from the power source and disconnect the client from the machine Bare wires are a danger to the client, so the nurse must disconnect the power source to the wires, then remove the wires from the client.

A nurse is teaching a couple about protecting their newborn baby from abduction while in the hospital. Which statement from the nurse is most appropriate when providing this teaching? If your baby is missing, we will issue an Amber alert, which will help us find him Do not allow anyone to take your baby to the nursery unless they show proper identification You should never let your infant out of your sight Do not allow anyone to transport your infant to the nursery except for you

Do not allow anyone to take your baby to the nursery unless they show proper identification Infant abduction is a scary topic for parents of newborns, yet nurses must educate parents about how to best protect their babies while in the hospital. The nurse should counsel the parents to watch their baby carefully and to never let anyone take the baby to the nursery who does not show proper identification.

A nurse receives a client arriving by ambulance. The nurse suspects that this client has Kawasaki disease. Which of the following sign or symptom would suggest this? Dry, cracked lips Fruity breath Red, beefy tongue Halitosis

Dry, cracked lips Kawasaki disease is a rare childhood disease in which blood vessels in the body become inflamed. It is characterized by a high fever lasting longer than 5 days, swollen lymph nodes, a rash on the mid-section and genital area, red, dry, cracked lips and a red, swollen tongue.

The nurse is planning care for a client and prioritizes health promotion and accident prevention. Which of the following age groups does this client most likely fall into, with accidents and injuries from recreational activities as the main health concern? Middle adulthood Early adulthood School age Adolescence

Early adulthood A client in early adulthood is in a prime stage of life to prioritize health promotion. This stage of life is also characterized by accidents and injuries as the main health concern.

A client is prescribed a topical glucocorticoid. The nurse knows that the absorption of glucocorticoid cream is greater in which of the following areas? Select all that apply. Back Soles of the feet Axilla Face Eyelids

Face, Eyelids, Axilla Absorption of glucocorticoid creams is greatest in thinner, permeable skin areas such as the axilla, eyelids, neck, perineum, scalp, and face.

The nurse is conducting education for a group of parents in the community. The nurse teaches the group that which of the following affects the growth and development of children? Select all that apply. Similarity of lifestyle to peers Availability of nutritional foods Cultural and family influences Family structure Access to outdoor spaces

Family structure A child's growth and development is affected in many ways. One of the variables that makes a difference in how well a child develops is family structure. When a family has one or two stable adults to provide security for a child, a child is more likely to thrive. Availability of nutritional foods Not having access to nutritious foods leads to poor overall health of a child, and impacts the health of that child as an adult as well. Access to outdoor spaces Access to outdoor spaces has been shown to positively impact a child's growth in many ways, including better physical health, strengthened motor skills, stress relief, increased attention and cognitive abilities, and production of vitamin D. Cultural and family influences The influence of family and culture makes an impact on a child's development by language, beliefs, and learned behavior.

An example of a type of long-acting insulin would be: Aspart (Novolog) Glargine (Lantus) Lispro (Humalog) Humulin R

Glargine (Lantus) Long-acting insulin is used to control blood glucose levels over a long period of time. For example, many people take long-acting insulin at bedtime to control blood sugar overnight. Long-acting insulin may be used in conjunction with rapid-acting forms of insulin. An example of long-acting insulin is glargine.

The nurse is treating a child who sustained a fall. An x-ray shows that the child's bone has been angulated beyond the limit, causing a compression in the bent side of the bone, and a slight break to the tension side of the bone. Which of the following fractures does the nurse suspect? Buckle fracture Bend Greenstick fracture Complete fracture

Greenstick fracture A greenstick fracture describes a bone fracture that resembles a green stick when it breaks. There is only a break through a part of the bone, as the bone was bent just barely beyond the limits. It is usually a closed fracture.

You are the nurse caring for a neonate that has presented with symptoms of meningitis. As the nurse, you know that which of the following is the most common cause of meningitis in this age group? Group B streptococci S. pneumoniae Neisseria meningitidis Meningococcal meningitis

Group B streptococci The most common bacterial cause of meningitis in neonates is Group B Streptococci.

A nurse is caring for a client with pulmonary edema. Which of the following factors can predispose a client to developing this condition? Select all that apply. Heart failure Acute respiratory distress syndrome Hypothyroidism Diabetes Inhalation of toxic gases

Heart failure Pulmonary edema occurs as a build up of fluid in the lungs, which causes shortness of breath. The condition is more likely to develop in situations where a client has excess fluid in the body. Heart failure is an example of a condition that can lead to pulmonary edema. Inhalation of toxic gases Inhaling toxic gases causes pulmonary injury which can result in severe pulmonary edema. Acute respiratory distress syndrome When a lung injury occurs that causes a physiological response like acute respiratory distress syndrome (ARDS), pulmonary edema can occur.

The nurse is administering an anti-platelet drug to a client. The nurse knows it is most important to monitor for which of the following adverse effects? Nausea and vomiting Flushing Prolonged QT interval Hemorrhage

Hemorrhage This is correct. Since an anti-platelet medication reduces the clotting ability of the blood, the nurse should monitor any client taking this type of medication for signs of bleeding. HODS is a mnemonic to help remember some drug combinations that cause adverse effects when taken with anti-platelet aggregates: Heparin = increased bleeding potential, Oral antidiabetic drugs + aspirin = uncontrolled BG results, Dipyridamole = increase bleeding potential, and lastly Steroids + aspirin = increased risk for GI ulceration.

The nurse is caring for a client with abdominal pain. While reviewing the client's past medical history, which diagnosis would concern the nurse?

Hirschsprung's disease Hirschsprung's disease is an intestinal disorder causing constipation due to lack of innervation to push stool through the colon. If the client is experiencing abdominal pain and have a diagnosis of Hirschsprung's disease, they likely have constipation and potentially a blockage.

A cardiac client is being discharged home today and will require home heart monitoring. The client's current vitals are: blood pressure 133/86 heart rate 87 pulse oximeter 98% room air temperature 98.7F respirations 18 The nurse knows to expect which of the following discharge orders?

Home with Holter monitor A Holter monitor may be worn to monitor his heart while outside of the hospital. This will monitor the heart and then the healthcare provider can review.

A 60-year-old client with coronary artery disease is being seen at a cardiology clinic for care. The nurse performs the intake assessment and asks the client some questions about his health history. Which of the following questions would assess for signs of chronic stressors in the client's life? Would you say that you follow a healthy diet? How often do you exercise? Do you take your medication every day? How do you like your job?

How do you like your job? Chronic stress contributes to poor health and a worsening of cardiac symptoms. The nurse can assess for chronic stress by evaluating those situations that would most likely cause repeated or ongoing stress in a client's life, which generally fall into six categories based on the Trier Inventory for the Assessment of Chronic Stress (TICS): work overload, worries, social stress, lack of social recognition, work discontent, and intrusive memories.

