NCLEX-HURST

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN/VN to the floor. Which clients would be appropriate assignments for the LPN/VN? 1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catherization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions.

1, 3 & 5. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Client #5 -It is considered within the scope of practice for an LPN/VN to monitor a transfusion of a blood product. 2. Incorrect: This client is post cardiac catherization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. 4. Incorrect: Atrial fibrillation places the client at risk for blood clots. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Assessing this client and titrating the diltiazem requires the skills of an RN. 6. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. These areas require the expertise of an RN and would not be appropriate for an LPN/VN.

When disposing of waste in a client's room, the nurse would place which item(s) in a biohazard red bag? 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client 5. Soiled dressing 6. Paper trash with identifying client information

1., & 5. CORRECT. Chest drainage units should be capped and placed in a large red biohazard bag for disposal. Dressings soiled with human waste, blood or body fluids should be disposed of in a red biohazard bag. 2. INCORRECT. Doxorubicin is an intravenous antineoplastic chemotherapy agent. IV bags and tubing used to administer chemotherapy medications should be disposed of intact and placed in a yellow or purple chemotherapy waste container with a lid. 3. INCORRECT. Client staples are considered a "sharp" and should be disposed of in a red biohazard sharps container. 4. INCORRECT. Tramadol is a non-hazardous waste medication, but it is also a Schedule IV narcotic. Narcotics should be disposed of in an irretrievable medicinal waste container or sharps container according to hospital policy. No matter the type of container used, for narcotics, it should be irretrievable. 6. INCORRECT. Paper trash containing client information should be disposed of in a manner that it is no longer readable, cannot be reconstructed and cannot be retrieved.

What would the nurse include in the teaching plan for a client with right sided heart failure? 1. There is a backup of blood in the right upper chamber of the heart. 2. There is swelling of lower extremities. 3. The heart rate decreases. 4. You may experience fatigue and depression. 5. You may have nausea and anorexia.

1., 2. 4. & 5. Correct: The blood backs up into the right atrium and venous circulation. Vascular congestion is evident by swelling of the lower extremities. Clients usually experience fatigue and depression. Ascites may increase pressure on the stomach and intestines causing GI upset with nausea and anorexia. 3. Incorrect: The heart rate increases in an attempt to increase cardiac output.

The homecare nurse is providing family teaching on safety issues for a client diagnosed with Parkinson's disease. What adaptations should the nurse instruct the family to initiate? 1. Install grab bars on tub walls. 2. Place nightlights in hallways. 3. Add bran and fiber to daily diet. 4. Remove scatter rugs or loose cords. 5. Keep bedroom dark, cool and quiet. 6. Put tennis balls on legs of walker.

1., 2., 3., 4., & 5. Correct: Parkinson's disease causes deterioration of the basal ganglia, ultimately impacting motor control and function. As muscles become stiff and rigid, mobility slows, resulting in poor coordination and loss of balance. Safety is a chief concern in all ADLs, requiring modifications in activity, nutrition, and the client's environment. Because Parkinson's disease affects mobility, modification such as grab bars and night lights are essential. Clients develop constipation because of decreased peristalsis, so adding bran and fiber can address impending bowel issues. Scatter, or throw, rugs along with loose extension cords on the floor create a fall risk because the client is unable to pick up feet during ambulation. The shuffling gait that develops increases the risk for falls. These clients also have problems with insomnia along with poor REM sleep, leading to daytime drowsiness. Making the bedroom conducive to sleep may help alleviate symptoms for a period of time. A dark, cool room with no distractions is the most appropriate sleep environment. 6. Incorrect: The proper method of utilizing a walker is to step into the walker, pause and then move it forward before stepping again. Even though clients with Parkinson's disease have a shuffling gait and stooped posture, sliding a walker with tennis balls on the walker legs presents a serious safety issue. The client would not have the ability to control the speed or hold the walker steady while stepping into it.

