Practice Question Banks 1-15 (Not Required)

The nurse is caring for a child diagnosed with Kawasaki disease. The nurse should monitor the child for which potential complication? Chronic vessel plaque formation Coronary artery aneurysm Pulmonary embolism Occlusions at the vessel bifurcations

Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis), affects the mucous membranes, lymph nodes, walls of the blood vessels and the heart. It can cause inflammation of the arteries, especially the coronary arteries of the heart, which can lead to aneurysms and possible myocardial infarction in the child. The other complications are not typically seen with Kawasaki disease.

The nurse in a pediatrician's office is speaking with the parent of an 8-year-old child who is concerned about the child receiving the annual flu vaccine due to an egg allergy. How should the nurse respond? A. "We have new types of flu vaccines where an egg allergy does not matter." B. "Your child should not be receiving the flu vaccine." C. "You can schedule an appointment to have the vaccine administered in our office." D."We can premedicate the child to prevent an allergic reaction."

"You can schedule an appointment to have the vaccine administered in our office." The Centers for Disease Control and Prevention (CDC) states that people with egg allergies can receive any licensed, recommended age-appropriate influenza (flu) vaccine (IIV, RIV4, or LAIV4) that is otherwise appropriate. People who have a history of severe egg allergy (those who have had any symptom other than hives after exposure to egg) should be vaccinated in a medical setting, supervised by a health care provider who is able to recognize and manage severe allergic reactions. The other responses are not correct. LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS contraindicationchildimmunizatio

The nurse is preparing a client for discharge following inpatient treatment for pulmonary tuberculosis. Which instruction should be given to the client? A. Continue taking medications until symptoms are relieved. B. Continue taking medications as prescribed. C. Avoid contact with children, pregnant women or immunosuppressed persons. D. Take medication with aluminum hydroxide if epigastric distress occurs.

Continue taking medications as prescribed. Early cessation of treatment may lead to development of drug-resistant tuberculosis (TB). Active TB is usually treated with a combination of four different antibiotics (Isoniazid, rifampin, ethambutol and pyrazinamide) and can now take anywhere from 6-12 months to completely kill the bacteria. As with any antibiotics, clients should continue to take medications even after they begin to feel better. There is no reason to avoid contact with children, pregnant women or immunosuppressed persons once discharged from the hospital as long as the client is adhering to medication schedules. Isoniazid should be taken on an empty stomach; ethambutol can be taken with food to avoid stomach upset. If taken with TB medications, aluminum hydroxide will interfere with absorption of these medications. LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM respiratory KEYWORDS tuberculosisTBmedicationteaching

A nurse is reviewing laboratory results for a client diagnosed with acute renal failure. Which result should be reported to the primary health care provider immediately? Venous blood pH of 7.30 Serum potassium of 6 mEq/L Hemoglobin of 9.3 g/dL Blood urea nitrogen of 50 mg/dL (1 attempt remaining)

Serum potassium of 6 mEq/L Serum potassium of 6 mEq/L

The nurse is conducting a teaching session to new nurses about the principles of pain management. Which principle is most important when assessing a client's pain level? Cultural sensitivity is fundamental to pain management. Clients have the right to have their pain relieved. Nurses should not prejudge a client's pain using their own values. The client's self-report is their actual pain level.

The client's self-report is their actual pain level.; Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but the most important consideration when assessing a client's pain is their self-report. LESSON Management of Care or Coordinated Care Ethical Practice COURSE RN Review KEYWORDS ethics pain

The nurse on a critical care unit is admitting a client who is experiencing a hypertensive urgency or crisis. Which assessment is the priority? Lung sounds Heart rate Orientation Pedal pulses

The organ most susceptible to damage in hypertensive crisis is the brain, due to the high risk for rupture of cerebral blood vessels leading to a stroke or hemorrhage. Therefore, a neurologic assessment that should include orientation and level of consciousness is the priority for this client. LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hypertensionbraincognitiveassessment

A nurse is teaching a group of adults about modifiable risk factors for cardiovascular disease. Which risk factor is most important to include? Smoking cessation Stress management Weight reduction Physical exercise

a/ Smoking cessation is a priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time, but the priority modifiable cardiac risk factor is smoking. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS adultcardiacrisksmoking

The nurse is assigned to a client who is newly diagnosed with active tuberculosis. Which intervention is the priority? Place the client in a private, negative pressure room. Have the client dispose of soiled tissues in a separate bag. Reinforce hand washing before and after entering the room. Collect several sputum samples for testing.

a;A client with active tuberculosis should be hospitalized in a negative pressure room, i.e., airborne precautions, to prevent spread of the disease. Placing the client on on airborne precautions is the priority because this bacteria can be suspended in the air for long periods of time and may be carried for long distances on air currents, infecting others. LESSON Safety and Infection Control Standard Precautions, Transmission-Based Precautions, Surgical Asepsis COURSE RN Review BODY SYSTEM respiratory KEYWORDS TBtuberculosisrespiratorairborne

The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis. Which finding is consistent with this diagnosis? Loss of half of visual field Shallow respirations Tonic-clonic seizures Confusion

b; Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate and stop sending messages to muscles. All muscles eventually weaken and atrophy, including the muscles needed to maintain effective respirations. People eventually lose their ability to speak, eat, move and breathe. The other findings are not typically seen with ALS. LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM nervous KEYWORDS ALSamyotrophic lateral sclerosisrespirations

The nurse is providing discharge teaching to the parents of a 15-month-old child diagnosed with Kawasaki disease. The child received intravenous immunoglobulin therapy during the hospitalization. Which information should the nurse include? High doses of aspirin will be continued for some time. The measles, mumps and rubella vaccine should be delayed. Complete recovery is expected within several days. Active range of motion exercises should be done frequently.

b; Discharge instructions for a child with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis), should include the information that immunoglobulin therapy may interfere with the body's ability to form appropriate amounts of antibodies. Therefore, live or attenuated (weakened) immunizations should be delayed. The measles, mumps, and rubella (MMR) vaccine contains three live attenuated viruses and should be delayed until the child's immune system recovers from this treatment. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS teachchildKawasakiimmunoglobulin

Today's prothrombin time for a client receiving warfarin is 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? Notify the primary health care provider immediately. Observe the client for hematoma development. Recognize that this is a therapeutic level. Assess for bleeding gums or IV sites.

c ;Today's prothrombin time for a client receiving warfarin is 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? Notify the primary health care provider immediately. Observe the client for hematoma development. Recognize that this is a therapeutic level. Assess for bleeding gums or IV sites. LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS prothrombinCoumadinwarfarintherapeutic

A nurse is assessing the health status of several clients at a community health event. The nurse should conduct a mental status examination on which clients? Clients who report memory lapses. Clients with obvious signs of depression. All clients participating in the event. Clients who display restlessness.

c A mental status assessment is a critical part of baseline information and should be a part of every screening. This assessment serves as a screening tool for the nurse to assess for mental status abnormalities. The tool evaluates the client's behavioral and cognitive functioning. LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review KEYWORDS healthfairassessmentalstatusexam

The nurse at a hypertension clinic has been teaching adult clients about modifiable risk factors. Which client response would best indicate that the teaching was effective? Responses to verbal questions Performance on written tests Reported behavioral changes Completion of a mailed survey

c If the clients alter behaviors such as smoking, drinking alcohol and stress management, these changes suggest that learning has occurred. Additionally, physical assessments, observed behaviors and laboratory data (e.g., blood tests) may confirm risk reduction. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS cardiacteachriskhypertension

A 15-year-old client has been placed in a cervico-thoraco-lumbo-sacral orthosis or CTLSO brace. Which statement by the client indicates a need for additional teaching? "I can take the brace off when I shower or take a bath." "The brace has to be worn all day and night." "I will only have to wear this brace for 6 months." "I should inspect my skin under the brace every day."

c The Milwaukee brace, also known as a cervico-thoraco-lumbo-sacral orthosis or CTLSO, is a back brace used in the treatment of spinal curvatures such as scoliosis or kyphosis in children. It is a full-torso brace that extends from the pelvis to the base of the skull.The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. The client's statement about only having to wear it for 6 months is incorrect and indicates a need for additional teaching. The other statements indicate a correct understanding. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS Milwaukee braceadolescentteachscoliosis

The nurse has been caring for the same client for 5 days. The client has been exhibiting manipulative behaviors. The nurse becomes aware of feeling reluctant to interact and care for the client. Which action should the nurse take? Report the feelings of reluctance to an objective peer or supervisor. Develop a behavior modification plan for the client. Talk with the client about the negative effects of their manipulative behaviors. Limit contact with the client to avoid reinforcement of the behaviors. (1 attempt remaining)

c The nurse who experiences stress in a professional relationship with a client can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of reactions that can influence the nurse-client relationship in positive and negative ways. Incorrect LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS manipulativebehavior

As a client is being discharged following resolution of a spontaneous pneumothorax, the client tells the nurse, "I'm going on a beach vacation next week." The nurse should instruct the client to avoid which activity? Sun bathing Surfing Scuba diving Swimming

c The nurse would strongly emphasize the need for the client with a history of spontaneous pneumothorax problems to avoid high altitudes, flying in an unpressurized (open) aircraft and scuba diving. The negative pressure associated with diving could cause the lung to collapse again. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM respiratory KEYWORDS dischargepneumothoraxteaching

The nurse is caring for a client who underwent a cardiac catheterization 2 hours ago. Which finding would indicate that the client is experiencing a potential complication from the procedure? Decreased urine output Increased blood pressure Increased heart rate Absent pedal pulse in the affected extremity

d Loss of the pulse in the extremity where the catheterization was performed would indicate a potential severe spasm of the artery or clot formation/occlusion below the site of insertion. It is common for the pulse to be intermittently weaker from the baseline. However, a total loss of the pulse is a medical emergency. The primary health care provider (HCP) should be notified immediately. Correct! LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS catheterizationcardiaccomplication

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease. The client reports persistent dyspnea. Which action should the nurse take? Place the client in low-Fowler's position. Lower the rate of oxygen flow. Instruct the client to breathe into a paper bag. Assist the client with pursed-lip breathing.

dl; The nurse should assist the client with pursed-lip breathing. Pursed-lip breathing during periods of dyspnea in clients with chronic obstructive pulmonary disease (COPD) helps to control the rate and depth of respirations. This will also help to prevent alveolar collapse and improve oxygenation. The other actions are not appropriate for this client. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM respiratory KEYWORDS COPDdyspneapursed-lip breathing

An 18-month-old child is awaiting a renal transplant. When reviewing the child's health history, the nurse notes that the child has not had the first measles, mumps, rubella (MMR) immunization. Which action should the nurse take? The risk of the vaccine's side effects are too great and it should not be given. The vaccine should be given now, before the transplant. An inactivated form of the vaccine can be given at any time. Live vaccines are withheld in children with renal chronic illness.

The measles, mumps and rubella (MMR) vaccine is a live virus vaccine, and should be given at this time, pre-transplant. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the child's compromised immune system. LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM urinary KEYWORDS childdialysisperitonealtransplantimmunization

The nurse is conducting a teaching session for a group of new nurses about types of oxygen delivery systems. Which system provides the most accurate delivery of oxygen? A Venturi mask A nasal cannula A simple face mask A partial non-rebreather mask

The most accurate way to deliver oxygen to a client is through a Venturi or Venti mask. The Venti mask is a high flow device that traps room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered with this system. The maximum amount of oxygen that can be delivered by a Venti mask is approx. 55%. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS oxygenaccurateVenturi

The nurse is planning care for a 2-year-old hospitalized child. Which issue will produce the most stress at this age? Fear of pain Separation anxiety Bodily injury Loss of control

Toddlers experience separation from their parents as a major stressor. Separation anxiety peaks in the toddler years and will produce the most stress at this age. LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS childhospitalstressseparationanxietytoddler

A newborn baby that was delivered at home without a birth attendant is admitted to the hospital for observation. The baby's initial temperature is 95° F (35° C). The nurse should recognize that the newborn is at risk for which complication? Metabolic alkalosis Lowered basal metabolic rate Hyperglycemia Hypoxemia

Variable decelerations A deceleration in fetal heart rate (FHR) may be benign or abnormal. Variable decelerations in FHR are often indicative of an interruption in the fetal oxygen supply due to umbilical cord compression. This is a complication that should be reported to the health care provider immediately. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS laborfetalmonitorrupture CONFIDENCE Need Help Fair Strong

The parents of a 4 year-old boy have just been informed that their son has a congenital neurologic disorder that is terminal. The nurse should anticipate the parents' reaction to fall into which crisis phase? Crisis phase Pre-crisis phase Resolution phase Impact phase

b; A crisis is a sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. The development of a crisis situation follows a relatively predictable course. Stages in a crisis go from the pre-crisis phase (phase 1) , to the impact phase (phase 2), then the crisis phase (phase 3), and finally the resolution phase (phase 4). The time frame of recent bad news places the parents in phase 1. In this phase, an individual is exposed to a precipitating stressor, resulting in increased anxiety and employment of previous problem-solving techniques. Incorrect LESSON Psychosocial Integrity Grief, Loss COURSE RN Review KEYWORDS terminaldisordercrisis

The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is 103°F (39.4°C). Which intervention would be most effective in lowering the child's temperature and promoting comfort? A. Apply extra layers of clothing to prevent shivering. B.Administer the prescribed antipyretic medication. C. Give a tepid sponge bath prior to giving an antipyretic medication. D. Immerse the child in a tub containing cool water.

b; A fever is not a primary illness. It is a physiologic mechanism the body uses to fight an infection. Although tepid sponge baths can lower the body temperature, they can distress febrile children (as evidenced by crying, shivering and goosebumps). Antipyretics can not only reduce the fever in the child, but they can also improve comfort and decrease irritability. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS temperaturetoddlerchildinfectionfever