The nurse has just administered captopril to a client for the first time. For which of the following side effects will the nurse monitor? Wet cough Hyperkalemia Urinary retention Hypertension

Hyperkalemia Captopril is an angiotensin converting enzyme (ACE) inhibitor. This medication helps reduce blood pressure by blocking angiotensin I from converting to angiotensin II. This causes decreased vasoconstriction, and decreased sodium and water reabsorption by the kidneys. However, restricting angiotensin II causes a decrease in aldosterone, which is responsible for potassium excretion. This leads to potassium retention and subsequent hyperkalemia.

A nurse is monitoring her client who is in the medical-surgical unit with a recent bowel resection. The client has an infusion of TPN with lipids running into a central line. Which of the following metabolic complications would the nurse most likely see with a client receiving TPN? Hyponatremia Hypermagnesemia Hypertriglyceridemia Hypoalbuminemia

Hypertriglyceridemia A client who receives TPN is at higher risk of certain metabolic complications, including hypo- or hyperglycemia, refeeding syndrome and hypertriglyceridemia. TPN contains a mixture of several vitamins and electrolytes, as well as dextrose and lipids. When a lipid emulsion is added, the client may be at higher risk of developing elevated triglycerides.

A new nurse is having a difficult time knowing which client should be seen first because they all seem important. The nurse preceptor helps and explains that the client with which of the following should be seen first? Febrile, tachycardia, and vomiting Abdominal pain, hypertensive and constipated Dizziness with normal vital signs Hypotension, tachycardia, and lethargy

Hypotension, tachycardia, and lethargy The hypotensive client with tachycardia is concerning for hypovolemia or shunting, especially with lethargy. This client is not stable. The lethargy indicates that blood flow and oxygenation are an issue.

A 74-year-old client has suffered a myocardial infarction; the critical care team places the client into a state of hypothermia as part of treatment. Which best describes why hypothermia is used after cardiac arrest?

Hypothermia protects the brain from damage caused by ischemia by slowing the brain's metabolism Therapeutic hypothermia, also known as targeted temperature management (TTM) is a form of treatment that may be used among some clients who have suffered a cardiac arrest. A client may be placed in a state of hypothermia after a myocardial infarction when his heart and brain have suffered damage from lack of oxygen. Research has shown that therapeutic hypothermia protects the brain from ischemic damage by slowing the brain's metabolism, resulting in improved neurological outcomes.

A 28-year-old female client has been diagnosed with type 2 diabetes. The nurse is talking with the client about diet, such as what foods to include and what foods to avoid. Which statement made by the client indicates that more teaching is needed?

I should increase my fiber intake to at least 45 grams each day The nurse should teach the client to increase fiber intake to 25 to 35 grams per day to regulate the gastrointestinal system. 45 grams per day is too much fiber intake. This can cause gastrointestinal difficulties such as bloating and gas, so the client who is not used to consuming large amounts of fiber should increase their intake slowly.

The nurse is administering timolol maleate ophthalmic solution in each of the client's eyes. Which statement by the client indicates the need for more teaching? Adverse reactions include dizziness and double vision I will continue to take this until eye pressure is normal I must wash my hands before putting in the drops This drug will decrease the fluid in my eye

I will continue to take this until eye pressure is normal Timolol maleate is a beta blocker used for glaucoma. With glaucoma, eye pressure will continue to be abnormally high for life, so the eye drops also are taken for the duration of the person's life. Adverse reactions include dizziness and double vision.

A postpartum client who had a vaginal delivery 24 hours ago is complaining of perineal pain. The nurse administers oxycodone with acetaminophen (Percocet) for pain control. An hour later, the patient still has pain rated at a "5" on a 0-10 scale. Which of the following medications could the nurse safely give to this client at this time that would not interact with the Percocet? Tramadol (Ultram) Aspirin Ibuprofen Darvocet (acetaminophen-propoxyphene)

Ibuprofen Percocet is a combination of oxycodone and acetaminophen that may be given as an oral tablet for pain control. It cannot be used with some other types of medications, as it can cause negative interactions between the drugs. Ibuprofen does not interact with Percocet and is not made of the same ingredients so it can be given close to the administration of Percocet if further pain medicine is needed.

A nurse is working in an outpatient clinic caring for clients who are recovering from minor surgical procedures. Which of the following must the nurse consider when documenting PRN pain medications that are frequently administered? Select all that apply.

If the nurse did not document the PRN administration, it is considered not done When a nurse administers a medication, it is essential that she documents the administration correctly. Failure to document medication administration is equivalent to saying that the drug was never given at all. Proper documentation communicates which medications were administered and when When giving PRN meds, the documentation should include what med was given and the time of administration. Documentation must include the medication's effects if it is a PRN order Under a PRN order, the nurse must also document the medications effects and the condition for which the medication was given. All PRN medications should be documented as soon as possible after being given This is correct. PRN medications must be documented at the time of administration.

The nurse is caring for a client whose echocardiogram revealed a low stroke volume. Nursing interventions should focus on which of the following? Select all that apply.

Increasing contractility: Stroke volume is the amount of blood pumped out of the heart with each beat, and is measured in mL. A normal stroke volume is 60-120 mL per beat and is calculated by taking the end-diastolic volume (a filled ventricle) minus the end-systolic volume (a ventricle after it has emptied). Increasing the contractility of the heart will help Increasing preload: Preload is the amount of stretch the ventricles experience as a result of being filled with blood. Increasing preload will help increase stroke volume, so this is an important focus for the client with a low stroke volume. Increasing perfusion: The purpose of the heart is to pump blood effectively in order to send oxygenated blood to the body. A low stroke volume results in decreased perfusion, so increasing perfusion is an appropriate focus for nursing interventions

The nurse is caring for a client with a staph infection. The client has an order for clindamycin. The nurse knows that this antibiotic fights bacteria in which of the following ways? Inhibiting uptake of ATP in the cell Inhibiting cell wall synthesis Inhibiting protein synthesis Inhibiting ribosomes from building proteins

Inhibiting protein synthesis This is correct. Clindamycin is part of the lincosamide family of antibiotics. This type of medication stops RNA/DNA communication, and therefore stops protein synthesis.

Intergroup Conflict

Intergroup conflict describes a type of conflict that occurs between two or more different groups. In this case, intergroup conflict would occur when there is conflicting between two areas, such as between the nursing unit and another area of the facility, such as the lab or dietary departments.

Dihydroergotamine (DHE) has been prescribed for a client who suffers from migraine headaches. The nurse understands that this medication can be given via which of the following routes? Select all that apply.