Which tasks are most appropriate for the hospice nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs

1., 3., 5., & 6. Correct: The UAP can bathe, listen to the client remininsce, weigh, and take the vital signs. These are within the scope of practice of the UAP. These assignments are routine and revolve around activities of daily living. 2. Incorrect: The task of providing spiritual support could best be delegated to the pastor or chaplain. 4. Incorrect: The nurse can not delegate routine medication administration to the UAP. This is not within the UAPs scope of practice. This is an LPN or RN responsibility.

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? 1. Weigh daily. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale and clothes if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting. 2. Incorrect: The client will work with their primary healthcare provider to create a controlled exercise program. This is usually done once healthy eating habits and some weight gain is achieved. See the word only in this option and think incorrect. 3. Incorrect: Do not argue or bargain with the client who is resistant to treatment. Be matter of fact about which behaviors are unacceptable and how privileges will be restricted for noncompliance. The person who is denying a problem and who also has a weak ego will use manipulation to achieve control.

A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

2. Correct: Continuous bladder irrigation is used following surgery to ensure that the bladder remains clear of blood clots.The nurse would need to increase the irrigation rate until the urine becomes light pink. 1. Incorrect: If the urine is not diluted, the client could form clots in the urine that could obstruct the urine flow. Charting the drainage color and amount would not address the issue. 3. Incorrect: Dark red color to the urine would warrant an increase in irrigation. There is no need to call the primary healthcare provider. If the color of urine doesn't clear or the vital sign show signs of shock (increased heart rate and decreased blood pressure) then notifying the primary healthcare provider would be needed. 4. Incorrect: This is the intervention that would be carried out if the client is hemorrhaging from the prostate. The balloon on the catheter would be used to apply pressure to the prostate and decrease bleeding. If there was more evidence of hemorrhage such as a decrease in blood pressure or increase in heart rate this type traction would be initiated. There is not enough evidence of hemorrhage at this point to initiate traction, therefore, more assessments should be performed.

A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? 1. Delusions 2. Hallucinations 3. Flashbacks 4. Depersonalization

2. Correct: Hallucinations are false sensory perceptions not associated with real external stimuli. When the client begins to respond to a stimuli that is not visible to the nurse, this is a hallucination. 1. Incorrect: Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. These beliefs are not consistent with reality. Often the client will either feel all powerful or have extreme unrealistic fears. 3. Incorrect: Flashbacks are a spontaneous recurrence of the hallucinogenic state without ingestion of the drug. These can occur months after the drug has been taken. 4. Incorrect: Depersonalization can occur, but it is the observation of oneself having an experience. The client may report feelings of being an outside observer of their own thoughts or body with a sense of loss of control. This is sometimes described as an out-of-body experience for the client.

The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene? 1. Lifting the affected leg with the palms of the hands 2. Covering the affected leg with a blanket to avoid chills 3. Placing plastic over the entire cast prior to bathing 4. Elevating the casted leg on two pillows

2. Correct: Plaster cast take 24-48 hours to completely dry. During this time they release heat. The new cast should not be covered so that heat from the cast can evaporate. If the heat is not allowed to dissipate, drying will take longer. 1. Incorrect: Plaster cast take 24-48 hours to completely dry. During this time the cast should be handled carefully as to avoid indentations. Handling the cast carefully with the palms and not the fingertips will prevent indentations. Indentations in the cast could cause skin breakdown inside the cast. 3. Incorrect: Yes, will keep cast from getting wet. Plaster casts should never get wet. The plaster cast does not hold up well in water. Wet casts can also irritate the skin underneath. 4. Incorrect: Yes, may elevate the leg. Fractures are prone to swelling. Elevating fractures while casted is a common occurrence. Elevation prevents swelling.

A client has received discharge education post extracapsular cataract surgery. Which statement made by the client indicates to the nurse that further teaching is needed? 1. "A protective eye patch will be needed for 24 hours." 2. "I will notify my primary heathcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal." 3. "I will clean the surgical eye with a clean tissue, wiping once from the inner aspect of the closed eye to the outer eye." 4. "When sleeping, I will avoid lying on the same side of my affected eye."