The nurse on an inpatient hospital unit answers a call light and enters a client's room. The client expresses anger stating they have been waiting for more than 5 minutes for a blanket. Which is the best response from the nurse? "Let's talk. Why are you upset about this?" "I see this is frustrating for you. I have a few minutes so let's talk." "I am surprised that you are upset. The request could have waited a few more minutes." "I apologize for the delay. I was involved in an emergency."

b. The best response from the nurse acknowledges the client's verbalized needs and encourages an open conversation. To say "let's talk" and ask a "why" question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not acknowledge the client's feelings is inappropriate. It is rude for the nurse to tell a client their request could wait a few minutes, and this response does not acknowledge the client's verbalized needs. Incorrect LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS angerdemandtherapeutic

The nurse is teaching a group of adolescents about sexually-transmitted infections. Which should the nurse emphasize as the most common sexually-transmitted infection? Herpes Chlamydia Human immunodeficiency virus (HIV) Gonorrhea

b; Chlamydia is the most frequently reported bacterial sexually-transmitted infection in the United States. This infection has subtle symptoms so an infected person is less likely to seek medical attention and more likely to unknowingly infect others. Prevention is similar to safe sex practices taught to prevent any sexually-transmitted infection including abstinence and the use of condoms during intercourse. Correct! LESSON Health Promotion and Maintenance High Risk Behaviors COURSE RN Review BODY SYSTEM reproductive KEYWORDS teachsexually transmitteddiseaseinfection

A nurse is teaching an 80-year-old client how to use a metered dose inhaler. The nurse is concerned that the client is unable to coordinate the release of the medication during the inhalation phase. Which intervention should improve the delivery of the medication? Request a home health nurse to visit the client at home. Ask a family member to assist the client with the inhaler. Use nebulized treatments at home instead. Add a spacer device to the inhaler canister.

d Use of a spacer is especially useful with older adults because it allows more time to inhale and requires less eye-hand coordination. If the client is not using the metered dose inhaler (MDI) properly, the medication can get trapped in the upper airway and lead to dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM respiratory KEYWORDS MDIinhalerspacer

A community health nurse is teaching a new parent group about primary prevention of lead poisoning in children. Which intervention should the nurse include? Boil tap water for 10 minutes prior to adding to formula or food. Monitor the child for developmental delays. Request chelation therapy from the child's pediatrician. Use bottled water to add to any formula concentrate or powder. (1 attempt remaining)

d Lead exposure to children can result from multiple sources and can cause irreversible and life-long health effects. No safe blood lead level in children has been identified. Even low levels of lead in blood have been shown to affect IQ, ability to pay attention and academic achievement. Lead-contaminated water continues to pose a risk for many communities in the United States. Drinking water may become contaminated by lead from old lead pipes or the lead solder used in sealing the water pipes in older communities, building and homes. To reduce the risk of lead poisoning in infants in communities at risk for lead-contaminated water, a preventative intervention is to use bottled water to prepare formula from concentrate or powder. Boiling water will kill bacteria in water but does not remove the lead. Developmental delays are an outcome of lead poisoning, not a preventative measure. Chelation therapy is a treatment option for children diagnosed with high serum levels of lead; it is not a preventative treatment. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM nervous KEYWORDS communityformulaleadpoisoning

The nurse is planning care for a newly admitted 78-year-old client who is diagnosed with severe dehydration. Which task would be appropriate for the nurse to assign to an unlicensed assistive person (UAP)? Monitor client's ability for movement in the bed from side to side. Check skin turgor every 4 hours and change the client's adult diaper. Converse with the client to determine if the mucous membranes are impaired. Report hourly outputs of less than 30 mL/hr within 15 minutes of the check.

d' When assigning tasks to an unlicensed assistive person (UAP), the nurse must communicate clearly about each delegated task with specific instructions on what must be reported and when. Because the nurse is responsible for all care-related decisions, only routine tasks should be assigned to UAPs because such tasks do not require clinical judgment and decision-making. Measuring hourly urine output and reporting the amount to the nurse is an appropriate task to delegate to a UAP. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS UAPassigndehydration

During the change-of shift-report, the nurse reports that one of the clients is of the Catholic religion and was admitted for the delivery of her ninth child. Which comment made by the nurse indicates a bias against the client? "The client's spouse is requesting to stay overnight with her." "I'm surprised that the client insists on a natural birth." "I'm wondering who is taking care of the other children." "All those people tend to indulge in large families."

d' A bias is a tendency, inclination, or prejudice toward or against something or someone. The nurse's comment indicates the bias that people of Catholic faith tend to have large families due to the religion's position on birth control. The other comments are not indicative of a bias by the nurse. Correct! LESSON Psychosocial Integrity Cultural Awareness, Cultural Influences on Health COURSE RN Review KEYWORDS prejudiceCatholicdelivery

The parents of a 7-year-old child tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? A. Insecurity and attention-getting are common motives. B. Complex thought processes help to resolve conflicts. C. Attempts to control the family using new coping styles. D. The ethical sense and feelings of justice are developing.

d. The ethical sense and feelings of justice are developing. Correct! The child is developing a sense of justice and a desire to do what is right. At age 7, children are increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment. This age group, 6-12 years of age, is called the school-aged group. Correct! LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS childbehaviorjusticesibling

A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client expresses fears about his prognosis. What should the nurse understand about this type of cancer? This surgery causes impotence and infertility. With early intervention, the cure rate for testicular cancer is about 50%. Intensive chemotherapy is the treatment of choice following surgery. This cancer has a five-year survival rate of 90% or greater with early diagnosis and treatment.

d..With aggressive treatment and early detection/diagnosis the cure rate is generally 90% or greater. The other options are incorrect information. After unilateral orchiectomy, the remaining testicle can produce adequate sperm for fertility and impotence is unlikely. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS orchiectomyfearprognosiscure rate

A client has had a positive reaction to a purified protein derivative (PPD) skin test. The client asks the nurse what the test result means. How should the nurse respond? "This means you have active tuberculosis." "You most likely have a resistant form of tuberculosis." "You most likely have a natural immunity to tuberculosis." "This means you have been exposed to tuberculosis"

d; The purified protein derivative (PPD) skin test is used to determine the presence of tuberculosis (TB) antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive test result. This indicates the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest X-ray and a sputum culture will be needed to determine if active TB is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB. LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS tuberculosisPPDpositiveexposure

The nurse is evaluating a stage III pressure ulcer. Which assessment finding would indicate that the prescribed treatment is working? A.The periwound texture is moist and soft B. The edge of the wound appears rolled or curled under C. Soft yellow tissue seen in wound bed D. The size of the wound is decreasing

d;A wound that is decreasing in size is healing. "Slough" is yellow, tan or green tissue that is not healing. Soft and denuded tissue in the periwound area indicate tissue breakdown due to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents epithelial cells from migrating to close the wound, preventing the wound from healing. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS pressure ulcerwound healing

The nurse receives change-of-shift report on an 80-year-old client diagnosed with middle-stage Alzheimer's disease. Which information should be of highest concern? A 10 mm Hg drop in the client's diastolic blood pressure. A change in the color and temperature of the client's fingers and toes. Reports of increased confusion, agitation and withdrawal. An increase in the client's basal heart rate by 10 bpm.

Reports of increased confusion, agitation and withdrawal. Correct Response Infections and pain can quickly exacerbate common symptoms of Alzheimer's disease, including confusion, agitation or withdrawal. A urinary tract infection (UTI) is one of the most common causes of sudden behavior changes in older clients. Because a UTI can quickly progress to urosepsis, the neurologic changes are of highest concern. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS UAPdementiachangeAlzheimer'sinfection

The nurse is assessing a 1-day-old newborn infant. The nurse notices that the infant's breasts are enlarged bilaterally with a thin, white discharge. Which action by the nurse is appropriate? Obtain a specimen of the fluid to check for glucose. Ask the mother about medications taken during pregnancy. Notify the health care provider immediately. Record the findings, noting they are normal.

d Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days to weeks after birth. This is a result of circulating maternal hormones after birth. This typically resolves on its own in the first few weeks after birth. Correct! LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS assessnewbornbreastdischarge

The nurse is assigned to a client who is newly diagnosed with active tuberculosis. Which intervention is the priority? Collect several sputum samples for testing. Have the client dispose of soiled tissues in a separate bag. Place the client in a private, negative pressure room. Reinforce hand washing before and after entering the room.

c; A client with active tuberculosis should be hospitalized in a negative pressure room, i.e., airborne precautions, to prevent spread of the disease. Placing the client on on airborne precautions is the priority because this bacteria can be suspended in the air for long periods of time and may be carried for long distances on air currents, infecting others. Incorrect LESSON Safety and Infection Control Standard Precautions, Transmission-Based Precautions, Surgical Asepsis COURSE RN Review BODY SYSTEM respiratory KEYWORDS TBtuberculosisrespiratorairborne

A client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't worth living anymore." Which statement is the best response by the nurse? "Maybe you are just having a bad day today." "Did you tell any of this to your family?" "Try to think of the many positive things in your life." "Have you thought about hurting yourself?"

"Have you thought about hurting yourself?"

The parent of a 4-month-old infant asks the nurse about how to protect the child from sunburn. Which of these statements is the best advice about sun protection for infants? "Sunscreen should not be used on children." "You should keep the baby inside unless it's cloudy outside." "Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." "Liberally apply a sunscreen with the minimum sun protective factor of 15 all over the child's body."

"Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned. A hat and light protective clothing should be worn. Sunscreen is not generally recommended for infants under the age of 6 months; however, the American Academy of Pediatrics states that it can be applied to small areas of the baby's skin that are exposed to the sun (such as the baby's face or the back of the hands). LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM integumentary KEYWORDS infantsunburnprotection

A new task force has been created at a hospital to address a recent increase in client falls. The first meeting is scheduled with members from several departments. Which statements by the nurse leader will increase meeting effectiveness? Select all that apply. "This meeting can go as long as needed to get things done." "Let's discuss when we should meet next and what information we will bring." "During our meeting today, we will share the information we have on client falls." "Please introduce yourselves and your departments." "Let's focus on the number of client falls first and then we can talk about staffing." "Today I will review the problem with client falls on our units."

"Let's discuss when we should meet next and what information we will bring." Correct Response "During our meeting today, we will share the information we have on client falls." Correct Response "Please introduce yourselves and your departments." Correct Response "Let's focus on the number of client falls first and then we can talk about staffing." Correct Response The leader increases meeting effectiveness by not permitting one person to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (e.g. on a whiteboard) and then follow up with written minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect for team members' other commitments. LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS managementsupervisioncollaboration CONFIDENCE

The nurse on a surgery unit is evaluating which client would be appropriate for patient-controlled analgesia (PCA). Which client would not be appropriate for PCA? A 71-year-old client with numerous arthritic nodules on their hands. A 25-year-old client with a history of Down syndrome. A 16-year-old client who reads at a fourth-grade level. A 4-year-old client with intermittent episodes of alertness.

4 ; The 4-year-old client (preschool-aged) is most likely to have difficulty with the use or understanding of a patient-controlled analgesia (PCA) pump. The preschooler also has a decreased level of consciousness and would not be able to fully benefit from the use of a PCA pump. School age children, ages 6 and up, are better candidates for PCA electronic pumps. Incorrect LESSON Pharmacological (and Parenteral Therapies) Pharmacological Pain Management COURSE RN Review KEYWORDS cancerpainPCAchildadolescent CONFIDENCE Need Help Fair Strong Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse see first? A 25-year-old client who is primipara, with cervical dilation of 1 cm and who is experiencing contractions 15 minutes apart. A 28-year-old client who is grand multipara, 4 cm dilated and 50% effaced. A 34-year-old client with a history of 2 prior vaginal term births and who is 2 cm dilated. A 17-year-old client who is 18 weeks pregnant with a report of no fetal heart tones and coughing up frothy sputum.

A 17-year-old client who is 18 weeks pregnant with a report of no fetal heart tones and coughing up frothy sputum. The 17-year-old client is likely experiencing an actual complication of left-sided heart failure and a possible stillborn birth. The other clients have expected findings, or potential, but not actual, complications. The nurse should see the client who is coughing up frothy sputum first. LESSON Management of Care or Coordinated Care Establishing Priorities COURSE RN Review KEYWORDS labordeliveryheartfailurestillborn

The nurse is teaching a client with cardiac disease who is taking furosemide and digoxin about foods rich in potassium. Which food choice best indicates the client understands the teaching? A small orange An apricot A baked potato A small banana

A baked potato; A baked potato contains approximately 610 mg of potassium. Apricots, oranges and bananas are also sources of potassium, but because of their size, they are not the highest in potassium. A baked potato is the highest in potassium of the given options and is the best choice. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review KEYWORDS potassiumdigitalistoxicityfood

A nurse is assessing the health status of several clients at a community health event. The nurse should conduct a mental status examination on which clients? Clients who report memory lapses. All clients participating in the event. Clients with obvious signs of depression. Clients who display restlessness.

A mental status assessment is a critical part of baseline information and should be a part of every screening. This assessment serves as a screening tool for the nurse to assess for mental status abnormalities. The tool evaluates the client's behavioral and cognitive functioning. LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review KEYWORDS healthfairassessmentalstatusexam

A nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed. The mother is sitting in a nearby chair. The mother says to the nurse, "take the baby out of here. I do not want it." Which response by the nurse is best? "You seem upset. Tell me what the pregnancy and birth were like for you." "This is a common occurrence after birth, but you will come to accept the baby." "What a beautiful baby! Her eyes are just like yours and so is her smile." "Many women have postpartum blues and need some time to love their baby."