Intravenously DHE can be given intravenously (IV), intramuscularly (IM), subcutaneously (SQ), or by nasal spray. When given orally there is a first pass effect in the liver, decreasing the drug's effectiveness. Subcutaneously DHE can be given subcutaneously (SQ). Intranasally DHE can be given by nasal spray. Intramuscularly DHE can be given by injection (IV, IM, SQ) or through a nasal spray. When given orally there is a first pass effect in the liver, decreasing the drug's effectiveness.

Which of the following is an advantage of using a peripherally inserted central catheter (PICC)? Select all that apply. It can be used for hemodialysis It can be inserted at the bedside by a trained PICC RN It is less painful with insertion It is cost effective It carries a lower risk of infection compared to peripheral IVs

It can be inserted at the bedside by a trained PICC RN A peripherally inserted central catheter (PICC) is a type of central line that is inserted in the upper arm and threaded to a central vein near the heart. A PICC is usually inserted by a specially trained "PICC nurse" and can be placed at the bedside. It is cost effective It is cost effective because it can remain in for up to six months.

The client is scheduled for a gastric emptying study. Which of the following best describes a gastric emptying study? It involves a small camera at the end of a flexible tube It involves drinking barium and watching the stomach empty It is a radionuclide study that scans the stomach emptying It involves a contrast medium taken orally to assess stomach emptying

It is a radionuclide study that scans the stomach emptying This type of test is performed when a client experiences vomiting, abdominal pain or gastroparesis. It is a radionuclide study in which the individual consumes a liquid or solid meal that contains a radioactive isotope for visualization. The test involves timing how long the meal takes to get through the stomach.

A patient has a non-tunneled central catheter placed for intravenous administration of antibiotics. Which of the following is true regarding this type of catheter?

It is designed to be used for a few days to weeks A non-tunneled catheter is one that is inserted and intended for use on a relatively short-term basis. The catheter can be used for a longer period than a peripheral IV, but it does not last as long as a tunneled catheter. It is typically inserted in the subclavian or jugular veins It is designed to last for several weeks and is usually inserted into the subclavian, jugular or femoral veins. Central lines can be inserted as tunneled or non-tunneled catheters. A tunneled catheter is inserted and then tunneled under the skin, while a non-tunneled catheter is inserted directly into a vessel. A tunneled catheter exits the chest and is associated with a lower risk of infection and can stay in place for several months but it must be inserted as a surgical procedure.

A client presents to the emergency room with c/o nausea, vomiting, and diarrhea. Which of the following medications is appropriate to treat this condition? Propanolol Loperamide Ibuprofen Indomethacin

Loperamide This is an antidiarrheal medication.

A bedridden client requires cradle boots bilaterally to prevent foot drop while in bed. Which of the following describes how to apply cradle boots? Select all that apply. Ensure that the client wears a pressure dressing around the ankle before applying the boot Maintain the foot in the flexed position Place the foot into the bottom portion of the boot Secure the boot snugly around the foot Apply the boots only when the client is lying prone

Maintain the foot in the flexed position When the boots are applied, the client's heel is placed in the boot and the foot is supported in the flexed position with a strap across the top to keep the foot in place. Place the foot into the bottom portion of the boot The bottom portion of the boot must cradle the foot. Secure the boot snugly around the foot Cradle boots may be placed on the client's feet to protect the skin and to keep the feet in alignment. This prevents foot drop.

After behavioral therapy has failed to help a client stay focused long enough to complete their studies, the nurse knows that the next step is medication. Which of the following medications is an example of what the client might be prescribed? Methylphenidate Metocloprimide Medazolam Metoprolol

Methylphenidate

A client giving a medication history tells you she is in the early stages of pregnancy. Which of the following drugs should be immediately discontinued?

Misoprostol This drug is an anti-secretory medication to prevent gastric ulcers. It can cause inadvertent miscarriages and should be discontinued in early pregnancy.

A nurse is caring for a client who is experiencing trouble with coordination and balance, spastic muscles, and numbness and tingling in the extremities. This client is most likely suffering from which of the following? Multiple sclerosis Fibromyalgia Guillain Barre syndrome Myasthenia gravis

Multiple sclerosis Multiple sclerosis is caused by a deterioration of the myelin sheath, and is characterized by fatigue, tremors, weakness, bowel and bladder dysfunction, and muscle spasticity. Fibromyalgia This is characterized by wide spread muscle pain and weakness. Guillain Barre syndrome This is characterized by weakness, breathing problems, and numbness and tingling. Myasthenia gravis This is characterized by double vision, ptosis, and weakness and fatigue.

There are 4 clients in the emergency room that have some sort of laceration or cut. Which laceration should the nurse see first? Forehead laceration from a fishhook Forearm cut from a mirror Finger laceration from a soup can lid Multiple wrist cuts from a razor blade

Multiple wrist cuts from a razor blade The client with multiple wrist lacerations is suspicious of a suicide attempt and should be seen first to place them in a safe environment.

A nurse is caring for a client who is experiencing nearsightedness. This is called which of the following? Myopia Strabismus Hyperopia Amblyopia

Myopia This term refers to nearsightedness, which means near objects are more clearly seen than far away objects Hyperopia This term refers to farsightedness, which means far away objects are more clearly seen than near objects.

The nurse is caring for a client who takes a diuretic for heart failure. The nurse is assessing the client and notes confusion, muscle weakness, and diminished deep tendon reflexes. The nurse checks the client's lab values. Which of the following lab values is consistent with this client's symptoms? Ca 10.8 mg/dL K 7.1 mEq/L Na 121 mEq/L Mg 1.6 mg/dL Cancel Quiz

Na 121 mEq/L This client is demonstrating signs and symptoms of hyponatremia. These include a rapid pulse that is thready or bounding depending on fluid status, weak respirations, skeletal muscle weakness, diminished deep tendon reflexes, confusion, headache, and increased GI motility. (Ca 10.8 mg/dL) Hypercalcemia presents as increased heart rate, hypertension, bounding pulses, skeletal muscle weakness, diminished deep tendon reflexes, and decreased motility. While hypercalcemia can cause confusion, a calcium level of 10.8 mg/dL is considered mild and usually results in no symptoms.

A client complains of severe pain following knee surgery. The nurse provides a dose of hydrocodone to help control this client's pain. Which of the following gastrointestinal conditions may develop as side effects to using this type of drug? Select all that apply.

Nausea Hydrocodone is a type of opioid analgesic that is used to control severe pain. It may cause complications like GI conditions such as constipation, nausea and vomiting, and respiratory depression. Constipation This is among the GI complication that is caused by opioid analgesics.

The nurse is caring for a client with low cardiac afterload. Which of the following medication orders would the nurse question?

Nitroprusside Nitroprusside is a potent vasodilator. A low afterload means that the client already has massive vasodilation and hypotension, so giving a vasodilator would worsen the problem.