2. Correct: This is an incorrect statement by the client. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days." Clients are instructed to report any pain that is unrelieved, redness around the eye, nausea or vomiting to the primary healthcare provider. 1. Incorrect: This is a true statement and does not require intervention. Following surgery, the eye is covered with a patch and a metal or plastic shield for protection from light and trauma. 3. Incorrect: This is the correct way to clean the surgical eye. Cleaning from the inner to outer canthus avoids entrance of microorganisms into the lacrimal duct. 4. Incorrect: This is a correct action. Increased intraocular pressure needs to be avoided. Clients are instructed to avoid sleeping on the operative side.

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? 1. Anti-embolic stockings 2. Smoking cessation 3. Moderate exercise 4. Application of heat 5. Low cholesterol diet 6. Decrease blood pressure

2., 3., 5. & 6. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Smoking is a major risk factor in developing PAD by contributing to arterial constriction. Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. A low cholesterol, heart healthy diet with more fruits and vegetables helps reduce cholesterol while decreasing blood pressure, both important goals towards controlling PAD. 1. Incorrect: Increasing arterial blood flow is important in the prevention or management of peripheral artery disease; however, anti-embolic stockings are designed to improve venous return in clients with decreased mobility. The use of these stockings would actually hinder arterial flow in lower extremities. 4. Incorrect: Clients with PAD often complain of cold extremities secondary to decreased arterial blood flow. But the application of heat such as use of a heating pad is unsafe and is always contraindicated in the elderly with PAD. Inability to sense temperature extremes may result in serious burns to lower extremities. Additionally, clients with PAD do not heal as well from injuries or wounds.

The nurse is providing care to a client who post laparoscopic cholecystectomy. Which finding would be of concern? 1. Right upper quadrant abdominal discomfort 2. Clay colored stool 3. Light yellow urine 4. Pruritus 5. Icteric sclera

2., 4., & 5. Correct: Injury to nearby structures, such as the bile duct, liver and small intestine can occur after this surgery. Clay colored stools and jaundice of the sclera are caused by recurring stricture or stone of the common bile duct. Pruritus occurs when bile reaches the skin. 1. Incorrect: The gallbladder is in the right upper abdominal quadrant, so discomfort would not be uncommon in this area postoperatively. 3. Incorrect: Light yellow colored urine is normal.

The nursing supervisor is preparing a staff development program concerning the legal parameters of torts. Which example would the supervisor include as an intentional tort? 1. Administering a 0900 medication at 1030. 2. Administering a medication to an incorrect client. 3. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave. 5. Raising the side rails without a prescription when a client is at risk to fall.

3. & 4. Correct: An intentional tort occurs when a person intends to perform an action that causes harm to another. Performing an invasive procedure without consent is considered battery because the client has not given consent for the procedure. Threatening to withhold a medication is intentionally threatening to harm the client by not administering the medication. 1. Incorrect: This is an unintentional tort. The nurse did not intend to administer the medication 90 minutes after the ordered time. 2. Incorrect: The nurse unintentionally jeopardized the safety of the client. This is an unintentional tort. 5. Incorrect: This intervention by the nurse is appropriate. In an emergency the side rails maybe raised when the safety of the client is at risk.

Which risk factor should the nurse include when planning to educate a group of women about breast cancer? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Early menarche

4. Correct: Early menarche before age 12 is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her life. A higher lifetime exposure to estrogen is linked to an increase in breast cancer risk. The earlier a woman starts having periods, the longer her breast tissue is exposed to estrogens released during the menstrual cycle and the greater her lifetime exposure to estrogen. 1. Incorrect: Studies show women who go through menopause after age 50 have increased risk of breast cancer. The risk for breast cancer increases as time period between menarche and menopause increases. 2. Incorrect: Small increase in risk with moderate alcohol consumption, not one glass of wine daily. Drinking low to moderate amounts of alcohol, however, may lower the risks of heart disease, high blood pressure and death. But, drinking more than one drink per day (for women) and more than two drinks per day (for men) has no health benefits and many serious health risks, including breast cancer. Alcohol can change the way a woman's body metabolizes estrogen (how estrogen works in the body). This can cause blood estrogen levels to rise. Estrogen levels are higher in women who drink alcohol than in non-drinkers. These higher estrogen levels may in turn, increase the risk of breast cancer. 3. Incorrect: Nulliparity (no pregnancies) is a known risk factor for breast cancer. Factors that increase the number of menstrual cycles also increase the risk of breast cancer, probably due to increased endogenous estrogen exposure.