A; nonjudgmental, open-ended response facilitates dialogue between the client and the nurse. The other three options ignore the situation and the needs of the mother. The nurse should recognize that this client may be having postpartum depression. The best response by the nurse is open-ended, allowing further discussion about the client's feelings and emotions. LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS postpartumbabycommunication

The nurse asks an unlicensed assistive person (UAP) to help with repositioning of a client in bed. Which actions by the nursing staff support correct ergonomics and safe client handling? Select all that apply. Adjust the height of the bed to hip level. Ask a visiting family member to help. Instruct the client to hold their breath. Use a friction-reducing device/sheet underneath the client. Lower the head of the bed into a flat position. Coordinate lifting together by counting to thr

Adjust the height of the bed to hip level. Use a friction-reducing device/sheet underneath the client. Coordinate lifting together by counting to three. Lower the head of the bed into a flat position. ; Adhering to ergonomic principles will help prevent injuries to the nursing staff and/or the client. Raising the bed to hip level, lowering the head of the bed, using a friction-reducing device and coordinating moving at the same time will help with repositioning the client in a safe manner and reducing the risk of injury, such as straining the lower back. Asking a visitor to help and asking the client to hold their breath are not appropriate. LESSON Safety and Infection Control Ergonomic Principles COURSE RN & PN Review KEYWORDS ergonomic principlessafety

A nurse is reviewing laboratory results for a client diagnosed with acute renal failure. Which result should be reported to the primary health care provider immediately? Serum potassium of 6 mEq/L Blood urea nitrogen of 50 mg/dL Hemoglobin of 9.3 g/dL Venous blood pH of 7.30

Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (approximate hemoglobin less than 13 g/dL in men or less than 12 mg/dL in women) is common with kidney disease. Blood urea nitrogen (BUN) is expected to be increased in acute renal failure (7 to 30 mg/dL is considered normal). Correct! LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM urinary KEYWORDS labrenal failurepotassium

A 3-year-old client has just returned from surgery for application of a hip spica cast. Which nursing action should the nurse implement? Use the crossbar to help turn the child from side to side. Drying the cast using a hair dryer set to "warm". Apply waterproof plastic tape to the cast around the genital area. Position the child flat in the bed and reposition from supine to prone every 2-4 hours.

Apply waterproof plastic tape to the cast around the genital area. The most important aspects of caring for the cast is to keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape should be applied around the genital area to prevent soiling of the cast. The child should be turned every 2 hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried, if it becomes damp, it can be either exposed to air or a hairdryer (set to cool) can be used to help dry the cast. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS castplasterspicadry

The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a research study about staff attitudes toward client care. All staff are invited to participate in the study, if they wish. This type of research participation affirms which ethical principle? Justice Anonymity Autonomy Beneficence

Autonomy; The principle of autonomy means individuals must be free to make independent decisions about participation in research without coercion from others. Anonymity means the person's identity is not revealed. Beneficence is the state or quality of being kind, charitable, beneficial or a charitable act. Justice relates to fairness. LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS managerresearchethicsautonomy

The nurse is using the new Ballard score to perform an assessment to determine the gestational age of a newborn infant. The total score can range from -10 to 50. The infant's score is near 50. What is a reasonable interpretation of this result? The baby is premature. The baby is small for gestational age. The baby experienced distress during labor. The baby is post-term.

Birth weight and gestational age are important indicators of a newborn's health and are used to identify any potential problems. A full-term pregnancy is usually 40 weeks. It's important to assess when gestational age is uncertain or the infant is smaller or larger than expected. The New Ballard scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments. The total score may range from -10 to 50. Premature babies have lower scores. Higher scores correlate with post-term maturity. Fetal distress during labor tends to result in lower scores. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review KEYWORDS newbornBallardassessmentpost-termpremature

Which finding should alert the nurse to the possible presence of a cataract in a client? Dull aching in the eye and eyelids Nearsightedness and loss of peripheral vision Farsightedness and loss of central vision Blurred vision and reduced color perception

Blurred vision and reduced color perception Correct! As the lens becomes opaque and less able to refract light appropriately, the client will experience blurred vision and a reduced ability to distinguish among different colors. The development of a cataract does not typically cause loss of peripheral or central vision and visual acuity, nor does it result in aching of the eye or eyelids. LESSON Basic Care and Comfort Assistive Devices COURSE PN Review KEYWORDS data collectioncataract CONFIDENCE Need Help Fair Strong

The nurse is caring for a child who was diagnosed with coarctation of the aorta. Which finding should the nurse expect when assessing the child? Normal femoral pulses Bounding pulses in the arms Strong pedal pulses Diminished carotid pulses Incorrect

Bounding pulses in the arms Coarctation of the aorta, which is a narrowing or constriction of the descending aorta, causes increased blood flow to the upper extremities, resulting in a bounding pulse in the arms. Cardinal signs include resting systolic hypertension, absent or diminished femoral and pedal pulses and a widened pulse pressure. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS coarctationaortachildpulsebounding

The nurse is caring for a client with breast cancer who received chemotherapy one week ago. Which finding is the priority to report to the health care provider? Discomfort in both breasts Skin tenting of the forearm Depressed mood Fever and chills

Chemotherapy causes myelo or bone marrow suppression, resulting in neutropenia, the reduction in neutrophils (white blood cells) that fight off infections. Neutropenic, i.e., immunocompromised, clients are at an increased risk for infection, sepsis and septic shock and the nurse has to be extra vigilant in monitoring for early signs of infection. A fever and chills are indicative of a possible infection and take priority to be reported to the HCP. The other findings are also important to note and should be addressed by the nurse after notifying the HCP of the fever and chills. vLESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN & PN Review KEYWORDS chemotherapyneutropeniainfection

The nurse is providing discharge teaching to a client who has had a total hip arthroplasty performed. Which instruction should the nurse include? Ambulate using crutches only. Do not cross your legs at the ankles or knees. Sleep only on your back and not on your side. Avoid climbing stairs for 3 months.

Clients who underwent a hip arthroplasty or replacement are at risk for dislocating the new hip joint if certain precautions are not followed. The risk will vary, depending on the surgical approach (anterior vs. posterior). To prevent a post-surgical hip dislocation, the nurse should instruct the client to prevent hip flexion beyond 90 degrees or hip hyperextension. Furthermore, it is generally recommended to keep the legs slightly abducted and avoid adduction such as crossing the legs. The other instructions are not appropriate or required following a hip arthroplasty. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS hipprosthesisimplanthometeach

The nurse is teaching a community class about human immunodeficiency virus (HIV) prevention. Which behavior increases the risk for HIV infection? Use of public bathroom facilities. Social contact with a person who has AIDS. Donation of blood to a local blood bank. Engaging in unprotected sexual encounters.

Engaging in unprotected sexual encounters. Because human immunodeficiency (HIV) is spread through exposure to blood and bodily fluids, unprotected intercourse and shared drug paraphernalia such as needles remain the highest risks for acquiring HIV. The other activities are not at-risk behaviors for HIV. Incorrect LESSON Health Promotion and Maintenance High Risk Behaviors COURSE RN Review BODY SYSTEM lymphatic KEYWORDS HIVpreventrisk

The nurse is planning a family care conference for a client who will be returning home with new medical needs. Which of these aspects of the discharge planning evaluation Family's understanding of the client's health care needs Coordination of follow-up care with interdisciplinary team Client's health insurance and prescription coverage Availability of community-based services

Family's understanding of the client's health care needs; Family members must be willing and able to provide the required care at the times needed and understand the client's health care needs before the client is discharged home. The discharge planning evaluation will take into account a wide variety of information, such as the home environment, and the availability of community-based services (such as support groups, hospice, or medical equipment and related supplies, etc.) Family members should understand the financial implications of discharge, including health insurance and prescription coverage. LESSON Management of Care or Coordinated Care Case and Resource Management COURSE RN Review KEYWORDS assessdischargepriorityhome

The nurse is caring for a client who received 2 units of packed red blood cells after an episode of gastrointestinal bleeding. Which laboratory value should the nurse monitor closely? White blood cells Bleeding time Platelets Hematocrit

Hematocrit The hematocrit is an indirect measurement of red blood cells (RBCs) number and volume. It is used as a rapid measurement of RBC count. It is used to determine the degree of anemia in a client and evaluate effectiveness of treatment such as a blood transfusion. It is performed in combination with a hemoglobin level, commonly referred to as an 'H&H'. A follow-up hemoglobin and hematocrit should be checked around 4 to 6 hours after the transfusion is completed. LESSON Pharmacological (and Parenteral Therapies) Blood and Blood Products - RN COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS bloodunitbleedinglab

A pregnant client at 34 weeks gestation is diagnosed with a pulmonary embolism. Which of these medications should the nurse plan to administer? Intravenous heparin Oral warfarin Oral low-dose aspirin Subcutaneous enoxaparin

Intravenous heparin Clients diagnosed with pulmonary embolism (PE), whether pregnant or not, are initially treated with intravenous unfractionated heparin. Alternatively, low molecular weight heparin such as enoxaparin can be used to treat women who are pregnant. Warfarin should never be given during pregnancy due to its teratogenic effects. Although aspirin has anticoagulant properties, low-dose aspirin therapy (81 mg) is more often used prophylactically, not for the treatment of a PE. LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review KEYWORDS pregnancyanticoagulantheparinlovenoxPEpulmonary embolism

A community health nurse has been caring for a woman who is 22 weeks pregnant and has a history of morbid obesity, asthma and hypertension. Which of these lab reports should be communicated to the primary health care provider immediately? Hemoglobin 13 g/dL and Calcium 5.1 mg/dL Magnesium 0.8 mEq/L and Creatinine 3 mg/dL Hematocrit 35% and platelets 200,000/mm3 Blood urea nitrogen 28 mg/dL and Glucose 225 mg/dL

Magnesium 0.8 mEq/L and Creatinine 3 mg/dL ;The lab reports of highest concern are the magnesium and creatinine. The magnesium level is low and the creatinine level is high, indicating acute renal failure, most likely related to gestational hypertension or preeclampsia. Hypomagnesemia can lead to seizure activity. These lab reports should be communicated to the primary health care provider (HCP) immediately. LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN Review BODY SYSTEM reproductive KEYWORDS adolescentobesityasthmahypertensionpregnantrenalmagnesiumcreatinine

An 80-year-old client arrives in the emergency room after a fall at home. The client has several large skin abrasions. Which action should the nurse perform first? Perform a head-to-toe assessment. Verify if the client has advance directives in place. Clean and apply an appropriate dressing to the abrasions. Document findings of alterations in the skin's integrity. (1 attempt remaining)

Perform a head-to-toe assessment.; The nurse should first perform a head-to-toe assessment to see if other body systems were affected by the fall. After that initial assessment, the nurse should perform the other actions. The nurse would then document information collected during the assessment, such as any injuries. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS responsibilityassess

A client who is taking isoniazid for tuberculosis asks the nurse about the possible side effects of this medication. The nurse informs the client to report which side effect of this medication to the primary health care provider (HCP)?Confusion and light-headedness Extremity tingling and numbness Photosensitivity and photophobia Double vision and visual halos

Peripheral neuropathy is a common side effect of isoniazid and other anti-tubercular medications. Extremity tingling and numbness should be reported to the primary health care provider (HCP). Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM respiratory KEYWORDS isoniazidside effect

The parents of a 4 year-old boy have just been informed that their son has a congenital neurologic disorder that is terminal. The nurse should anticipate the parents' reaction to fall into which crisis phase? Impact phase Pre-crisis phase Resolution phase Crisis phase

Pre-crisis phase A crisis is a sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. The development of a crisis situation follows a relatively predictable course. Stages in a crisis go from the pre-crisis phase (phase 1) , to the impact phase (phase 2), then the crisis phase (phase 3), and finally the resolution phase (phase 4). The time frame of recent bad news places the parents in phase 1. In this phase, an individual is exposed to a precipitating stressor, resulting in increased anxiety and employment of previous problem-solving techniques. Incorrect LESSON Psychosocial Integrity Grief, Loss COURSE RN Review KEYWORDS terminaldisordercrisis

A community health nurse is speaking to a group of community members about alternative therapies. What is the focus of chiropractic treatment? Spinal column manipulation Electrical energy fields Exercise of the joints Mind-body balance

Spinal column manipulation The theory underlying chiropractic treatment is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation). Incorrect LESSON Health Promotion and Maintenance Self-Care COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS communityhealthpromotionchiropractor

The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse assign to an unlicensed assistive person (UAP)? Report mental status changes and level of mental clarity. Assess and document skin turgor and skin color changes. Test a stool sample for occult blood and report the results. Suggest foods that are high in iron and prepare a list for the client.

Test a stool sample for occult blood and report the results.; Unlicensed assistive personnel or persons (UAP) perform routine tasks that have known or expected outcomes because these tasks typically do not require nursing judgment or decision-making. Any nursing intervention that requires independent, specialized nursing knowledge, skill or judgment cannot be assigned to UAP.

The parents of a 5-month-old infant report that the infant has "vomited 9 times in the past six hours." Which complication should the nurse monitor the infant for? Hemodilution Metabolic alkalosis Hypervolemia Respiratory acidosis

Vomiting results in a loss of acid from the stomach. Prolonged vomiting results in excess loss of acid and leads to metabolic alkalosis. Manifestations of metabolic alkalosis include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse. LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS vomitingmetabolic alkalosispediatric

A client has been admitted to an inpatient behavioral health unit for severe depression and suicidal threats. The client has been placed on suicide precautions. The nurse should be aware that the danger of the client attempting suicide is greatest during what period of time? After a visit from the client's estranged partner. At the time of the client's greatest despair. During the night shift when staffing is limited. When the client's mood or energy level improves.

When the client's mood or energy level improves.; The risk for suicide is often increased when there is an improvement in mood and energy level. This can occur when the client is being treated and receiving new or increased doses of antidepressants. The medications can make the client feel less ambivalent and give the client the energy to carry through with the threat for suicide. LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS depressionsuicide; A nurse in an obstetrics clinic is taking a health history from a 40-year-old woman in the first trimester of pregnancy. Which information from the health history requires priority follow-up from the nurse? She has been taking an ACE inhibitor for her blood pressure for the past 2 years. She has been taking 800 mcg of folic acid daily for the past year. Her father and brother have type 1 diabetes. Her partner was treated for tuberculosis as a child. A; She has been taking an ACE inhibitor for her blood pressure for the past 2 years.