A student nurse is observing a client's heart rate and notices a regular rhythm, heart rate of 65, 1 P wave followed by 1 QRS, PR interval of 0.16 seconds and a QRS complex of 0.06 seconds. The nurse knows that this is which of the following rhythms?

Normal sinus rhythm Characteristics of a regular rhythm, heart rate of 65, 1 P wave followed by 1 QRS, PR interval of 0.16 seconds, and a QRS complex of 0.06 seconds describe a normal sinus rhythm.

A nurse is working on a telemetry unit and notices the rhythm pictured. This rhythm is correctly identified as which of the following rhythms?

Normal sinus rhythm This rhythm is normal sinus. Using the "1500" method, there are 18 small boxes between 2 normal QRS complexes. Divide 1500/18 = 83 beats per minute - therefore NSR.

The nurse observes a normal sinus rhythm on the 5-lead telemetry monitor after a client has been in atrial fibrillation with a rapid ventricular response. Which of the following should the nurse do first?

Obtain a 12 lead EKG The rhythm change needs to be confirmed with a 12 lead EKG.

A client is being admitted to the hospital from a nursing home and has several medications with him. Which of the following are steps in the medication reconciliation process? Select all that apply.

Obtain a complete list of the client's current medication Medication reconciliation involves reviewing the medications that a patient is taking when he is admitted to a facility. Compare the providers orders to the client's list of medications This is correct. These two resources should be compared. They may not be identical, but the nurse and client must understand why the two lists are different in the event that it is an error. Resolve discrepancies that exist between the client's medication list and the provider order The nurse then ensures that the prescribing provider is aware of the home medications and the provider determines if these medications should continue while the patient is in the facility, or if they should be discontinued, held or changed.

A nurse is caring for a client who has soft, malleable bones due to a vitamin D deficiency. What is the best term used to describe this condition? Osteomalacia Osteoporosis Hypoosteosis Arthritis

Osteomalacia "Osteo-" refers to bones, while "-malacia" refers to softening. Osteomalacia is a condition of soft bones, most commonly caused by Vitamin D deficiency. Osteoporosis "-poro" refers to pores or holes. Osteoporosis is a condition of porous bones, usually caused by calcium deficiency.

The nurse is caring for a client who is experiencing hypotonic labor. What do you expect for her plan of care? Morphine Oxycodone Oxytocin Turn the client

Oxytocin During hypotonic labor, oxytocin should be given to help uterine stimulation and increase contractions

The nurse in the trauma bay is concerned that a client is suffering from a stomach injury related to a gun shot wound. Which of the following signs and symptoms is the nurse observing?

Pain in the epigastrium or upper left quadrant These are classic symptoms associated with stomach trauma.

A nurse works as part of an interdisciplinary team that discusses care for a client who is being admitted from a long-term care facility. Which task is not appropriate for the nurse to delegate to the LPN that is part of the team? Setting up oxygen for the client to use Orienting the client to the room and the environment Performing an initial assessment and checking vital signs Applying leads to connect to the cardiac monitor

Performing an initial assessment and checking vital signs This is not an appropriate task for an LPN. A nurse who works with an LPN or a nursing aide may delegate some tasks associated with admitting a client to the facility, but the RN is still ultimately responsible for the delegated tasks. The nurse can ask the LPN to perform tasks such as connecting the client to the monitor, providing oxygen, or orienting the client to the room, but the RN must be the person to perform the initial intake assessment on the client.

Signs and symptoms of volume overload in a client include which of the following? Select all that apply. Peripheral edema Dry eye sockets Dyspnea Extreme thirst Jugular venous distension

Peripheral edema Peripheral edema is a sign of fluid volume overload. Jugular venous distension Signs and symptoms of volume overload include dyspnea from fluid overload in the lungs, peripheral edema, and jugular venous distension. Dyspnea Dyspnea is a sign of fluid volume overload.

The nurse is caring for an older adult client with decreased cardiac output related to new-onset atrial fibrillation. In planning care for this client, which of the following activities is appropriate?

Plan for frequent rest periods throughout the shift The client with decreased cardiac output has less blood volume than normal pumping through his or her body, and therefore will not be able to tolerate a physically demanding routine. The nurse should plan to allow for plenty of rest for this client. Limit activities by bundling care The client's cardiac system is unable to compensate for increased activity, and multiple interruptions and requests that require physical exertion could harm the client. The nurse will best manage this client by limiting activities

The nurse is caring for a client with disseminated intravascular coagulopathy. Which lab would the nurse expect to be abnormal? Mean corpuscular volume Red blood cells Platelets White blood cells

Platelets A platelet count indicates the client's blood clotting ability. This number is low when a client is in DIC.

A client arrives at the emergency room and the nurses assess that the client who has a loss of consciousness, incoherent, eyes are open to painful stimuli, and withdraws to pain. The nurse knows that which of the following is the priority nursing intervention? Call a Neurological Consult Give 5mg of Valium IV Prepare for intubation Give one amp of IV dextrose

Prepare for intubation The client is exhibiting a Glasgow Coma Scale score of 8 which is indicative of a moderate to severe head injury. In this situation, there is a concern that the client may not be able to maintain an effective and spontaneous breathing pattern and the nurse should anticipate that a definitive airway, such as an endotracheal tube, may need to be inserted to protect the client's airway.

A drug is given that is considered an antagonist for a specific receptor. What effect(s) should the nurse expect? Select all that apply. Prevent other neurotransmitters from acting on that receptor Attract other neurotransmitters to the receptor to produce an effect Stimulate an opposite effect from the receptor site Stimulate the receptor to produce its effect Bind to the receptor, but the receptor produces no effect

Prevent other neurotransmitters from acting on that receptor An antagonist medication will prevent the effects of the receptor being activated. Preventing other neurotransmitters from acting on that receptor by physically blocking is one way to produce this action. Bind to the receptor, but the receptor produces no effect The purpose of an antagonist is to prevent the effects of the receptor being targeted. This can be done by binding to the receptor but not activating it - this prevents it from being activated by any other means.

The nurse caring for a newborn diagnosed with patent ductus arteriosus explains to the client's parents that the ductus arteriosus is an opening between which of the following? Left and right atrium Left and right ventricle Superior vena cava and the aorta Pulmonary artery and the aorta

Pulmonary artery and the aorta The ductus arteriosus (DA) is an opening between the pulmonary artery and the aorta. It is present during fetal circulation to allow blood to bypass the fetus's lungs which are full of fluid and not working. The DA usually closes with the pressure changes that occur in the heart after the umbilical cord is clamped.

A client with heart failure has an estimated cardiac output of 2.5 L/min. The nurse expects which of the following vital signs to be consistent with this?

Pulse 118 Normal cardiac output is between 4-8 L/min. Since this client has low cardiac output, the nurse would expect the heart to compensate by increasing the heart rate.