An injured client brought to the emergency room by ambulance insists on leaving before being seen by the primary healthcare provider. What is the nurse's priority action? 1. Explain potential risks of leaving without proper care. 2. Insist the client sign "Against Medical Advice" form. 3. Calmly convince client to wait for needed treatment. 4. Notify primary healthcare provider immediately.

4. Correct: The nurse must notify the primary healthcare provider immediately about the client's desire to leave without care. The client cannot be physically prevented from leaving, or threatened with possible dire consequences by the nurse. The primary healthcare provider can explain potential risks of non-treatment and obtain a signature on the AMA form. 1. Incorrect: The client must be informed about the potential risks of leaving without medical treatment and that information is best explained by either the emergency room healthcare provider or primary healthcare provider based on knowledge of the client's potential injuries. 2. Incorrect: An "Against Medical Advise" (AMA) form is designed to protect staff and facility from potential litigation filed by clients leaving without treatment. However, a client cannot be forced to sign the form and this is not the nurse's priority action. 3. Incorrect: The nurse can use therapeutic techniques to discuss the situation and try to discover why the client wants to leave. However, there is another priority more important for the nurse.

A fully alert and competent client is in end-stage cardiac disease. The client says, "I'm ready to die," and refuses to take nourishment. The family urges the client to allow the nurse to insert a feeding tube. What action should the nurse take? 1. Tell the family that the feeding tube will be inserted after the client becomes unresponsive. 2. Ask the primary healthcare provider to have the dietician talk with the client about food preferences. 3. Notify the case manager to arrange a meeting with the client's family . 4. Provide additional information as requested by the client concerning nourishment.

4. Correct: This client is alert and competent, and has the right to make healthcare decisions and the right to die with dignity. The nurse should provide any additional information as requested by the client. 1. Incorrect: This is inappropriate, as it does not follow the client's wishes and would be a violation of client rights. 2. Incorrect: The client has made the decision to refuse nourishment so this action ignores this decision and violates client rights. 3. Incorrect: The nurse should honor the client's wishes first. The family would only need to meet if the client became unable to make decisions on their own. Even so, these decisions could not violate any advance directives that were in place.

Normal absolute neutrophil count (ANC)

1500-8000/mm3

Sublingual doses of nitroglycerin can be repeated every _____ minutes. What time frame should the nurse expect the earliest onset of effectiveness?

every 5 mins The drug would start to be effective before 5 minutes.

Which assessments will provide the nurse with the most information regarding a client's neurologic function? 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability

1. & 5. Correct: Yes, the most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command. 2. Incorrect: No, only helps with the determination of brain death. 3. Incorrect: Identifies diseases of the brain and spinal cord. 4. Incorrect: This should be last resort.

What activities would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) caring for a client post-cholecystectomy? 1. Measuring and recording intake and output. 2. Assisting with ambulation in the hallway. 3. Reinforce information about a low fat diet. 4. Assisting with daily hygiene. 5. Measuring and recording vital signs. 6. Monitor for increased surgical site pain during activity.

1., 2., 4., & 5. Appropriate actions for UAPs include measuring and recording I&O and vital signs. UAPs may also assist with ambulation and assist or perform activities related to daily hygiene. 3. Incorrect: Reinforcing teaching can be done by the LPN or RN. 6. Incorrect: Monitoring should be performed by the nurse.

Which statement made by a 67 year old client who recently retired indicates to the nurse that client has developed ego integrity? 1. "I want to make my mark on the world." 2. "I am satisfied with my life so far." 3. "I wish I could go back and fix the mistakes I have made." 4. "Life is too short. I have more living to do."

2. Correct: Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. 1. Incorrect: Generativity versus stagnation is the seventh of eight stages of Erikson's theory of psychosocial development. This stage takes place during middle adulthood (40 to 65). Generativity refers to "making your mark" on the world through creating or nurturing things that will outlast an individual. 3. Incorrect: Feeling regret over past decisions or mistakes can lead to despair. To reach ego integrity, the client must accept mistakes made and look at accomplishments achieved in life. 4. Incorrect: Success in this stage will lead to the virtue of wisdom. Wisdom enables a person to look back on their life with a sense of closure and completeness and accept death without fear.