The nurse is caring for a client on a medical-surgical unit who reports difficulty falling asleep and sleeping through the night. The nurse should implement which interventions to promote sleep? Select all that apply. Avoiding intake of caffeine products after 4:00 pm Assisting client with deep breathing exercises before bedtime Administering a prescribed PRN sleep aid Encouraging client to watch television before bedtime Administering the prescribed diuretic in the morning

a,b,c, e Effective interventions for falling asleep and sleeping through the night can include the administration of a PRN sleep aid as a pharmacological intervention and deep breathing exercises before bed as a non-pharmacological intervention to promote relaxation and subsequent sleep. Limiting caffeine intake in the evening may also promote sleep. Administration of diuretics close to bedtime should be avoided as the client may awaken during the night to void when given later in the day. Watching television or computer screens before bedtime can disrupt the sleep cycle, as blue light is known to impair circadian rhythms. LESSON Basic Care and Comfort Rest, Sleep COURSE RN & PN Review KEYWORDS sleepcircadian rhythmsleep aid

During a yearly health screening, an older female client reports having perimenopausal symptoms including irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage the symptoms. Which non-pharmacological interventions should the nurse include? Select all that apply. "Yoga may help you manage stress and relieve symptoms." "Use deep breathing exercises when you start having a hot flash." "You should drink at least 8-10 glasses of water a day." "1-2 glasses of red wine with dinner can help you manage stress." "Incorporate more vegetables and legumes in your diet." "Try exercising just before bedtime to help you sleep more soundly."

a,b,c, e Measures that have been found to be effective in helping manage symptoms of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6-8 breaths per minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant-based diet can also help. LESSON Health Promotion and Maintenance Lifestyle Choices COURSE RN & PN Review BODY SYSTEM reproductive KEYWORDS non-pharmologicalinterventionsnaturalself-carediet

A client who has been receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unit with a diagnosis of septicemia. Which nursing intervention is the priority? Prepare the client for insertion of a new CVAD. Place the client on contact precautions. Insert an indwelling urinary catheter. Change the dressing over the site of the existing CVAD.

a; Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it is likely that the existing CVAD is the source of the blood stream infection, it should be removed and the tip sent for culture and sensitivity testing. The nurse should anticipate this action and the priority is to prepare the client for insertion of a new CVAD. The other interventions are not indicated or appropriate for this client. LESSON Pharmacological (and Parenteral Therapies) Parenteral, Intravenous Therapies - RN COURSE RN Review BODY SYSTEM lymphatic KEYWORDS chemotherapycentral linesepsisCVAD

The nurse is caring for a client with a nasogastric tube and is preparing to administer an enteral feeding through the tube. Which is the best method to confirm correct tube placement prior to beginning the feeding? Check the pH level of the aspirated contents. Place the end of the tube in water to check for air bubbles. Auscultate the abdomen while instilling 10 mL of air into the tube. Measure the length of tubing from nose to epigastrium.

a; Once the initial placement of the tube has been confirmed by X-ray, the nurse should check the pH of the aspirated contents before administering medications or enteral feeding solutions. A properly placed nasogastric tube will contain aspirate with an acidic pH. This is the best method for the nurse to check the tube placement. If tube placement is in doubt, an order for an X-ray should be obtained. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS nasogastrictubeenteralpHaspirate

The nurse in a pediatrician's office is speaking with the parent of an 8-year-old child who is concerned about the child receiving the annual flu vaccine due to an egg allergy. How should the nurse respond? "You can schedule an appointment to have the vaccine administered in our office." "We can premedicate the child to prevent an allergic reaction." "Your child should not be receiving the flu vaccine." "We have new types of flu vaccines where an egg allergy does not matter."

a; The Centers for Disease Control and Prevention (CDC) states that people with egg allergies can receive any licensed, recommended age-appropriate influenza (flu) vaccine (IIV, RIV4, or LAIV4) that is otherwise appropriate. People who have a history of severe egg allergy (those who have had any symptom other than hives after exposure to egg) should be vaccinated in a medical setting, supervised by a health care provider who is able to recognize and manage severe allergic reactions. The other responses are not correct LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS contraindicationchildimmunizationegg

A community health nurse is speaking to a group of community members about alternative therapies. What is the focus of chiropractic treatment? Spinal column manipulation Mind-body balance Exercise of the joints Electrical energy fields

a; The theory underlying chiropractic treatment is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation). LESSON Health Promotion and Maintenance Self-Care COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS communityhealthpromotionchiropractor

A client with severe iron-deficiency anemia is prescribed a parenteral form of iron (i.e., iron dextran). Which intervention does the nurse prepare to implement before administering the medication? Administer a small test dose. Use the Z-track administration method. Obtain the client's vital signs. Obtain informed consent.

a; The most serious adverse effect of iron dextran is an anaphylactic reaction. Although anaphylactic reactions are rare, their possibility demands that iron dextran be used only when clearly required. To reduce this risk, each dose must be preceded by a small test dose and the client must be closely monitored while receiving the test dose. The nurse should be aware that even the test dose can trigger anaphylactic and other hypersensitivity reactions. In addition, even when the test dose is uneventful, patients can still experience anaphylaxis. The medication does not require informed consent and obtaining the client's vital signs does not prevent an anaphylactic reaction. If the medication is ordered to be administered intramuscularly, the Z-track technique should be used to minimize discomfort, leakage and surface discoloration.

The client is scheduled for a coronary artery bypass procedure. When conducting pre-operative teaching with the client, which action should the nurse perform first? Assess the client's learning style. Mail a videotape to the home. Tour the coronary intensive care unit. Administer a written pre-test.

a; The first step in the teaching process consist of assessing how the client learns best. That way, the nurse increases success of the teaching by delivering the education in a format that the client understands and prefers. Therefore, the nurse should first assess the client's preferred learning style (e.g., reading a handout or watching a video). LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review KEYWORDS teachpre-opbypass

A parent asks about expected motor skill development for their 3-year-old child. Which activity is considered a typical motor skill for that age? Riding a tricycle Jumping rope Tying shoelaces Playing hopscotch

a; 3-year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include peddling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and fine motor skills that are more typical for older children. LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS motorskillchildcoordination

A client is admitted with severe injuries resulting from an auto accident. The client's vital signs are BP 120/50 mmHg, pulse rate 110 bpm, and respiratory rate of 28 breaths per minute. Which action should the nurse complete first? Administer oxygen as ordered. Initiate continuous blood pressure monitoring. Institute continuous cardiac monitoring. Initiate the ordered intravenous therapy.

a; Early findings of shock are associated with hypoxia and manifested by a rapid heart rate and rapid respirations. The nurse should use the Airway-Breathing-Circulation approach to prioritize interventions. Therefore, maintaining adequate oxygenation is critical and oxygen should be administered first. The other interventions are secondary to oxygen therapy. LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS accidentinjuryshockprioritization

The nurse on a telemetry unit is assessing orthostatic vital signs on a client with cardiomyopathy. The client's systolic blood pressure decreased from 145 to 110 mmHg between the supine and upright positions. The client's heart rate increased from 72 to 96 bpm during that time. The client reports feeling lightheaded when standing up. Which action should the nurse implement? Increase the client's PO fluid intake for the next 2 hours. Instruct the client to empty their bladder and reassess their BP. Restrict the client's PO fluids for the next 4-6 hours. Instruct the client to follow a high protein diet. (1 attempt remaining)

a; The client is experiencing postural hypotension. Postural hypotension is a decrease in systolic blood pressure of at least 15 mmHg, accompanied by an increase in heart rate of 15 to 20 beats above the baseline with a change of position from supine to upright. This is often accompanied by lightheadedness. Fluid replacement is appropriate, and must be instituted very cautiously. The client with cardiomyopathy will also be sensitive to changes in fluid status and fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for one to two hours, the client should be reassessed for resolution of the postural hypotension. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS cardiomyopathyblood pressuresystoliclightheadedness The nurse on an inpatient medical unit is caring for a client who is in the advanced stage of multiple myeloma. Which intervention should the nurse include in the plan of care? Monitor the client for hypokalemia. Place the client in protective isolation. Administer diuretics as ordered. Use careful repositioning techniques.

A newborn baby that was delivered at home without a birth attendant is admitted to the hospital for observation. The baby's initial temperature is 95° F (35° C). The nurse should recognize that the newborn is at risk for which complication? Hypoxemia Metabolic alkalosis Hyperglycemia Lowered basal metabolic rate

a; This newborn has hypothermia and it at risk for cold stress. This can cause a variety of physiologic stresses including increased oxygen consumption and reduced partial pressure of oxygen in arterial blood or PaO2, i.e., hypoxemia. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97°F (36°C). Normal core body temperature for newborns is 97.7° F-99.3° F (36.5° C-37.3° C) LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN & PN Review KEYWORDS newbornhospitalcoldtemperaturestress

A client is started on long-term corticosteroid therapy for an autoimmune disorder. Which statement by the client indicates the need for more teaching by the nurse? "I will keep a record of my weight each week." "For 1 week each month I will stop taking the medication." "I will be sure to eat foods that are high in potassium." "The medication needs to be taken with food."

b. Corticosteroids should never be stopped abruptly, they should always be weaned. To suddenly stop this medication may result in a sudden drop in the blood pressure from a loss in fluid volume associated with adrenal crisis. Clients should be warned not to abruptly stop taking the medication. Corticosteroids can lower the amount of potassium in the body so the client should eat more potassium rich foods. Weight gain is an expected effect of corticosteroid therapy. Clients should regularly keep track of their weight. Generally, corticosteroid medications are taken with breakfast. LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM endocrine KEYWORDS corticosteroidpotassiumweightstop

During the change-of shift-report, the nurse reports that one of the clients is of the Catholic religion and was admitted for the delivery of her ninth child. Which comment made by the nurse indicates a bias against the client? "The client's spouse is requesting to stay overnight with her." "All those people tend to indulge in large families." "I'm surprised that the client insists on a natural birth." "I'm wondering who is taking care of the other children."

b; A bias is a tendency, inclination, or prejudice toward or against something or someone. The nurse's comment indicates the bias that people of Catholic faith tend to have large families due to the religion's position on birth control. The other comments are not indicative of a bias by the nurse. LESSON Psychosocial Integrity Cultural Awareness, Cultural Influences on Health COURSE RN Review KEYWORDS prejudiceCatholicdeliveryattitude

The nurse receives an order to administer intravenous gentamicin to a client. For which finding should the nurse contact the health care provider to clarify the order? Low serum albumin High serum creatinine Low serum blood urea nitrogen High gastric pH

b; Gentamicin is an aminoglycoside antibiotic that is excreted primarily by the kidneys. If there is reduced renal function as evidenced by the elevated serum creatinine level, the client is at greater risk for drug toxicity and further renal damage. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM urinary KEYWORDS gentamicintoxiccreatininerenal

The nurse is caring for a primigravida client who is in active labor. Which assessment finding may be an early indication that the client is developing a complication of the labor process? The mother's blood pressure is 138/88 mmHg. The fetal heart rate has been around 180 bpm for several minutes. The mother's temperature is 100° F (37.7° C). The cervical dilation is measuring 4 cm. (1 attempt remaining)

b; The finding that indicates a possible complication of the labor process is the fetal heart rate of 180 bpm for several minutes. The normal fetal heart rate is typically somewhere between 120 and 160 bpm. Although the heart rate will fluctuate during labor and between contractions, prolonged fetal tachycardia can be an early sign of hypoxia. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM reproductive KEYWORDS fetal heart ratelaborcomplicationpregnancy

A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client expresses fears about his prognosis. What should the nurse understand about this type of cancer? This surgery causes impotence and infertility. This cancer has a five-year survival rate of 90% or greater with early diagnosis and treatment. Intensive chemotherapy is the treatment of choice following surgery. With early intervention, the cure rate for testicular cancer is about 50%.

b; With aggressive treatment and early detection/diagnosis the cure rate is generally 90% or greater. The other options are incorrect information. After unilateral orchiectomy, the remaining testicle can produce adequate sperm for fertility and impotence is unlikely. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS orchiectomyfearprognosiscure rate

The nurse is teaching a client about effective stress management techniques prior to a surgical procedure. Which technique should the nurse recommend for this client? Distraction Deep breathing Imagery Biofeedback

b; Deep breathing is a reliable and valid method for stress reduction and can be taught and reinforced in a short period of time preoperatively. The other approaches require more time and repetition over time for maximum effectiveness. LESSON Basic Care and Comfort Rest, Sleep COURSE RN Review KEYWORDS stressmanagementsurgery

The nurse receives change-of-shift report on an 80-year-old client diagnosed with middle-stage Alzheimer's disease. Which information should be of highest concern? A 10 mm Hg drop in the client's diastolic blood pressure. Reports of increased confusion, agitation and withdrawal. A change in the color and temperature of the client's fingers and toes. An increase in the client's basal heart rate by 10 bpm.

b; Infections and pain can quickly exacerbate common symptoms of Alzheimer's disease, including confusion, agitation or withdrawal. A urinary tract infection (UTI) is one of the most common causes of sudden behavior changes in older clients. Because a UTI can quickly progress to urosepsis, the neurologic changes are of highest concern. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS UAPdementiachangeAlzheimer'sinfection

The nurse is providing information to a client about propranolol. Which statement by the client indicates the teaching has been effective? "I could have an increase in my heart rate for a few weeks." "I can have a heart attack if I stop this medication suddenly." "I may experience seizures if I stop the medication abruptly." "I should expect to feel nervousness during the first few weeks."

b; Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremors. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, dysrhythmias, or even a myocardial infarction (i.e., heart attack). Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS propranololInderalheart attack