Which of the following terms indicates and infection in the renal pelvis? Pyelonephritis Glomerulonephritis Cystitis Folliculitis

Pyelonephritis The term "pyelo" refers to the pelvis, "nephro" refers to the kidneys, and "itis" refers to infection or inflammation

The telemetry nurse is reviewing an EKG strip and notes the following: Rate 60, PR interval 0.14 seconds, QRS complex 0.2 seconds, P:QRS ratio 1:1. Which of the following results causes the nurse to suspect a bundle branch block?

QRS complex 0.2 seconds This is a widened QRS complex, which means the client has a bundle branch block. All other values are consistent with normal sinus rhythm.

The nurse is caring for a client who becomes pale, weak, and diaphoretic. The nurse suspects the client is experiencing shock. What is the first thing this nurse should do?

Raise client's legs This is called the passive leg raise, which is routinely done to clients experiencing shock. The thought is that this promotes blood return from the legs to the vital organs.

The nurse is caring for a client with congestive heart failure. This client regularly takes a vasodilator. The nurse understands that this type of drug helps congestive heart failure in what ways? Select all that apply.

Reduce cardiac afterload n general, a vasodilator benefits the client in heart failure by dilating blood vessels so that cardiac afterload is reduced. When peripheral blood vessels are dilated, circulation is enhanced which means that both skeletal and coronary circulation is increased. The kidney's arterioles are also dilated which promotes blood filtration. Dilate the kidney's arterioles This is an effect of vasodilators. Enhance skeletal muscle circulation This is an effect of vasodilators.

A student nurse is reviewing the client's EKG on a telemetry unit. The student nurse is attempting to identify the rhythm as a normal sinus rhythm. Which of the following steps should the student nurse identify for normal sinus rhythm? Select all that apply.

Regular pattern Normal sinus rhythm (NSR) has a regular pattern. Heart rate between 60-100 BPM NSR has a heart rate of 60-100 BPM. Normal PR interval NSR has a normal PR interval of 0.12-0.20 seconds.

A nurse is working with a client who has a central catheter in place that is measuring central venous pressure (CVP). When looking at the waveform, the nurse understands that the descending portion of the wave indicates which of the following?

Relaxation of the atria Central venous pressure (CVP) is measured within the superior vena cava, and shows the pressure with which blood is returned to the superior vena cava and right atrium. Systole and diastole produce a waveform on the monitor that the nurse should check to ensure that central venous pressure is being measured appropriately. The phases represented on the waveform show end diastole, early, mid and late systole and early diastole (labeled a, c, v, x and y). When pressure increases (during systole), the waveform rises. The descent of the waveform (x) represents the period of atrial relaxation.

A nurse is caring for a client complaining of chest pain. A 12-lead EKG (ECG) shows normal sinus rhythm. After 30 minutes, the client's lab work results and shows elevated troponin. What are the priority interventions at this time? Select all that apply.

Repeat the EKG (ECG) The client could be having a non-ST elevation myocardial infarction (NSTEMI). A repeat EKG will help to confirm this, as well as ensure no changes have occurred since the client arrived. Re-evaluate the chest pain The nurse should re-evaluate the client's chest pain to determine if there have been any changes, better or worse. If the pain has not subsided, it is possible the client is having a non-ST elevation myocardial infarction (NSTEMI). Notify the provider The repeat EKG, repeat pain evaluation, and a new set of vitals should be reported to the provider as soon as possible. It is highly possible the client is having an NSTEMI, which requires immediate intervention.

The nurse is caring for a client who requires large amounts of opioids for pain control. The nurse will be most concerned about monitoring for which side effect? Hypotension Respiratory depression Physical dependency Convulsions

Respiratory depression This is correct. Respiratory depression is the most serious side effect of an opioid.

A client is scheduled for a thyroidectomy and the nurse knows that which of the following positions would be expected for surgical positioning? Trendelenburg Left lateral Reverse trendelenburg Right lateral

Reverse trendelenburg This position is common for head and neck surgeries to allow for better access to the surgical site.

A client is planning to take ketorolac IM (Toradol) for pain and must self-administer the drug at home. Which of the following information would the nurse give this client about selecting the correct location for the administration of this type of injection? Select all that apply.

Rotate injection sites Some clients must self-administer intramuscular injections, in which case the nurse would need to provide education about how to perform the injections correctly. The client should rotate sites to avoid development of scar tissue. The ventrogluteal site may be too difficult to use for self-administration Some sites are more difficult to reach if the client is giving himself the injection. By providing adequate teaching, the nurse can educate the client how to administer this type of medication in the safest method possible.

The nurse is caring for a diabetic client who takes insulin. Which of the following actions should the nurse take to avoid complications? Reuse syringes for a week before replacing Rotate sites for providing insulin Mix long acting insulin first Encourage discarding the needles in the garbage

Rotate sites for providing insulin The nurse should rotate sites for providing insulin to avoid lipodystrophy, which affects insulin absorption and distribution.

The nurse preceptor is charting a physical assessment on a client. The nurse charts hearing "S1, S2" heart sounds and asks the student what this means. Which of the following responses from the student is correct?

S1 is the sound of the AV valves closing, and S2 is the sound of the aortic and pulmonary valves closing The sounds heard during auscultation of the heart represent valves closing. S1, during ventricular systole, is the sound of the mitral and tricuspid valves closing. These are the valves between the atria and ventricles. S2, during ventricular diastole, are the sounds of the aortic and pulmonary valves closing.

After reviewing a normal sinus rhythm on an EKG strip, the student nurse is able to determine the electrical conduction originated in which of the following?

SA node In NSR, the electrical conduction originates in the SA node. Next, it travels to the AV node, then through the Bundle of His, and then to the Purkinje fibers.

A client that has been hospitalized for three days complains of sudden chest pain to the nurse and has no history of heart disease. The nurse knows that which of the following orders should be implemented?

STAT EKG It would be an appropriate order to initiate because an EKG will show a current one-time view of the heart's rate and rhythm. STAT troponin level It will determine if there is any heart damage. Continuous cardiac monitoring telemetry This would be needed to continuously monitor the heart for any changes in rate or rhythm.

A nurse finished getting report on four clients and now is deciding who is the priority. The client with which of the following should be seen first?

STEMI with heparin infusing and requested to go to the bathroom Clients receiving heparin are at an increased risk for bleeding, therefore a fall can be extremely detrimental. This client needs to be seen first to assess their gait, heparin drip, IV patency, and level of assistance to the bathroom.

A student nurse is studying the electrocardiogram graph paper. The nurse understands the X-axis on the graph paper indicates which of the following? Amplitude Millivolts Minutes Seconds

Seconds The X-axis measures seconds. The Y-axis measures millivolts.