A nurse is caring for a pediatric client who has been diagnosed with hypothyroidism. What is essential for the nurse to teach the parents of this child? 1. Administer the liquid medication with soy milk. 2. Notify primary healthcare provider of slow heart rate. 3. Monitor glucose before meals and at bedtime. 4. Wait 4 hours after giving medication before giving iron supplements.

4. Correct: Wait for 4 hours before giving child iron supplements, antacids that contain calcium or aluminum hydroxide, or calcium supplements as it interferes with medication. 1. Incorrect: Give the medication with a liquid, except soy milk, which interferes with the ability to absorb the thyroid hormone. 2. Incorrect: Bradycardia is seen with hypothyroidism. When taking thyroid medication, we want to watch for signs of hyperthyroidism such as tachycardia, rapid weight loss, sweating, restlessness. 3. Incorrect: Hypothyroidism does not affect glucose.

A client, scheduled for a total hysterectomy for advanced cervical cancer, is crying and states, "I want to have more children! I do not know if I should have this procedure." Which responses by the nurse are appropriate? 1. Allow the client to discuss her fears. 2. Tell the client that her health is more important than having children. 3. Explain to the client that cryotherapy may be an option for treatment. 4. Advise the client to delay surgery until she is absolutely sure. 5. Encourage client to discuss with surgeon again about the total hysterectomy.

1. & 5. Correct: This may be anticipatory grieving and being scared. Let the client talk and encourage her to talk again to the primary healthcare provider. She may need reassurance that she is making the right decision. 2. Incorrect: This is negating the client's feelings and is not helpful in this situation. 3. Incorrect: Cryotherapy is destruction of tissue by freezing with liquid nitrogen. Cryotherapy may be used with precursor lesions (mild to moderate dysplasia). It is not an appropriate treatment for advanced cervical cancer. 4. Incorrect: The cancer is already in an advanced stage. Will the waiting help her survive?

What is the first nursing action that should be taken in caring for a client with suspected tuberculosis? 1. Identify the client's symptoms promptly. 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

1. Correct: First, identify the client's symptoms. 2. Incorrect: Not before proper identification of client's symptoms. 3. Incorrect: Not before proper identification of client's symptoms. 4. Incorrect: Not before proper identification of client's symptoms.

Which interventions should a nurse discuss with a client for primary prevention of skin cancer from exposure to ultraviolet light? 1. Use sunscreen when outdoors. 2. Stay in the shade when outdoors. 3. Wear wide brimmed hats when outdoors. 4. Examine skin every 3 months for changes. 5. Have an annual skin assessment by a dermatologist.

1., 2. & 3. Correct: Using sunscreen, staying in shaded areas, and wearing wide brimmed hats are effective interventions to prevent skin cancer. 4. Incorrect: Examine your whole body monthly for possible changes that may be precancerous or cancerous lesions. Early detection is considered secondary prevention. 5. Incorrect: Assessment by a dermatologist is not a primary prevention strategy. Early diagnosis is considered secondary prevention.

The homecare nurse is instructing a client with chronic obstructive pulmonary disease (COPD) about the importance of a nutritious diet to avoid weight loss. The nurse knows that teaching has been effective when the client selects which foods for a breakfast menu? 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast

1., 2., 3. & 4. Correct: Maintaining weight and nutrition is vital to the health of clients with (COPD). Extreme fatigue along with excessive mucus production decreases the client's ability to eat complete, well-balanced meals, leading to weight loss or malnourishment. Therefore, the nurse would instruct the client to eat small, frequent meals high in protein and fiber. Good sources of protein include eggs, cheese, fish and poultry, beans and even nuts. Fresh fruit such as bananas along with non-carbonated beverages such as orange juice are excellent breakfast food choices. 5. Incorrect: Although milk and dairy products like yogurt could be considered part of a healthy breakfast, it is recommended that COPD clients use 1% or 2 % milk products to avoid increasing mucus production. This client should select the orange juice from the choices provided. 6. Incorrect: Dry toast provides little nutrient value, and may actually increase coughing because of its brittle nature. Coughing quickly leads to exhaustion rather than eating. This client would benefit more from a more palatable choice such as muffin or French toast.