The nurse is conducting teaching with a family whose newborn infant was diagnosed with hypothyroidism. Which point is important for the nurse to emphasize during the teaching? Physical growth will be stunted. This rare problem is always hereditary. Hormone replacement therapy will prevent complications. Expect the child to be developmentally delayed.

c It is important to emphasize that early identification (ideally before 13 days old) and continued treatment with levothyroxine thyroid hormone replacement will correct hypothyroidism in newborns and prevent future problems. If undetected and untreated, hypothyroidism can result in poor growth, weight gain, slow heart rate, low blood pressure and babies who are unusually quiet. An untreated child will be at risk for permanent brain damage and intellectual disabilities. Approximately one in every 4,000 babies is born with hypothyroidism. Congenital hypothyroidism can be caused by a variety of factors, only some of which are genetic. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM endocrine KEYWORDS newbornhypothyroidthyroid hormone

The community health nurse is planning a teaching session for a family with children about safety and risk-reduction in their home. What information is most important to obtain prior to the session to ensure the teaching is effective? The number of children in the home. The ages and occupations of the parents. The ages of the children in the home. The physical layout of the home. (1 attempt remaining)

c; Although all of the information is important for the nurse to consider, the ages and developmental levels of the children are the most important considerations for anticipatory guidance associated with safety, and should be given priority when developing a teaching plan. With this information, the nurse can individualize the teaching session to meet the specific needs and risks of the children in the home. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review KEYWORDS riskhomeagedevelopmental

The nurse is completing a health history of a client diagnosed with Alzheimer's disease. The nurse reviews a list of the client's medications and supplements routinely taken at home. Which treatment should be a cause for concern by the nurse? Ginkgo biloba Omega-3 fatty acids Coconut oil Donepezil

c; Donepezil, rivastigmine, and galantamine are most commonly used in the treatment of Alzheimer's disease (AD). Complementary and integrative therapies use to treat AD include Gingko biloba (a plant extract) and omega-3 fatty acids. While there isn't sufficient research to support using these treatments, continued use won't necessarily be harmful. However, coconut oil, which is a source of caprylic acid, is a concern. While there has been limited research on Katasyn (an experimental drug containing caprylic acid), there is no scientific evidence that coconut oil is safe and effective or prevents cognitive decline. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS Alzheimer'sginkgo bilobaomega-3coconut oil

The client is having an intravenous pyelogram procedure. After the contrast material is injected, which client reaction should be acted upon by the nurse immediately? a. Face turning a deep ruddy red color. b. An excessive salty taste in the mouth. c. Hives with severe itching all over the body. d. A feeling of excessive warmth.

c; Hives over the body with severe itching is a sign of anaphylaxis and should be acted upon with the administration of epinephrine immediately. The other reactions are considered normal after the dye injection. Prior to any dye injection procedure clients should be informed that these symptoms may occur. Correct! LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN Review BODY SYSTEM urinary KEYWORDS IVPintravenous pyelogramcontrastanaphylaxis

The nurse working in an intensive care unit is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment for this client? Urine output Heart rate Blood pressure Neurologic status

c; Nitroglycerin (NTG) is a vasodilator used to promote myocardial tissue perfusion and relieve chest pain associated with coronary artery occlusion. The systemic vasodilation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure should be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin should also be placed on continuous ECG monitoring. NTG is not known to affect neurologic status, urine output or heart rate. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS nitroglycerinIVintravenousblood pressureangina

The home health nurse is preparing for a home visit of a new client. Which action is most important to ensure the safety of the nurse during the visit? Carry a cell phone, pager and/or hand-held alarm. Observe for evidence of weapons in the home. Remain alert and leave if cues suggest the home is not safe. Review documentation for previous entries about violence.

c; The home health nurse is preparing for a home visit of a new client. Which action is most important to ensure the safety of the nurse during the visit? Carry a cell phone, pager and/or hand-held alarm. Observe for evidence of weapons in the home. Remain alert and leave if cues suggest the home is not safe. Review documentation for previous entries about violence. LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN & PN Review KEYWORDS safehomevisitrisk

The nurse is caring for a client following a right lower lung lobectomy. During the assessment of the chest drainage unit, the nurse notices bubbling in the water-seal chamber. What is the first action the nurse should take? Check for any increase in the amount of drainage. Position the client in a supine position. Assess the chest tube dressing, tubing and drainage system. Call the primary health care provider immediately.

c; The first action the nurse should take is to thoroughly check the dressing, tubing and drainage system. Intermittent bubbling in the water seal chamber right after surgery usually indicates an air leak from the pleural space. This is a common finding and should resolve as the lung re-expands. Continuous bubbling usually means a leak in the chest drainage unit such as a loose connection or a leak around the insertion site. Other nursing actions will include assessing the color and amount of the drainage and auscultating the lungs. After the initial post-operative period, the nurse will assist the client to change positions, cough and deep breathe to help re-expand the lung and promote fluid drainage. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM respiratory KEYWORDS subcutaneouschest tubethoracicair leak

The charge nurse is making assignments for the upcoming shift. Which client would be most appropriate to assign to a licensed practical nurse (LPN)? A 64-year-old client diagnosed with a possible transient ischemic attack who has neurological abnormalities. A 53-year old client who is confused since surgery 2 days ago. A 76-year-old client who has cystitis, and is being treated with an indwelling urinary catheter. A 31-year-old client with multiple lacerations from a recent trauma and requires complex dressing changes.

c; The most stable client is the one diagnosed with cystitis. This client, who has predictable outcomes and minimal risk for complications, would be most appropriate to assign to the licensed practical nurse (LPN). The other clients require more complex care, specialized nursing knowledge, and skill or judgment that the registered nurse (RN) should provide. Correct! LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assignLPNRNstablepredictable

A client who is two days post abdominal surgery has the following vital signs: blood pressure of 120/70 mm Hg, heart rate of 110 bpm, respiratory rate of 26 breaths per minute and a temperature of 100.4°F (38°C). The client suddenly develops severe shortness of breath, cyanosis and pallor. Which assessment is the priority? Assess the pupils for unequal responses to light. Palpate the pulses for bounding and irregularity. Auscultate the lungs for diminished breath sounds. Check for orthostatic hypotension.

c; This client could be experiencing a complication from surgery, such as a pulmonary embolism (PE). A PE occurs as a result of a piece of a clot from the veins in the leg that has broken off and traveled to the lungs. The breath sounds will most likely be diminished or absent in the lung where the embolus lodged, thus a respiratory assessment is the priority. LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM respiratory KEYWORDS short of breathSOBbreath soundsclotembolus

The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder. Which behavior supports this diagnosis? The client exhibits repetitive, involuntary movements. The client prefers to interact with female staff members. The client is seen washing her hands every 15 minutes. The client verbalizes suspicions about thefts on the unit.

c;Washing her hands every 15 minutes indicates compulsive behaviors seen with obsessive compulsive disorder (OCD). OCD is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions). Affected individuals are often unable to stop the compulsive behaviors. The other behaviors are not typically seen with OCD. Verbalizes suspicions reflect a paranoid thought process seen with delusional disorders, such as schizophrenia or schizoaffective disorder. Repetitive involuntary movements are side effects seen with certain antipsychotic medications. LESSON Psychosocial Integrity Mental Health Concepts COURSE RN & PN Review KEYWORDS Obsessive-compulsive disorder (OCD)

The nurse in an intensive care unit is reviewing the laboratory results for several clients. Which laboratory result indicates that the client has a partially compensated metabolic acidosis? pH of 7.48 HCO3 of 28 mEq/L Chloride of 100 mEq/L PaCO2 of 30 mmHg

d. With metabolic acidosis, the nurse should expect to see a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L). Compensation means that the body is trying to get the pH back to a normal range of 7.35 to 7.45. A pure metabolic acidosis will elicit a compensatory response by the lungs in form of a decrease in PaCO2 (normal range is 35 to 45 mm Hg). Therefore, the PaCO2 level of 30 mm Hg indicates a partially compensated metabolic acidosis. A pH of 7.48 indicates an alkalosis and the chloride level does not pertain to the acid-base imbalance or compensation. LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN Review KEYWORDS labmetabolicacidosis

As a client is being discharged following resolution of a spontaneous pneumothorax, the client tells the nurse, "I'm going on a beach vacation next week." The nurse should instruct the client to avoid which activity? Sun bathing Swimming Surfing Scuba diving

d; The nurse would strongly emphasize the need for the client with a history of spontaneous pneumothorax problems to avoid high altitudes, flying in an unpressurized (open) aircraft and scuba diving. The negative pressure associated with diving could cause the lung to collapse again. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM respiratory KEYWORDS dischargepneumothoraxteaching

The nurse is talking on the phone with the parent of a 4-year-old child. The child was recently diagnosed with varicella. Which statement by the nurse demonstrates appropriate teaching? "I recommend using an antiviral medication to relieve itching." "The illness is only contagious when the lesions are present." "Chewable aspirin is the preferred analgesic for pain." "Papules, vesicles and crusts will be present at the same time."

d; It is appropriate to teach the parent to expect the different types of varicella (chickenpox) lesions that will be present on the child's body at the same time. Children should not be medicated with aspirin due to the possibility of developing Reye syndrome. A person with chickenpox is contagious for 1 to 2 days before skin lesions appear and remain contagious until all of the lesions have crusted over. Antiviral medications would not relieve itchy skin. LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS childchickenpoxteach

The nurse is working with an unlicensed assistive person (UAP). Which newly admitted client would be most appropriate to assign to the UAP? An 81-year-old client diagnosed with severe depression A 22-year-old client withdrawing from heroin, who is reporting seeing spiders A 15-year-old client diagnosed with dehydration and anorexia A 47-year-old client diagnosed with obsessive-compulsive disorder

d; The unlicensed assistive person (UAP) can be assigned to a client with a chronic condition after an initial assessment is performed by the nurse. The client with obsessive-compulsive disorder (OCD) is most appropriate to assign to the UAP. This client has minimal risk of medical instability. The other clients will require closer monitoring by the nurse due to the potential for medical complications or increased safety concerns. Correct! LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS techUAPadmitLPN

The nurse is teaching a client with chronic renal failure about their medications. The client questions the purpose of taking aluminum hydroxide. How should the nurse respond? "It increases your urine output." "It will reduce your blood's calcium levels." "It is taken to control gastric acid secretions." "It decreases your blood's phosphate levels."

d; Aluminum binds to phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidneys. Antacids such as aluminum hydroxide are commonly used in clients with chronic renal failure to decrease serum phosphate levels. Aluminum hydroxide will not increase urine production, control gastric acid secretions or lower serum calcium levels. Correct! LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM urinary KEYWORDS renal failurealuminum hydroxideamphojel CONFIDENCE

The nurse is reviewing the lab results of a full term, 30-hour-old newborn infant. The nurse knows that the first-time mother is Rh negative. Which of these findings is the priority to report to the health care provider? Hematocrit of 52% Apgar score of 8 at birth Jaundice is observed Serum bilirubin of 11 mg/dL

d; Jaundice is a common condition in newborns. But for a full-term infant who is 30 hours-old, a total serum bilirubin level of 11 mg/dL is high, indicating the possibility of hemolysis due to Rh incompatibility. The concern about hyperbilirubinemia is increased because the mother is Rh negative. Therefore, that finding is the priority finding to report to the health care provider. The other findings are either normal (hematocrit) or not as important at this time. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS Rhnewbornbilirubin

A client who is taking isoniazid for tuberculosis asks the nurse about the possible side effects of this medication. The nurse informs the client to report which side effect of this medication to the primary health care provider (HCP)? Double vision and visual halos Confusion and light-headedness Photosensitivity and photophobia Extremity tingling and numbness

d; Peripheral neuropathy is a common side effect of isoniazid and other anti-tubercular medications. Extremity tingling and numbness should be reported to the primary health care provider (HCP). Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM respiratory KEYWORDS isoniazidside effect

The nurse is using the new Ballard score to perform an assessment to determine the gestational age of a newborn infant. The total score can range from -10 to 50. The infant's score is near 50. What is a reasonable interpretation of this result? The baby is premature. The baby is small for gestational age. The baby experienced distress during labor. The baby is post-term.

d; Birth weight and gestational age are important indicators of a newborn's health and are used to identify any potential problems. A full-term pregnancy is usually 40 weeks. It's important to assess when gestational age is uncertain or the infant is smaller or larger than expected. The New Ballard scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments. The total score may range from -10 to 50. Premature babies have lower scores. Higher scores correlate with post-term maturity. Fetal distress during labor tends to result in lower scores. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review KEYWORDS newbornBallardassessmentpost-termpremature

A community health nurse is teaching a new parent group about primary prevention of lead poisoning in children. Which intervention should the nurse include? Monitor the child for developmental delays. Boil tap water for 10 minutes prior to adding to formula or food. Request chelation therapy from the child's pediatrician. Use bottled water to add to any formula concentrate or powder.

d; Lead exposure to children can result from multiple sources and can cause irreversible and life-long health effects. No safe blood lead level in children has been identified. Even low levels of lead in blood have been shown to affect IQ, ability to pay attention and academic achievement. Lead-contaminated water continues to pose a risk for many communities in the United States. Drinking water may become contaminated by lead from old lead pipes or the lead solder used in sealing the water pipes in older communities, building and homes. To reduce the risk of lead poisoning in infants in communities at risk for lead-contaminated water, a preventative intervention is to use bottled water to prepare formula from concentrate or powder. Boiling water will kill bacteria in water but does not remove the lead. Developmental delays are an outcome of lead poisoning, not a preventative measure. Chelation therapy is a treatment option for children diagnosed with high serum levels of lead; it is not a preventative treatment. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM nervous KEYWORDS communityformulaleadpoisoning