The nurse is assessing a client with advanced AIDS. Which of the following are expected findings? Select all that apply. Skin breakdown Obesity Mouth ulcers Leukopenia Fluid overload

Skin breakdown Malnutrition and illness leads to weakened skin structure, and results in skin breakdown. This is a common finding in clients with advanced AIDS. Mouth ulcers Stomatitis, or ulcers in the mouth, are a frequent finding with clients who have AIDS. Most commonly these are due to viruses such as cytomegalovirus or herpes simplex virus. Leukopenia White blood cells are destroyed by the human immunodeficiency virus. By the time a client progresses to AIDS, labs will reflect profound leukopenia.

The nurse is caring for a client with a hypertensive crisis. The nurse is monitoring for signs and symptoms that would indicate either an urgent or an emergent situation. Which of the following signs indicate an emergent situation? Select all that apply. Anxiety Crackles in the lungs Shortness of breath Confusion Slurred speech

Slurred speech This is a stroke-like symptom and indicates a medical emergency. Other stroke symptoms include facial drooping, one sided weakness, and confusion. Confusion This is a stroke-like symptom and indicates a medical emergency. Other stroke symptoms include facial drooping, one sided weakness, and slurred speech. Crackles in the lungs This indicates increased pulmonary hypertension and is a sign that the hypertensive crisis has progressed to an emergent situation.

A client with chronic airway disease has been prescribed theophylline. Which best describes the mechanism of action of theophylline in the body? Select all that apply. Inhibition of cyclooxygenase Suppression of the response of the airways to stimuli Smooth muscle relaxation Vasodilation Suppression of production of prostaglandins

Smooth muscle relaxation Theophylline is a drug that is administered to help some clients who have difficulty breathing. It works by causing smooth muscle relaxation, which opens the airways. Suppression of the response of the airways to stimuli Theophylline is further effective because it suppresses the response of the airways to outside stimuli that could cause them to constrict. theophylline is a bronchodilator.

A staff nurse describes the nurse manager as a Laissez-faire leader. Which characteristics best describe this type of nurse leader? Select all that apply. A leader who does not tolerate mistakes A nurse who relies on staff to make most decisions Someone who provides little or no direction Someone who encourages open communication A person who prefers a hands-off approach

Someone who provides little or no direction A person who prefers a hands-off approach A nurse who relies on staff to make most decisions Within nursing practice, there are several noted styles of leadership. Laissez-faire leadership describes a style in which the nurse leader is laid back and does not provide much direction to staff. This type of leader keeps mostly a hands-off approach to management and often relies on staff to make most decisions.

A nurse has decided to take a new position in the risk management department of the hospital. Which of the following describes a responsibility of a nurse risk manager? Select all that apply. Preparing evidence if a suit against the facility goes to court Manages risk for the facility Manages risk for the clients in the facility Participating in loss prevention Supervising claims made by healthcare staff

Supervising claims made by healthcare staff A risk management nurse is responsible for protecting certain aspects of the healthcare facility, such as by investigating claims made by staff. Participating in loss prevention A risk management nurse is responsible for protecting certain aspects of the healthcare facility, such as by investigating claims made by staff and supporting loss prevention. The risk management nurse has other duties as well, including managing the risk of clients in the facility, and keeping track of incidents that occur within the facility. Manages risk for the facility The risk management nurse has other duties as well, including managing the risk of clients in the facility. Manages risk for the clients in the facility A risk management nurse is responsible for protecting certain aspects of the healthcare facility, such as by investigating claims made by staff and supporting loss prevention. The risk management nurse has other duties as well, including managing the risk of clients in the facility, and keeping track of incidents that occur within the facility.

Four clients in the emergency room are having chest pain. The nurse knows that which of the following accompanying chest pain would be the most concerning? Supraventricular tachycardia, BP 92/48 A seat belt sign, RR 22 Shortness of breath, SpO2 92% Atrial fibrillation, HR 96

Supraventricular tachycardia, BP 92/48 A client with supraventricular tachycardia (SVT) and chest pain is urgent because the chest pain indicates that the coronary arteries are not perfusing properly. This is the main concern with extremely fast heart rates like SVT, the heart perfuses itself during diastole - but with a high rate, the diastole period is extremely short and risks decreasing coronary perfusion. Even more concerning is the slight hypotension accompanying this rhythm. This client needs to be converted back to a sinus rhythm as soon as possible to prevent an MI or cardiac arrest.

Which of the following medications is an example of a drug that a client might receive as a muscle relaxant during surgery? Lidocaine Propofol Codeine Suxamethonium

Suxamethonium Suxamethonium is a depolarizing skeletal muscle relaxant medication. It is often given just before intubation to make it easier to place the endotracheal tube because the client's body is relaxed. Lidocaine is a medication for pain Propofol is a sedative/hypnotic Codeine is a medication used for pain

A nurse is assigned 4 clients with various diagnoses and is reviewing their orders. The nurse would expect to put the client with which of the following diagnosis on continuous cardiac monitoring telemetry?

Syncope The client with syncope should be placed on a continuous heart monitor telemetry to ensure that the rate and rhythm are within normal limits.

The nurse is caring for a client with worsening congestive heart failure. Which of the following are expected findings in a client with this condition? Select all that apply. Tachycardia Brain natriuretic peptide level of 90 pg/mL Warm, pink skin Shortness of breath at rest Slow capillary refill

Tachycardia The client with worsening heart failure will have tachycardia as the heart makes an attempt to keep up with cardiovascular demands. Slow capillary refill Circulation is compromised in the client with congestive heart failure, so capillary refill time is slowed. Shortness of breath at rest Because of the loss of effective pumping, the heart is unable to meet oxygen demands, even at rest. The client with worsening congestive heart failure will have shortness of breath at rest, and profound shortness of breath with normal activities such as walking. A BNP of <100 pg/mL is normal. The client with congestive heart failure will have a BNP of >100 pg/mL.

There are 4 clients in the waiting room that the nurse must see in order of priority. Which of the following clients should the nurse see first based on the chief complaint? Knee pain and swelling Failure to thrive Testicular pain and swelling Abdominal cramping

Testicular pain and swelling Testicular pain with swelling could be a testicular torsion and this is considered a medical emergency. This client needs to be seen quickly, because torsion cuts off the blood supply to the testicles, which can result in the loss of the affected testicle.

Banner Mobility Assessment Tool (BMAT)

The BMAT is an assessment tool the nurse may use to determine a client's level of mobility in order to be able to prevent complications. The tool consists of four assessments: Sit up in bed and shake a hand by reaching across the midline, stretch and straighten a knee then point toes, stand, and march in place then advance a step.

A nurse is teaching a diabetic client about how to give insulin injections to himself on a daily basis. The nurse teaches the client that the area where insulin is absorbed most rapidly after injection is which of the following? The buttocks The abdomen The upper arms The upper legs

The abdomen A diabetic client who must administer injections uses various sites on the body with subcutaneous tissue. Certain sites absorb the medication more quickly than others. The abdomen is known as the fastest and most evenly absorbed location for insulin.