What potential contributing factors for transient urinary incontinence should a nurse assess in an elderly female client? 1. Fecal impaction 2. Diuretic use 3. Diabetic 4. Chronic urinary retention 5. Vaginitis

1., 2., 3., & 5. Correct: Transient incontinence: a temporary type of urinary incontinence caused by an illness or a specific medical condition that is short-lived and is, therefore, quickly remedied by appropriate treatment of the condition and a disappearance of symptoms. Fecal impaction can compress the urethra resulting in urinary incontinence. Use of diuretics can make it difficult to get to the toilet in time to void, thus causing urinary incontinence. Diabetics have polyuria, which can contribute to urinary incontinence. Vaginitis, a condition caused by an infection or inflammation of the vagina, can contribute to urinary incontinence. 4. Incorrect: Urinary incontinence that is associated with chronic retention occurs when the bladder does not empty properly, resulting in frequent leakage of small amounts of urine. This is a chronic, rather than a transient condition.

The nurse is caring for a client hospitalized with dissociative amnesia. Which nursing interventions are appropriate for this client? 1. Obtain client likes and dislikes from family members. 2. Expose the client with data regarding the forgotten past. 3. Expose client to stimuli that was a happy memory of the past. 4. Hypnotize the client to help restoration of memory. 5. Ensure client safety.

1., 3. & 5. Correct: Considering likes and dislikes may help the client to remember. Using information to expose the client to stimuli that were happy memories may help the client remember. The client's disorder may lead to inattention to safety. Think safety first! 2. Incorrect: Do not expose the client to data regarding the forgotten past. Clients who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state. Dissociative amnesia is marked by an inability to recall important personal information, often traumatic or stressful in nature. 4. Incorrect: This is not a nursing function. Hypnosis is not in the nurse's scope of practice.

After assessing a client, the nurse determines that the client has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which interventions would the nurse include for this client? 1. Have client attempt to void again (double voiding). 2. Encourage the client to void every 8 hours. 3. Perform Credé method. 4. Have client listen to sound of running water. 5. Teach intermittent catheterization for retention, if needed.

1., 3., 4. & 5. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Place bedpan, urinal, or bedside commode within reach. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. Perform Credé method over bladder to increase bladder pressure. If these methods are unsuccessful, the client will need education on intermittent catheterization. 2. Incorrect: Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create infection.

A parent asks the nurse why their child should be immunized against Rubella. What should the nurse tell the parent? 1. Rubella can cause a severe rash over the body, and a high fever which can lead to febrile seizures. 2. Rubella is the most common cause of meningitis and acquired deafness. 3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect. 4. Rubella complications can include swelling of the testicles or ovaries, deafness, encephalitis or meningitis and can lead to death.

3. Correct: The goal of rubella immunization is to protect unborn children from developing birth defects in utero. 1. Incorrect: Rubella can cause a mild rash on the face and low-grade fever. 2. Incorrect: Before the vaccine, mumps was the most common cause of meningitis and acquired deafness. 4. Incorrect: These are complications of the mumps.

At a monthly staff meeting in a long-term care facility, the charge nurse requests staff input to create new activities for the clients. An RN has been assigned to gather information for staff consideration. What method would provide the RN with the best data for this project? 1. Ask clients' families which activities they would like to have available. 2. Research professional articles for guidelines to activities in long-term care. 3. Have clients peruse a variety of games and select what interests them. 4. Contact other facilities to inquire what types of programs they provide.

2. Correct: Research based criteria generally have a high rate of success because the testing has been completed under controlled circumstances and are practice based. 1. Incorrect: Although it would be acceptable to speak with the clients' families, this would not provide the most complete data for the project. Families would not likely understand pertinent considerations such as cost of supplies, number of staff required to assist, or clients' ability to participate. 3. Incorrect: While encouraging client input does allow for some independence, multiple choices can be overwhelming for elderly clients. There would also be an unnecessary expense in purchasing and providing multiple choices for the clients. 4. Incorrect: Most facilities individualize activities based on clientele, funding, and even location. Activities that work in one long term care facilities may not be appropriate for another facility.