Two members of the interdisciplinary team are arguing about the plan of care for a client. Which strategy could be used to de-escalate the situation? Tell the team members they must calm down and be reasonable. Adjourn the meeting and reschedule when everyone has calmed down. Interrupt, apologize for the interruption and change the subject. Bring the communication focus back to the client. (1 attempt remaining)

d; Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is an effective de-escalation strategy because it is an example of effective communication and collaboration. The other options are non-productive and may even make the situation worse. Incorrect LESSON Management of Care or Coordinated Care Collaboration with Interdisciplinary Team COURSE RN & PN Review KEYWORDS interdisciplinaryde-escalationcommunication CONFIDENCE

The nurse is teaching a client who has coronary artery disease about nutrition. What information should the nurse include? Do not exceed 40 grams of carbohydrates a day. Limit sodium intake to 7 g per day. Eat foods rich in vitamin K. Avoid large and heavy meals.

d; Eating large, heavy meals can pull blood away from the heart to aid in the digestion process. This may result in angina for clients with coronary artery disease (CAD). This is important information to emphasize to the client with CAD. The other modifications are not appropriate or required with CAD. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS arterydiseasenutrition

The nurse smells smoke and notices a small fire in a non-client storage area. The alarm system begins to sound. Which action should the nurse take next? Wait for the arrival of the fire department. Back out of the room and close the door. Place a thermal blanket over the fire. Extinguish the fire using an ABC fire extinguisher.

d; Main Menu119of171 Main ContentRef # 5446The nurse smells smoke and notices a small fire in a non-client storage area. The alarm system begins to sound. Which action should the nurse take next? Wait for the arrival of the fire department. Incorrect Back out of the room and close the door. Place a thermal blanket over the fire. Extinguish the fire using an ABC fire extinguisher. Correct Response A fire in any health care facility presents great potential for harm. In this situation, there are no clients in imminent danger and the alarm has been activated. The nurse should attempt to extinguish the fire using an appropriate fire extinguisher. The ABC type is appropriate for all types of fires. Backing out of the room and closing the door may allow the fire to burn out of control. Using a blanket is not appropriate at this time. If the fire is manageable, the nurse should attempt to extinguish it and not wait for the fire department to arrive. Incorrect LESSON Safety and Infection Control Emergency Response Plan COURSE RN & PN Review KEYWORDS Firefire safetyfire extinguisher

The home health nurse is planning a care conference for the family of a 2-year-old child with cerebral palsy. Which goal should the nurse suggest to the family? Teach the child self-care skills. Decide on a long-term care facility. Prepare the child for independent toileting. Promote the child's optimal development.

d; Promote the child's optimal development. Correct Response The primary goal of nursing care for the child is to promote the child's optimal development. The child should be supported and encouraged to learn and grow to their fullest potential. Self-care and toileting may not be appropriate goals for the child due to the cerebral palsy. It is premature to discuss if the child should be placed in a long-term care facility. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS evaluationdevelopmentalchildgoal CONFIDENCE Need Help

A group of nurse managers is tasked with making several important staffing decisions. Which statement describes the advantage of using a decision grid to make decisions? It is the only truly objective way to make a decision in a group. It is the fastest way for group decision-making. It allows data to be graphed for easy interpretation. It is both a visual and a quantitative method of decision-making.

d;A decision grid allows the group to visually examine alternatives and evaluate them quantitatively or more objectively. It does not necessarily make the decision-making faster or interpretation easier. There are other tools available to aid in decision-making by a group. LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS decisiongrid

A client who previously had a stroke refuses to take the daily aspirin prescribed by their health care provider. Which statements should the nurse include in her response to the client? Select all that apply. "If you don't take aspirin every day, you might die." "Can you tell me what concerns you have about the aspirin?" "Do you experience any nausea when you take the aspirin?" "Would you like to take the aspirin at another time of day?" "Do you take your other medications as prescribed by your provider?"

eveyrthing except a Although clients have the right to refuse medications, the nurse should still try to determine the underlying reasons for the client's refusal. Aspirin is a platelet aggregate inhibitor that is often prescribed for clients with cardiovascular disease (CVD) and stroke to prevent another thrombotic event and future stroke. Aspirin can cause gastrointestinal (GI) irritation and should be taken with food. The nurse can increase the client's adherence to their prescribed medication regimen by investigating their reasons for refusal, exploring any misconceptions about the drug and reinforcing the importance of the medication in preventing another stroke. In addition, involving the client in making decisions about when to take the medication can help the client accept the regimen. Stating that the client might die if they do not take the medication is nontherapeutic, inappropriate and violates the client's right to autonomy. LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN & PN Review KEYWORDS noncompliancenonadherencemedication administration CONFIDENCE

The nurse is caring for a client who had an extracorporeal shockwave lithotripsy procedure for kidney stones. Which statement by the nurse demonstrates appropriate client teaching? "Avoid the intake of citrus fruits for the next 2 months." "Increase your intake of milk and dairy products." "Drink at least 3000 to 4000 mL of fluids each day." "Limit your intake of sodium to no more than 2 grams a day."

"Drink at least 3000 to 4000 mL of fluids each day."; An extracorporeal shockwave lithotripsy (ESWL) procedure is a non-invasive method for treating stones in the kidney or ureter. It utilizes an energy source which generates a shock wave that is directed at the stone, breaking it up and allowing it to be flushed out of the kidney or ureter. After an ESWL, the client should drink 3 to 4 quarts (3,000 to 4,000 mL) of fluids each day. This extra hydration will aid in the passage of fragments of the broken up renal calculi and help prevent formation of new calculi. The other instructions are not appropriate or required after an ESWL.

The nurse is caring for a client who is diagnosed with Hodgkin's disease and is scheduled for radiation therapy to the whole body. The nurse would expect the client to experience which side effect? a. Nausea b. Neutropenia c. Night sweats d. High fever

a; As a result of radiation therapy, which is at the lymph nodes throughout the body, nausea often results (radiation sickness). Night sweats are an expected finding with Hodgkin's disease. These clients are not likely to have a high fever because the lymphatic or immune system is not fully functional. Neutropenia is a side effect of chemotherapy.

The nurse in a primary health care provider's office is talking to a 35-year-old female client about her new diagnosis of uterine fibroids. Which statement by the woman indicates that additional teaching is needed? "Even if the fibroids do not cause problems, they must still need to be taken out." "Fibroids occur more frequently in women my age but no one knows what causes them." "Uterine fibroids are noncancerous tumors that grow slowly." "I sometimes experience pelvic pressure and pain, along with heavy menstrual bleeding."

"Even if the fibroids do not cause problems, they must still need to be taken out." Fibroids that cause no findings may require only "watchful waiting". The client may just need pelvic exams or ultrasounds periodically to monitor the fibroid growth. Treatment for the symptoms of fibroids (e.g. painful menses and heavy periods) may include oral contraceptives, an intrauterine device (IUD), iron supplements to prevent or treat anemia (due to heavy periods), non-steroidal anti-inflammatory drugs (NSAIDs) for cramps or pain or even short-term hormonal therapy to help shrink the fibroids. Surgical removal using my lobectomy or hysterectomy is usually reserved as a final alternative after other treatment options have failed to provide adequate relief. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM reproductive KEYWORDS fibroidfemaleperiodpainnoncancerousmenstrual CONFIDENC

The nurse asks an unlicensed assistive person (UAP) to help with repositioning of a client in bed. Which actions by the nursing staff support correct ergonomics and safe client handling? Select all that apply. A. Adjust the height of the bed to hip level. B. Use a friction-reducing device/sheet underneath the client. C. Coordinate lifting together by counting to three. D. Ask a visiting family member to help. E. Instruct the client to hold their breath. D. Lower the head of the bed into a flat position.

- Adjust the height of the bed to hip level. -Use a friction-reducing device/sheet underneath the client. -Coordinate lifting together by counting to three. -Lower the head of the bed into a flat position. Adhering to ergonomic principles will help prevent injuries to the nursing staff and/or the client. Raising the bed to hip level, lowering the head of the bed, using a friction-reducing device and coordinating moving at the same time will help with repositioning the client in a safe manner and reducing the risk of injury, such as straining the lower back. Asking a visitor to help and asking the client to hold their breath are not appropriate. Incorrect LESSON Safety and Infection Control Ergonomic Principles COURSE RN & PN Review KEYWORDS ergonomic principlessafety

The nurse from a women's wellness health clinic is temporarily assigned to an adult medical unit. Which of these client assignments would be most appropriate for this nurse? A newly diagnosed client with type 2 diabetes mellitus who is learning about foot care A newly admitted client with a diagnosis of pancreatic cancer and severe dehydration A client admitted for a barium swallow after a transient ischemic attack. A client who was in a motor vehicle accident who has an external fixation device on their leg (1 attempt remaining)

A client who was in a motor vehicle accident who has an external fixation device on their leg The nurse from the wellness clinic should be assigned to the client with the leg fracture. This client is the most stable and providing care for this client has predictable outcomes. The contraindications in the other clients are: "newly diagnosed," "after a transient ischemic attack (TIA)," and "newly admitted...severe dehydration." All of these clients have a health concern that's less stable than the client who has a stable fracture. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assignstablepredictable

The nurse from a women's wellness health clinic is temporarily assigned to an adult medical unit. Which of these client assignments would be most appropriate for this nurse? a. A newly diagnosed client with type 2 diabetes mellitus who is learning about foot care b. A client who was in a motor vehicle accident who has an external fixation device on their leg c. A client admitted for a barium swallow after a transient ischemic attack. d. A newly admitted client with a diagnosis of pancreatic cancer and severe dehydration

A client who was in a motor vehicle accident who has an external fixation device on their leg The nurse from the wellness clinic should be assigned to the client with the leg fracture. This client is the most stable and providing care for this client has predictable outcomes. The contraindications in the other clients are: "newly diagnosed," "after a transient ischemic attack (TIA)," and "newly admitted...severe dehydration." All of these clients have a health concern that's less stable than the client who has a stable fracture. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assignstablepredictable

The respiratory therapist arrives to draw blood from a client for an arterial blood gas analysis. What should the nurse understand about the collection procedure? Supplemental oxygen should be turned off 30 minutes prior to collecting the sample. The blood sample must be kept at room temperature and delivered to the lab as soon as possible. Firm pressure should be applied over the puncture site for at least 5 minutes after the sample is drawn. The femoral artery is the preferred sample site.

Firm pressure should be applied over the puncture site for at least 5 minutes after the sample is drawn.; After drawing the sample, it is very important to press a gauze pad firmly over the puncture site until bleeding stops or for at least 5 minutes. The client should not be asked to hold the pad because if insufficient pressure is used, a large painful hematoma may form. The radial artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is receiving oxygen, it should not be turned off unless ordered. The sample of arterial blood must be kept cold, preferably on ice, to minimize chemical reactions in the blood. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS arterial blood gasABGhematoma

A hospitalized 8-month-old infant is receiving digoxin to treat Tetralogy of Fallot. Prior to administering the next dose of the medication, the parent reports that the baby vomited one time, just after breakfast. The infant's heart rate is 92 bpm. What action should the nurse take? Double the next dose to make up for the medication lost from vomiting. Hold the medication and notify the primary health care provider. Give the scheduled dose after the client is done eating lunch. Reduce the next dose by half and then resume the normal medication schedule.

Hold the medication and notify the primary health care provider. Correct! Toxic side effects of digoxin include bradycardia, dysrhythmia, nausea, vomiting, anorexia, dizziness, headache, weakness and fatigue. It isn't typically necessary to hold the medication for infants and children if there is only one episode of vomiting. However, it is appropriate to hold the medication and notify the primary health care provider (HCP) of the vomiting episode and the lower than normal heart rate. A digoxin level may need to be drawn. The normal resting heart rate for infants 1 to 11 months old is 100 to 160 bpm. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS infanthospitaltetralogy of Fallotvomitdigoxin CONFIDENCE Need Help Fair Strong Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

A client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't worth living anymore." Which statement is the best response by the nurse? "Maybe you are just having a bad day today." "Did you tell any of this to your family?" "Try to think of the many positive things in your life." "Have you thought about hurting yourself?"

It is most important to determine whether someone who voices thoughts about death is considering suicide (i.e. suicidal ideation). Individuals may provide both behavioral and verbal clues as to the intent of their acts. Behavioral clues include giving away prized possessions, getting financial affairs in order, writing suicide notes and demonstrating a sudden lift in mood. Verbal clues may be both direct and indirect. An example of a direct statement includes, "I want to die." An example of an indirect statement includes, "I don't have anything worth living for anymore". This client's statement indicates suicidal ideation and the client's safety is the highest priority. The nurse should ask the client directly about thoughts or plans to harm themselves. The other responses are not therapeutic and will not help identify if the client is at risk for suicide. The best statement by the nurse follows the nursing process by collecting more data about the client's statement. Correct! LESSON Psychosocial Integrity Crisis Intervention COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS depressionsuicide risk

While being admitted for surgery, a client refuses to sign the surgical consent form. Which nursing actions should the nurse take? Select all that apply. Notify the health care provider. Inform the unit charge nurse. Convince the client to sign the consent form. Have a family member sign the consent form. Document the client's refusal in the medical record.

Notify the health care provider. Inform the unit charge nurse. Document the client's refusal in the medical record. The nurse should document the client's refusal to sign the consent form in the medical record. The nurse is responsible for notifying the charge nurse to keep them informed of the client's decision. The health care provider should be notified so they can discuss the consequences of not having the surgery and potential treatment alternatives with the client. It is not in the nurse's scope to convince a client to have a procedure they have the right to refuse. Unless the client has been deemed incompetent, the nurse should not have anyone sign on their behalf when they have refused treatment because this could create a claim of battery LESSON Management of Care or Coordinated Care Informed Consent COURSE RN & PN Review KEYWORDS Informed consentsurgery.