Which best describes the viral load of HIV in the body? The amount of an opportunistic infection that can lead to severe illness The amount of virus present in blood and body fluids The amount of the virus the infected person is able to transmit The amount of virus that can cause an infection

The amount of virus present in blood and body fluids A person who becomes infected with HIV will have a viral load, which is the amount of the HIV virus present in blood and body fluids of the infected person. A person who is not infected with HIV does not have a viral load. A person who is infected should understand and know his or her viral load and how it is changing over time to determine if the disease is advancing.

A client who has undergone a below-the-knee amputation is getting ready for a fitting for prosthesis. The nurse performs interventions to shrink the leg stump. Which activity is part of stump shrinkage? Select all that apply. The bandage is wrapped around the stump and kept smooth The stump is shrunk to a point that it is half its original size The nurse uses an elastic roller bandage The nurse should inspect the stump before applying the bandage The client needs pain medication before the procedure

The bandage is wrapped around the stump and kept smooth After wrapping the stump tightly, the nurse ensures that the bandage is smooth and free of wrinkles. The nurse should inspect the stump before applying the bandage The nurse will always inspect the area of the body being wrapped to check for any lesions, redness, openings, or bruises that may need addressed. The nurse uses an elastic roller bandage After an amputation, the nurse may need to wrap the stump to shrink it in order to prepare it to fit into a prosthesis. The nurse wraps the stump using an elastic roller bandage after first inspecting the site for signs of redness or drainage.

The nurse is assessing an 8-year-old child. Which of the following findings would the nurse note as abnormal? The child has not lost all their temporary teeth The child cannot write in cursive The child does not feel the need to be independent The child has not lost any temporary teeth

The child has not lost any temporary teeth At around age 6, a child begins to lose baby teeth. If a child has not lost these teeth at this point, the nurse would note this as abnormal.

A client with epilepsy has received a new prescription for phenytoin (Dilantin). When giving the client his prescription information, the nurse should be sure to include which of the following important information about this drug? Phenytoin should not be taken if a person is allergic to penicillin-based antibiotics Phenytoin should not be used in a client who has high blood pressure The client will be immunocompromised when taking this drug The client may develop increased thoughts of suicide while taking it

The client may develop increased thoughts of suicide while taking it Phenytoin is an anticonvulsant drug most commonly used in the management of seizures. A client may have a number of side effects associated with taking the drug, but emotional changes, such as increased depression or anxiety should be reported to the provider. The client may be at increased risk of suicidal ideation while taking phenytoin.

An 11-year-old girl was born with congenital adrenal hyperplasia. The nurse is working with her family to help the parents prepare for the child to start puberty soon. Which information would the nurse give to the family about pubertal changes that occur with this condition? The client will probably not grow pubic or armpit hair The client may have abnormal menstrual periods or may not menstruate at all The client will most likely grow to be much taller than her peers The client will most likely develop a deep voice

The client may have abnormal menstrual periods or may not menstruate at all Congenital adrenal hyperplasia (CAH) is a group of disorders that affect the adrenal glands and their ability to secrete hormones. The condition causes abnormal growth and development in children. When a child with this condition reaches the age of puberty, the parents should be taught that the child may not undergo puberty in a manner similar to her peers. Among girls, CAH may cause abnormal menstrual periods or in some cases, no menstrual periods.

The nurse is caring for an ambulatory client who has been placed on telemetry. Which information regarding nursing care of a client on telemetry is true? Select all that apply.

The client may located on one unit of the hospital but monitored on another unit Telemetry is a method of cardiac monitoring in which a client's heart rate and rhythm are monitored from a central unit of the hospital The client cannot shower with the telemetry leads in place The leads must be removed when the client showers. Telemetry monitors heart rate and rhythm Telemetry is a method of cardiac monitoring in which a client's heart rate and rhythm. The leads are connected to the client's chest using gelled electrodes that stick to the client's skin. The electrical current of the heart is displayed on a monitor and continuously watched by a telemetry technician. The client can move around without being tethered to the monitor screen The nurse must inform the technician whenever the client will be leaving the monitoring area or removing the leads for any reason.

A client with heart failure has a new prescription for furosemide. Which information would the nurse include as part of teaching this client about this medication? Select all that apply. High doses of Lasix can cause hearing loss The client may need to monitor his sodium and potassium intake with this medicine The medication is given to prevent fluid retention The client should not take blood pressure medications with furosemide Furosemide should only be used if the client cannot urinate

The client may need to monitor his sodium and potassium intake with this medicine Furosemide decreases the reabsorption of sodium in the kidneys, which helps remove fluid. This action of a loop diuretic causes sodium and potassium losses from the body, so these electrolytes must be monitored. The medication is given to prevent fluid retention Furosemide is a diuretic medication most commonly used to reduce edema associated with heart failure. Education for the client taking furosemide should include the reason for taking the medication, effects the drug will have on electrolyte levels, and the dangers of taking too much of the drug. High doses of Lasix can cause hearing loss This is an effect of furosemide, and the client must be educated to monitor for this.

A client has been brought into the emergency department after being injured during a construction accident. During assessment and treatment, a law enforcement officer arrives and asks for information about the client. Which information can the healthcare center disclose to law enforcement? The client's employment status The client's name and address The intentions of the client for being at a construction site The insurance company paying for the treatment

The client's name and address Some situations that involve law enforcement require the nurse to provide information to officials. Nurses may be limited on the type and amount of information they are able to provide and it usually means that only information that is pertinent to the case is required. Information the nurse may give includes the patient's name, address, date of birth and place of birth, distinguishing physical characteristics (tattoos, etc), blood type, date and time of treatment, and type of injury. Information a nurse may NOT give to law enforcement include DNA, dental records, or analysis of blood or tissue.

During shift report, the incoming nurse is told that a client's echocardiogram revealed an ejection fraction (EF) of 43. The nurse knows that this means which of the following?

The client's ventricles are not pumping blood efficiently An ejection fraction (EF) measures the fraction of blood ejected from the ventricles. This is most often measured in the left ventricle, since this is the ventricle that pushes blood out to the body. A normal EF is between 55-75%, with slight variations between males and females. When the EF is low, this means that the ventricles are pumping a lower percentage of blood than normal.

The nursing student is discussing cardiac index with the preceptor. The student correctly understands cardiac index as a measure of which of the following?

The correlation of body surface area to cardiac output Cardiac index accounts for body size in relationship to cardiac output. The larger the size of an individual (measured by body surface area), the more output their heart will need to produce in order to adequately perfuse the body.

A nurse has an order for meclizine PO to give to a client PRN dizziness. Which of the following factors would the nurse consider before administering this medication? Select all that apply.