When providing care to a client diagnosed with pheochromocytoma, which actions could the nurse safely delegate to the unlicensed nursing personnel (UAP)? 1. Explain the purpose of the vanillylmandelic acid test. 2. Remove caffeinated beverages from the client's meal tray. 3. Remind client not to smoke. 4. Instruct the client to limit activity. 5. Monitor hydration status.

2., & 3. Correct: The UAP can follow directions about removing items from a client's meal tray. The UAP can provide simple instruction reminders after the nurse has provided teaching. 1. Incorrect: The UAP cannot teach. 4. Incorrect: This is teaching and cannot be done by the UAP. Further explanation by the nurse would need to be included as well. 5. Incorrect: The UAP cannot evaluate, which would include monitoring hydration status. The UAP could collect data but cannot monitor or evaluate.

The nurse is teaching a client, recovering from a myocardial infarction (MI), about the prescribed diet of low sodium, low saturated fat, and low cholesterol. Which statements, if made by the client, would indicate to the nurse that teaching has been successful? 1. "I should drink fruit juices rather than soft drinks." 2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 4. "I should use 2% milk when cooking." 5. "There is no restriction on egg white consumption."

2., 3., & 5. Correct: Popcorn without salt is a healthy snack choice for clients on a low sodium, low saturated fat, and low cholesterol diet. Homemade tomato sauce can be made without adding salt. The American Heart Association no longer makes recommendations on how many egg yolks to eat or not to eat. A good, general guideline is to eat no more than 1 egg yolk a day, up to 5 total a week. There is no restriction on egg whites (including those used in baking and cooking). 1. Incorrect: Consume whole vegetables and fruits rather than fruit juices. Fruit juices have added sugars and lack fiber. 4. Incorrect: Use skim or 1% milk rather than 2% or whole milk.

A client with leukemia receiving high dose chemotherapy is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of the tumor lysis syndrome? 1. Thrombocytopenia 2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 5. Hypomagnesemia 6. Hyperphosphatemia

2., 3., 4., & 6. Correct: When the cells are destroyed or lyse from the chemotherapy, there is a release of potassium and phosphates from the cells. Therefore, hyperkalemia and hyperphosphatemia are direct results of the cellular destruction. Purines are also released during cellular destruction. The purines are metabolized and converted to uric acid, which leads to hyperuricemia. So why is hypocalcemia correct? Do you remember that phosphorus and calcium have inverse relationships? So, if the phosphorus is high, the calcium will be low. That is why the client will have hypocalcemia. 1. Incorrect: Although clients who are on chemotherapy often have thrombocytopenia, or low platelet counts, this is not a hallmark sign of tumor lysis syndrome. 5. Incorrect: Hypomagnesemia is not a hallmark sign of the tumor lysis syndrome. However, as uric acid levels increase from the cellular lysis, the uric acid crystals can create a mechanical obstruction in the renal tubules of the kidneys and lead to acute kidney injury. If the kidneys are not working properly, will magnesium be excreted properly? No! Therefore, a later finding of the kidney injury could be hypermagnesemia, not hypomagnesemia.

A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries

3. Correct: Hypothyroidism clients tend to have constipation due to decreased motility of the GI tract and need increased fiber and fluid intake. Popcorn is high in fiber. 1. Incorrect: People with hypothyroidism have a slow metabolism and do not need high protein but a well balanced diet. Almonds are high in protein. 2. Incorrect: Cheese and crackers are high in sodium. This client is at risk for CAD, so sodium should be limited. 4. Incorrect: This client does not need high potassium, which fried sweet potatoes have. The high potassium dietary approaches to stop hypertension (DASH) diet is only for healthy clients with hypertension.