An inpatient client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." Which action should the nurse take? Calmly focus on reality orientation to time, place and person. Document the statement on the client's chart and report it to the nursing manager. Assist with the report of the client's complaint to the police. Obtain more details of the client's claim of abuse by a nurse.

Obtain more details of the client's claim of abuse by a nurse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, assessment before interventions and before documenting or reporting the complaint. Correct! LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN Review KEYWORDS abuseadvocacy

The home health nurse is preparing for a home visit of a new client. Which action is most important to ensure the safety of the nurse during the visit? Remain alert and leave if cues suggest the home is not safe. Carry a cell phone, pager and/or hand-held alarm. Review documentation for previous entries about violence. Observe for evidence of weapons in the home.

Remain alert and leave if cues suggest the home is not safe. Nurses need to assess and manage safety risks and have ongoing clinical supervision and support when making home visits. The most important action a nurse can take to ensure safety during a home visit is to always remain alert and to leave if there are any cues that the home is not safe. Proper safety should begin with a thorough assessment of the client's home to identify potential risks, such as pets (a commonly assessed hazard), drug use and weapons. The nurse should also develop a plan to eliminate the risks and understand that there is always the option to end a visit early if the environment does not seem safe. Carrying a phone, using a buddy system, learning about the client prior to the visit can also help mitigate risks. LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN & PN Review KEYWORDS safehomevisitrisk

The nurse has been caring for the same client for 5 days. The client has been exhibiting manipulative behaviors. The nurse becomes aware of feeling reluctant to interact and care for the client. Which action should the nurse take? A. Talk with the client about the negative effects of their manipulative behaviors. B.Develop a behavior modification plan for the client. C.Limit contact with the client to avoid reinforcement of the behaviors. D. Report the feelings of reluctance to an objective peer or supervisor.

Report the feelings of reluctance to an objective peer or supervisor. Correct! The nurse who experiences stress in a professional relationship with a client can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of reactions that can influence the nurse-client relationship in positive and negative ways. LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS manipulativebehavior CONFIDENCE

A client is admitted to an ambulatory surgery center and underwent a right inguinal orchiectomy. Which goal is the priority before the client should be discharged home?

The client's postoperative pain is well-managed. The client is able to tolerate a general diet. The client's psychological counseling is scheduled. The client is able to ambulate in the hallway with assistance. An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate, or cancer of the male breast). Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home. They should at least tolerate liquids before discharge. The client should be able to walk without assistance prior to discharge. Psychological counseling may be needed as part of long-term aftercare; however, this is not the priority prior to discharge. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM reproductive KEYWORDS orchiectomypostoperativepain

The nurse is evaluating self-management of a client who has type 1 diabetes. Which statement made by the client should be of highest concern? "I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" "I count the number of carbohydrates I eat. I eat several servings of fresh fruit per day." "Here are my glucose test readings that I wrote on my calendar. I check my blood sugar twice a day." "I give my insulin to myself in my thighs and belly. I make sure to alternate the sites."

The client's statement about having a penny in their shoe without realizing it, indicates this client may have peripheral neuropathy. Peripheral neuropathy can lead to lack of sensation in the lower extremities. When clients cannot feel potential tissue injuries (something in their shoe), they are at high risk for impaired skin integrity such as diabetic foot ulcers. The other statements indicate that the client is managing their diabetes appropriately. "I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM endocrine KEYWORDS type 1diabetesskinneuropathy

The nurse is teaching a client about effective stress management techniques prior to a surgical procedure. Which technique should the nurse recommend for this client? Imagery Deep breathing Biofeedback Distraction

b. Deep breathing is a reliable and valid method for stress reduction and can be taught and reinforced in a short period of time preoperatively. The other approaches require more time and repetition over time for maximum effectiveness. Incorrect LESSON Basic Care and Comfort Rest, Sleep COURSE RN Review KEYWORDS stressmanagementsurgery CONFIDEN

The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy tube. What nursing action is needed before starting the feeding? Select all that apply. Milk or massage the tube Verify the length and placement of the tube Elevate the head of the bed 30 to 45 degrees Flush the tube with 30 mL of warm water Keep the feeding product refrigerated until ready to use Palpate the abdomen

Verify the length and placement of the tube Elevate the head of the bed 30 to 45 degrees Flush the tube with 30 mL of warm water Prior to starting every feeding, the nurse should verify the length and placement of the percutaneous endoscopic gastrostomy (PEG) tube, flush the tube with 30 mL of warm (not hot and not cold) water, and elevate the head of the client's bed at least 30°. The nurse should also verify the presence of bowel sounds before starting the feeding. There is no need to milk the tube unless it is obstructed. Feeding products should be brought to room temperature before administration to prevent gastrointestinal discomfort. LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN & PN Review BODY SYSTEM gastroinstestinal

The nurse is teaching a 65-year-old female client who is newly diagnosed with osteoporosis. Which type of exercise is best for this client? "Do weight-bearing exercise or resistance activities." "Start a weight loss program to reduce your weight." "Do yoga to strengthen muscles and protect bones." "Go running 3 to 5 times per week."

Weight-bearing or resistance exercises are best in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes these exercises. Placing weight on bones against gravity helps to promote ossification. Running should be avoided because it can place too much stress on the bone and cause stress fractures. Weight loss might be indicated for osteoarthritis. Although yoga can help with balance and muscle strengthening, it does not directly benefit osteoporosis. LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS osteoporosisexerciseteachingweight-bearingresistance

The nurse is providing care for a 9-year-old child with cerebral palsy who has recently been admitted for repeated episodes of aspiration pneumonia and weight loss. During a discussion with the child's caregivers, which statement by the nurse demonstrates client advocacy? "It is possible that we may need to discuss inserting a feeding tube." "I will show you how to do manual jaw control during feedings." "Let's review some deep breathing and coughing exercises." "An orthotic device may help with positioning during feedings."

a ; Deep breathing and coughing exercises may be helpful, but they will not prevent aspiration. The nurse should reinforce manual jaw control and proper positioning during feeding. However, due to repeated episodes of aspiration, it is likely that the client is having significant difficulty controlling the muscles of the tongue/throat and jaw. The nurse needs to discuss the possibility of inserting a feeding tube to prevent future complications associated with repeated aspiration and weight loss. LESSON Management of Care or Coordinated Care Advocacy COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS advocacyteachingsaftey

The nurse working at a community health clinic is screening clients for risk factors of hypertension. Which client is at highest risk for developing hypertension? A 60-year-old Asian American male. A 65-year-old African American male. A 55-year-old Hispanic female. A 40-year-old Caucasian female.

b The incidence of hypertension (HTN) is greater among African Americans than other groups in the United States. Males have higher rates of HTN than females. Increased age also increases the risk for developing HTN. Therefore, the client with all of these risk factors is at highest risk for developing hypertension. Correct! LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hypertensionriskincidence CONFIDENCE Need Help Fair Strong

Following a surgical procedure, pneumatic compression devices are applied to both lower extremities of an adult client. The client reports that the device is hot and the client is sweating and itching. Which steps should the nurse take? Select all that apply. A. Collaborate with the primary health care provider for anti-embolism stockings to be worn under the sleeves of the device. B.Inform the client that removing the device will likely result in the formation of deep vein thrombosis C. Explain that the primary health care provider ordered the device and it cannot be removed. D. Check for appropriate fit E. Confirm pressure setting of 45 mm Hg

a, d, e, In any situation in which a client has discomfort associated with a medical device, the nurse should ensure it is applied correctly and functioning safely. The usual safe and effective pressure range is 35-55 mmHg. Explanations to the clients should support their informed decision-making capabilities and should not be phrased to intimidate or remove client autonomy. Applying anti-embolism stockings under the disposable sleeves of the device may help with the sweating and itching. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN & PN Review KEYWORDS anti-embolism stockingspneumatic compression devicepostoperative care

A client who previously had a stroke refuses to take the daily aspirin prescribed by their health care provider. Which statements should the nurse include in her response to the client? Select all that apply. a. "Would you like to take the aspirin at another time of day?" b."Can you tell me what concerns you have about the aspirin?" c. "Do you experience any nausea when you take the aspirin?" d. "If you don't take aspirin every day, you might die." e. "Do you take your other medications as prescribed by your provider?"

a. "Would you like to take the aspirin at another time of day?" b. "Can you tell me what concerns you have about the aspirin?" c. "Do you experience any nausea when you take the aspirin?" e. "Do you take your other medications as prescribed by your provider?" Although clients have the right to refuse medications, the nurse should still try to determine the underlying reasons for the client's refusal. Aspirin is a platelet aggregate inhibitor that is often prescribed for clients with cardiovascular disease (CVD) and stroke to prevent another thrombotic event and future stroke. Aspirin can cause gastrointestinal (GI) irritation and should be taken with food. The nurse can increase the client's adherence to their prescribed medication regimen by investigating their reasons for refusal, exploring any misconceptions about the drug and reinforcing the importance of the medication in preventing another stroke. In addition, involving the client in making decisions about when to take the medication can help the client accept the regimen. Stating that the client might die if they do not take the medication is nontherapeutic, inappropriate and violates the client's right to autonomy. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN & PN Review KEYWORDS noncompliancenonadherencemedication administration CONFIDENCE Need Help Fair Strong Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

The nurse is assessing a client who just returned to the medical surgical unit after a segmental lung resection surgery. During the assessment, the client is coughing and clearing their throat. What is the first action the nurse should take? Suction excessive tracheobronchial secretions. Assist the client to turn, deep breathe and cough. Administer the PRN pain medication. Apply the pulse oximeter and monitor oxygen saturation.

a/ This type of surgery involves removing a bronco-vascular segment of a lung lobe. It is typically used to remove small, peripheral lung tumors. Surgical manipulation during this procedure, along with anesthesia, and increased mucus production can lead to airway obstruction, which is why the nurse may need to suction the client if there are excessive secretions. The first action the nurse should take is to suction the excessive secretions. Since this client just returned from surgery, it is not the time to ask the client to turn, cough and deep breathe. Vital signs and oxygen saturation are important data to gather, but clearing the client's airway by suctioning needs to be done first. LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM respiratory KEYWORDS lungresectionpostopsuction

The nurse is planning a family care conference for a client who will be returning home with new medical needs. Which of these aspects of the discharge planning evaluation should receive priority consideration? Family's understanding of the client's health care needs Coordination of follow-up care with interdisciplinary team Client's health insurance and prescription coverage Availability of community-based services (1 attempt remaining)

a; Family members must be willing and able to provide the required care at the times needed and understand the client's health care needs before the client is discharged home. The discharge planning evaluation will take into account a wide variety of information, such as the home environment, and the availability of community-based services (such as support groups, hospice, or medical equipment and related supplies, etc.) Family members should understand the financial implications of discharge, including health insurance and prescription coverage. Incorrect LESSON Management of Care or Coordinated Care Case and Resource Management COURSE RN Review KEYWORDS assessdischargepriority

The nurse is caring for a client with a diagnosis of cirrhosis of the liver and ascites. What should the nurse emphasize to the unlicensed assistive personnel (UAP) about providing care for this client? a. The client should ambulate as tolerated, resting in bed with legs elevated between walks. b. The client should remain on bed rest in the semi-Fowler's position. c.The client is to ambulate as tolerated and be positioned in semi- Fowler's position when in bed. d. The client may ambulate and sit in a chair as tolerated.

a; Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client to gradually increase the duration and frequency of walks. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS cirrhosis liver ascites activity

The nurse is caring for a client who is diagnosed with Hodgkin's disease and is scheduled for radiation therapy to the whole body. The nurse would expect the client to experience which side effect? High fever Nausea Night sweats Neutropenia (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

b . As a result of radiation therapy, which is at the lymph nodes throughout the body, nausea often results (radiation sickness). Night sweats are an expected finding with Hodgkin's disease. These clients are not likely to have a high fever because the lymphatic or immune system is not fully functional. Neutropenia is a side effect of chemotherapy. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM lymphatic KEYWORDS Hodgkin's diseaseradiationtherapy

The nurse in a primary health care provider's office is talking to a 35-year-old female client about her new diagnosis of uterine fibroids. Which statement by the woman indicates that additional teaching is needed? a. "Even if the fibroids do not cause problems, they must still need to be taken out." b. "Fibroids occur more frequently in women my age but no one knows what causes them." c. "I sometimes experience pelvic pressure and pain, along with heavy menstrual bleeding." d."Uterine fibroids are noncancerous tumors that grow slowly." (1 attempt remaining)

a; Fibroids that cause no findings may require only "watchful waiting". The client may just need pelvic exams or ultrasounds periodically to monitor the fibroid growth. Treatment for the symptoms of fibroids (e.g. painful menses and heavy periods) may include oral contraceptives, an intrauterine device (IUD), iron supplements to prevent or treat anemia (due to heavy periods), non-steroidal anti-inflammatory drugs (NSAIDs) for cramps or pain or even short-term hormonal therapy to help shrink the fibroids. Surgical removal using my lobectomy or hysterectomy is usually reserved as a final alternative after other treatment options have failed to provide adequate relief. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM reproductive KEYWORDS fibroidfemaleperiodpainnoncancerousmenstrual

A new nurse is asking about stoma care for a client with a new ostomy. Which type of ostomy poses the highest risk for skin breakdown? Ileostomy Ileal conduit Sigmoid colostomy Transverse colostomy

a; Ileostomy output, which is from the small intestine, is of a continuous, liquid nature. This output contains gastric and enzymatic agents that when present on skin can denude the skin in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin protection must be delivered to prevent skin breakdown. With a transverse colostomy the stool is of a somewhat mushy and soft nature. With a sigmoid colostomy the output is formed with an intermittent output. An ileal conduit is a urinary diversion with the ureters being brought out to the abdominal wall. LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS stomaskinbreakdownfecal

The nurse is admitting a male client who is newly diagnosed with a frontal lobe brain tumor. Which statement by the client's spouse would support this diagnosis? "I find the mood swings hard to deal with." "He has a hard time reading small print." "It seems that he has to urinate more frequently." "His breathing rate is usually below 12."