The drug should be administered when the client's condition requires it, as determined by the nurse This is the appropriate manner to give a PRN medication. The nurse must assess the client using objective and subjective data before administering the medication This is true regarding PRN medication administration. The order by the provider indicates how frequently the medication can be given A PRN order may be given to treat some client conditions, such as pain or dizziness. The order for a PRN drug must state the condition for which to administer the drug, the drug dosage and route, and the maximum amount the client may take. The nurse cannot administer the drug more often than the order indicates This is true of PRN medications.

A nurse is caring for a client who is recovering from a myocardial infarction and has many medications and procedures scheduled. The nurse must delegate some of the client care tasks to an LPN who is also working on the unit. Which of the following components must the nurse consider when deciding what to delegate?

The educational training and certification of the LPN Whether it seems to be in the moment or not, delegation is a critical decision for registered nurses who make a choice to have another person take on some of the tasks of client care. The nurse who delegates a task is still responsible for the care provided and the tasks performed. Therefore, tasks should be delegated carefully and responsibly. The registered nurse must consider the scope of practice of the delegatee. When working with an LPN, the nurse must understand the educational training and certification of the nurse to know what tasks are within the LPN's scope of practice and what can be delegated.

Utilitarianism within nursing is described as which of the following? The consideration of personal character and values in decision making The ability of the nurse to think abstractly The idea of promoting the most good for the greatest amount of people The study of ethics focused on rules and the nurse's duties

The idea of promoting the most good for the greatest amount of people Within nursing, utilitarianism is a type of ethical theory that considers how the nurse can do the most good, with limited resources, for the greatest amount of people. According to this theory, by acting in this manner, the nurse is said to be utilizing the best outcome for society.

A multi-trauma client returns from radiology and the CT scan reveals a grade-V splenic laceration. The nurse anticipates the next action for plan of care for this client to be which of the following? Liver panel Discharged home The operating room Admission to a med-surg floor

The operating room The grade-V injury indicates the client has a completely shattered spleen and requires either immediate repair or removal of the organ. Grade-V injuries require surgical intervention

The student nurse is studying a Wigger's diagram and notes a diastolic pause. The student correctly understands that which of the following occurs during diastolic pause?

The ventricles fill with blood Diastolic pause is the final moment before the ventricles contract. During this time, the ventricles are filling to their maximum volume in order to prepare for contraction.

Which description best defines preload?

The volume of blood returning to the heart and filling the ventricles at the end of diastole The heart follows a specific cycle of filling and contracting that is effective in pumping blood to the organs and tissues. Preload is measured at the end of diastole of the previous heartbeat, and represents the volume of blood in the ventricles at their fullest point. The muscle fibers in the ventricles stretch in preparation for the next contraction in order to pump the 'load' of blood in contraction, or systole.

A student nurse is measuring an EKG strip. Which of the following elements on this rhythm strip demonstrate that this client is in normal sinus rhythm? Select all that apply.

There is one P wave for every QRS complex This describes a P:QRS ratio of 1:1. This is a characteristic of normal sinus rhythm. The small boxes between R waves are equal in number from one R-R interval to the next This describes a regular rhythm, which is characteristic of normal sinus rhythm. The rate is 90 beats per minute A heart rate between 60-100 bpm is characteristic of normal sinus rhythm. If the rate is below 60 bpm, the client is in bradycardia. If the rate is above 100 bpm, the client is in tachycardia. The QRS complex is 0.08 seconds A QRS complex between 0.06 and 0.12 is characteristic of normal sinus rhythm.

A nurse is caring for a client with a new order for erythropoietin. The nurse knows that this is given for which of the following reasons? To stimulate the making of angiotensin II by angiotensin I To increase sodium in the bloodstream, increasing blood pressure To increase red blood cell production by the bone marrow To suppress aldosterone production

To increase red blood cell production by the bone marrow Erythropoietin is a growth factor that stimulates production of red blood cells (erythrocytes). This is used to treat varying sources of anemia, such as anemia from chronic kidney disease, chemo-induced anemia, and anemia in clients who are surgical candidates. Effects are seen in about two weeks, with normal hematocrit levels reached in 2 to 3 months.

The nurse is caring for a client on the labor and delivery unit who is prescribed methylergonovine. The nurse knows this medication is given for which of the following reasons? Select all that apply. To reduce nausea and vomiting during labor To manage postpartum hemorrhage To increase the strength of contraction of the uterus To stimulate the birth of the fetus To assist the laboring client to relax through contractions

To manage postpartum hemorrhage Methylergonovine is an ergot alkaloid, used to manage postpartum hemorrhage. It stimulates the uterine muscle to produce firm contraction of the uterus, which is necessary to stop bleeding. To increase the strength of contraction of the uterus Methylergonovine is an ergot alkaloid, used to manage postpartum hemorrhage. It stimulates the uterine muscle to produce firm contraction of the uterus, but is only given after the baby and placenta have delivered.

The nurse is administering facial peripheral nerve stimulation to a client. The nurse knows the electrodes are placed properly when which of the following is observed? Twitching in the upper lip Twitching in the lip Twitching in the tongue Twitching in the eyebrows

Twitching in the eyebrows When electrodes are placed properly for the facial nerve, the nurse will observe eyebrow twitching.

The nurse is caring for a client in renal failure who has recently learned that she must begin dialysis. Which of the following is an indication that the client would benefit from peritoneal dialysis instead of hemodialysis?

Vascular access failure When a client has a failing hemodialysis graft, they become candidates for peritoneal dialysis. Congestive heart failure Because there is less fluid exchanged in peritoneal dialysis compared to hemodialysis, the client in heart failure benefits from peritoneal dialysis. An active lifestyle A person with an active lifestyle is a candidate for peritoneal dialysis because there is more flexibility and control for the client to work the dialysis into his or her schedule versus hemodialysis. A fear of needles A client who is afraid of needles benefits from peritoneal dialysis, because a catheter is utilized, so the client does not need to have a needle inserted with each dialysis exchange. Intolerance to hemodialysis A client who simply cannot tolerate hemodialysis will benefit from peritoneal dialysis, because it is a more gentle form of waste removal, functioning more similarly to the kidneys.

A nurse is conducting a pre-op screening on a client preparing for a coronary artery bypass graft procedure. Which substance used by the client can indicate that the client is at higher risk of post-op bleeding? Bisacodyl Loperamide Omeprazole Vitamin E supplements

Vitamin E supplements When performing a pre-op assessment, the nurse must check whether the client takes medications that could increase the risk of bleeding. With certain procedures, such as a CABG, the risk of bleeding is even greater because of the surgery's complexity. Over-the-counter medications that can increase the risk of bleeding include supplements such as vitamin E, cayenne, turmeric, gingko, garlic, or ginseng, as well as some analgesics, such as ibuprofen.