A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare provider? 1. Midabdominal pain radiating to the shoulder 2. Nausea and vomiting periodically for several hours 3. Abdominal rigidity with pain in the left lower quadrant 4. Elimination pattern of constipation alternating with diarrhea

3. Correct: Pain in the lower left quadrant with abdominal rigidity indicates the client is experiencing a perforated diverticuli and is a medical emergency. Abdominal rigidity indicates either perforation or internal bleeding. Both of these symptoms are considered an "acute abdomen" and are emergencies. 1. Incorrect: Midabdominal pain radiating to the shoulder is a common s/s for a client with cholecystitis but is not a medical emergency. 2. Incorrect: Nausea and vomiting periodically for several hours is often seen with diverticulitis but is not a medical emergency. 4. Incorrect: Elimination pattern of constipation alternating with diarrhea indicates a partial bowel obstruction and may require further investigation, but this is not a medical emergency.

The nurse evaluates an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this occurrence is caused by which electrolyte imbalance? 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia

3. Correct: The most serious complications of hypokalemia are cardiac changes. Hypokalemia impairs myocardial conduction and prolongs ventricular repolarization. This can be seen by a prominent U-wave (a positive deflection following the T-wave on the EKG). The U-wave is not totally unique to hypokalemia, but its presence is a signal for the clinician to check the serum potassium level. 1.Incorrect: Remember hypermagnesemia results in the client having a sedated appearance, decreased deep tendon reflexes, decreased level of consciousness, decreased respiratory rate, and ultimately cardiac arrest. 2. Incorrect: In hypocalcemia, this client is not sedated and will have an increased nerve excitability, tetany, appearance of Trousseau's, and Chvostek's sign. Cardiac manifestations include V-tach. 4. Incorrect: Hyponatremia results in neurological symptoms: confusion, irritability, and ultimately coma.

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40; arterial line BP 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 setting to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds.

4. Correct. When an alarm sounds, the first action by the nurse should be to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experiencing. Depending on the assessment findings, the other actions may be necessary. Excessive positive pressure can result in lung complications, including a pneumothorax. This could quickly progress to a tension pneumothorax. Therefore, the nurse should consider any sudden changes in oxygen saturations and signs of respiratory distress as life threatening. Immediate assessment of the client is warranted with actions taken based on the findings. 1. Incorrect. Depending on the assessment findings, this action may be necessary. Check the ventilator after checking the client. The ventilator is checked following the client assessment to assure that it is working properly and that the settings are appropriate. 2. Incorrect. Depending on the assessment findings, this action may be necessary. The goal of mechanical ventilation is optimal gas exchange by maintaining oxygen delivery and alveolar ventilation. The lowered oxygen saturation could be the result of the underlying illness, but since there was an abrupt change, mechanical factors should be considered as well. The nurse would need to institute other measures to promote gas exchange in addition to consideration of increasing the fraction of inspired oxygen. 3. Incorrect. Depending on the assessment findings, this action may be necessary. Ventilation use increases the production of secretions, regardless of the initial reason for ventilating support. The client must be assessed first for the presence of secretions by auscultating the lungs bilaterally. If excessive secretions are present, suctioning should be performed with caution to prevent damage to the airway mucosa.

What should the summer camp nurse include when teaching a group of adolescents about West Nile Virus? 1. Antiviral medications are used to treat West Nile Virus. 2. Using insect repellent containing diethyltoluamide (DEET) will kill the virus when a mosquito makes skin contact. 3. Nothing can be done to prevent West Nile Virus. 4. Symptoms of West Nile Virus include headache, fever, and fatigue

4. Correct: The West Nile Virus begins with flu-like symptoms such as headache, fatigue, and fever. These symptoms, however, may continue for several months. 1. Incorrect: There is no medication to treat West Nile Virus infection. 2. Incorrect: Insect repellent repels the mosquito but has no effect on the virus the mosquito is carrying 3. Incorrect: There are prevention methods that can be initiated to attempt to prevent West Nile Virus, such as using insect repellant with DEET as instructed; dress in clothing that covers arms and legs; cover crib, stroller, and baby carrier with mosquito netting; use screens on windows and doors; repair holes in screens to keep mosquitoes outside; use air conditioning when available; sleep under mosquito net if sleeping outdoors; and check inside and outside home for standing water (where mosquitoes lay eggs).