a; The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in symptoms such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior. The other statements do not pertain to symptoms or changes in behavior typically seen with frontal lobe problems. LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM nervous KEYWORDS braintumorlabilitybehavior

At the client's request, the nurse performs a fingerstick to test the client's blood glucose and the results are 322 mg/dL. Following the insulin sliding scale orders, the nurse administers 3 units of insulin lispro at 11:00 AM. When does the nurse anticipate the insulin lispro will begin to act? A. 11:15 am B. 12:00 PM C. 3:00 pm D. 1:00 pm

a; The onset of action for insulin lispro, which is a rapid acting insulin, is 10 to 15 minutes after administration. It was administered at 11:00 AM, so it will begin to act at 11:15 AM. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM endocrine KEYWORDS Humaloginsulin

The nurse is reviewing the lab results of a full term, 30-hour-old newborn infant. The nurse knows that the first-time mother is Rh negative. Which of these findings is the priority to report to the health care provider? A. Serum bilirubin of 11 mg/dL B.Jaundice is observed C. Hematocrit of 52% D. Apgar score of 8 at birth

a;Jaundice is a common condition in newborns. But for a full-term infant who is 30 hours-old, a total serum bilirubin level of 11 mg/dL is high, indicating the possibility of hemolysis due to Rh incompatibility. The concern about hyperbilirubinemia is increased because the mother is Rh negative. Therefore, that finding is the priority finding to report to the health care provider. The other findings are either normal (hematocrit) or not as important at this time. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS Rhnewbornbilirubin

The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder. Which behavior supports this diagnosis? The client is seen washing her hands every 15 minutes. The client exhibits repetitive, involuntary movements. The client prefers to interact with female staff members. The client verbalizes suspicions about thefts on the unit.

a;Washing her hands every 15 minutes indicates compulsive behaviors seen with obsessive compulsive disorder (OCD). OCD is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions). Affected individuals are often unable to stop the compulsive behaviors. The other behaviors are not typically seen with OCD. Verbalizes suspicions reflect a paranoid thought process seen with delusional disorders, such as schizophrenia or schizoaffective disorder. Repetitive involuntary movements are side effects seen with certain antipsychotic medications. Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN & PN Review KEYWORDS Obsessive-compulsive disorder (OCD)

The nurse is evaluating the plan of care for a client who has been requesting a daily laxative to aid in having a bowel movement. What additional interventions should the nurse include in the client's plan of care? Select all that apply. a. Instruct the client to walk at least 30 minutes 3 to 5 times per week. b. Have the client keep a bowel elimination record. c. Encourage the client to drink more caffeinated beverages. d. Request a prescription for psyllium. e. Encourage the client to drink 2 to 3 liters of fluids a day.

abde Some clients believe that they are constipated if they do not have a daily bowel movement. This misconception can lead to laxative abuse, causing cathartic colon syndrome, a condition where the colon becomes dilated and atonic (absence of muscle tone). Clients with that condition cannot defecate without the help of a laxative. The nurse should provide additional education (or reinforce education) about interventions to prevent constipation, such as increased intake of dietary fiber and fluids, regular exercise, establishing a regular time to defecate and avoiding delaying defecation and using laxatives. Daily bulk-forming laxatives such as psyllium work like dietary fiber and do not cause dependence. Caffeine should be avoided because it will increase urination, which in turn will reduce fluid volume and harden the stool. LESSON Basic Care and Comfort Personal Hygiene COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS constipation

An internal disaster has occurred at the hospital. The charge nurse is asked to review acuity of the clients on the unit and determine which clients can and cannot be discharged. Which of these clients should not be discharged? a. A 17-year-old client diagnosed with sepsis 5 days ago and whose vital signs are within normal limits. b. A 24-year-old client in the second day of treatment for an overdose of acetaminophen. c. A 75-year-old client admitted two days ago with an acute exacerbation of ulcerative colitis. d. A 40-year-old client known to have had an uncomplicated myocardial infarction 4 days ago. (1 attempt remaining)

b; An overdose of acetaminophen requires close observation for several days. Also, the duration of the course of treatment for the oral antidote N-acetylcysteine (NAC) is approximately 72 hours. NAC will protect the liver if given within 8 hours after an acute ingestion. When compared with the other clients, the client who overdosed on acetaminophen is the least stable and should not be discharged. Incorrect LESSON Safety and Infection Control Emergency Response Plan COURSE RN Review KEYWORDS disasteracuitydischargeacetaminophen

The nurse at a hypertension clinic has been teaching adult clients about modifiable risk factors. Which client response would best indicate that the teaching was effective? A. Responses to verbal questions B. Reported behavioral changes C. Performance on written tests D. Completion of a mailed survey

b; If the clients alter behaviors such as smoking, drinking alcohol and stress management, these changes suggest that learning has occurred. Additionally, physical assessments, observed behaviors and laboratory data (e.g., blood tests) may confirm risk reduction. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS cardiacteachriskhypertension

A nurse in a rural community uses telehealth to provide care and education to clients in remote locations. What are the perceived benefits of using telehealth? Telehealth standardizes electronic sharing of health information data. Telehealth removes the time and distance barriers from the delivery of care. Telehealth greatly reduces health care costs for the clients who use it. Telehealth empowers clients to take a greater interest in their illness.

b; Telehealth is the use of technology to deliver health care, health information or health education at a distance. People in rural areas and homebound clients can communicate with primary health care providers via telephone, email or video consultation, thereby removing the barriers of time and distance for access to care.

The nurse is reviewing a new prescription for a client with conjunctivitis that reads: Administer ciprofloxacin solution 1 gtt OD Q4H. Which action should the nurse take next? Ask another nurse for their interpretation of the order. Apply one drop of the medication in the client's right ear every 4 hours. Contact the prescriber to clarify and rewrite the order. Squeeze one drop of the medication in the client's left eye every 4 hours.

c Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every". Although "gtt" is not on the official "Do Not Use List", it is best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous workaround. The next action the nurse should take is to call the primary health care provider (HCP) who prescribed the medication and clarify the order. Incorrect LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN & PN Review KEYWORDS abbreviationerrorworkaroundODgtt

The nurse is completing a head-to-toe assessment on a client. The nurse notes a pulsating mass in the client's periumbilical area. Which assessment is appropriate for the nurse to perform? Percuss Palpate Auscultate Measure the length

c The nurse should auscultate the mass. If the finding of a bruit is present, this could confirm the presence of an abdominal aortic aneurysm. The mass should not be palpated or percussed because of the risk of rupture. Correct! LESSON Health Promotion and Maintenance Techniques of Physical Assessment or Data Collection COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS masspulsateperiumbilicalauscultate

A woman who is 5 days postpartum and has a history of pregnancy-induced hypertension, calls the hospital triage nurse hotline to ask for advice. She states, "I have had the worst pounding headache for the past two days. Since this afternoon, everything I look at appears blurred. Nothing I have taken helps." What action should the nurse take? Advise the client to have someone bring her to the obstetrician's as soon as possible. Explain to the client that changes in her hormones may be the problem. Instruct the client to call 911 to be brought to the nearest emergency room. Ask the client to explain what exactly she has taken for the headache and how often.

c The woman is describing symptoms related to pregnancy-induced hypertension (PIH) that appears to be progressing to preeclampsia/eclampsia. PIH may progress to preeclampsia and eclampsia prior to, during, or up to 10 days after delivery. This places the woman at risk for seizure activity which is a medical emergency. The client should call 911 to be brought immediately to the closest emergency room (ER). LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM reproductive KEYWORDS PIHhypertensionheadachepregnancy

The clinic nurse is assisting with medical billing. The nurse uses the Diagnosis Related Group (DRG) manual for which purpose? To identify findings related to a medical diagnosis. To implement nursing care based on case management protocols. To determine reimbursement for a medical diagnosis. To classify nursing problems from the client's health history.

c. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment. The nurse uses this manual to determine reimbursement for medical diagnoses. LESSON Management of Care or Coordinated Care Case and Resource Management COURSE RN Review KEYWORDS DRGdiagnosis related groupreimbursement

The nurse is caring for a 4-year-old child with a greenstick fracture. The nurse is teaching the parents about the child's fracture. How should the nurse describe this type of fracture? "A child's bone is more flexible and can be bent 45 degrees before breaking." "Your child's bones are weak and will break more easily." "Bones of children are more porous than adults', leading to incomplete breaks." "Fractures in children are harmless and tend to heal quickly."

c; Bones in children are generally more porous than adult bones. This allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side develops an incomplete fracture. The other statements are not correct. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS childgreenstickfractureporous

The nurse is providing discharge teaching to the parents of a 15-month-old child diagnosed with Kawasaki disease. The child received intravenous immunoglobulin therapy during the hospitalization. Which information should the nurse include? A. Active range of motion exercises should be done frequently. B. High doses of aspirin will be continued for some time. C. The measles, mumps and rubella vaccine should be delayed. D. Complete recovery is expected within several days.

c; Discharge instructions for a child with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis), should include the information that immunoglobulin therapy may interfere with the body's ability to form appropriate amounts of antibodies. Therefore, live or attenuated (weakened) immunizations should be delayed. The measles, mumps, and rubella (MMR) vaccine contains three live attenuated viruses and should be delayed until the child's immune system recovers from this treatment. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS teachchildKawasakiimmunoglobulin

An inpatient client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." Which action should the nurse take? Calmly focus on reality orientation to time, place and person. Assist with the report of the client's complaint to the police. Obtain more details of the client's claim of abuse by a nurse. Document the statement on the client's chart and report it to the nursing manager.

c; The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, assessment before interventions and before documenting or reporting the complaint. LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN Review KEYWORDS abuseadvocacy

A client with schizophrenia is admitted to a mental health center with acute paranoia. The client tells the nurse: "I am a government official being followed by spies." Upon further questioning, the client states: "My warnings must be heeded to prevent nuclear war." Which action is most appropriate for the nurse to take? Ask for more information about the spies. Contact the government agency. Listen quietly without comments. Confront the client's delusions.

c; The client's comments demonstrate grandiose ideas or delusions of grandeur. The most appropriate action is to calmly listen and avoid being pulled into the client's delusional thinking. At some point, validation of the present situation will need to be done. Confrontation would be an inappropriate action and non-therapeutic. LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review BODY SYSTEM nervous KEYWORDS mentaloutpatientlistendelusion

The nurse witnesses a client having a seizure. Which observation is important to note to determine the type of seizure? A. The exact time from beginning to end. B. Loss of bowel or bladder control. C. The sequence and types of muscle movement. D. Identifying the pattern of breathing.

c; All behaviors observed during and after the seizure need to be reported and recorded. However, accurate descriptions of seizure activity and a system for recording and reporting activity is essential to seizure management. For example, during the seizure event, the nurse needs to observe the client's facial expression, muscle tone, movements (e.g. jerking or twitching) the parts of the body involved, and any automatic or repeated movement (e.g. lipsmacking, chewing, swallowing). Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS seizureobservation

The nurse is preparing to administer an albuterol nebulizer treatment to an 11-year-old child with asthma. Which assessment finding should be brought to the health care provider's attention prior to administering the medication? Lower extremity edema Respiratory rate of 28 Heart rate of 116 bpm Temperature of 101 F (38.3 C)

c; One of the more common adverse effects of beta-adrenergic medications, such as albuterol, is an increase in heart rate. Normal resting heart rate for children 10-years-old and older is the same as adults: 60 to 100 bpm. The nurse should report the heart rate to the health care provider prior to administering the medication. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM respiratory KEYWORDS Proventilalbuterolasthmaheartrate

A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. Which action should be the nurse's priority? Administer pain medication. Cover the areas with dry sterile dressings. Initiate intravenous therapy. Assess for dyspnea or stridor.

d Due to the location of the burns, the client is at risk for the development of upper airway edema and subsequent respiratory distress. The other options are correct, but the priority is to assess breathing and manage the airway. The client with any signs of airway injury may need be intubated. Correct! LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM respiratory KEYWORDS burnairwayedemarespiratory distress

There is an order for a 25-year-old client, who is unresponsive after suffering a traumatic brain injury, to be transferred from the hospital to a long-term care facility today. Which staff member should the charge nurse assign to care for this client? Licensed practical nurse (LPN) Nursing student in final semester before graduation Unlicensed assistive person (UAP) Registered nurse (RN)

d Registered nurse (RN) Correct! The Registered Nurse (RN) is responsible for facilitating continuity of care for clients and their families during the transfer from one health care setting to another. The transfer to a long-term care facility often requires referrals and coordinating information from many different providers about treatments, therapies and medications. The charge nurse should assign this client to a RN. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assigncharge nursetransfercontinuity

A client diagnosed with an acute anterior myocardial infarction is receiving nitroglycerin and heparin intravenously. The client still reports chest pain. Which action should the nurse take? Auscultate heart and lung sounds. Review and compare serial ECG strips. Administer antidysrhythmic drugs as indicated. Administer intravenous morphine sulfate as ordered.

d.Nitrates are useful for pain control due to their coronary vasodilator effects. The nurse will titrate the intravenous nitroglycerin infusion for chest pain according to standing orders, but if chest pain is unrelieved by the nitroglycerin infusion, the nurse can administer morphine intravenously (IM injections are avoided because they can alter the CPK). Morphine not only relieves pain and reduces anxiety, but also dilates the blood vessels. After giving the pain reliever, the nurse can do a more in-depth assessment of the client (auscultate heart and lung sounds, review ECGs, vital signs and labs). Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS emergencymyocardial infarctionpainprioritization

The nurse is providing care for a 9-year-old child with cerebral palsy who has recently been admitted for repeated episodes of aspiration pneumonia and weight loss. During a discussion with the child's caregivers, which statement by the nurse demonstrates client advocacy? "Let's review some deep breathing and coughing exercises." "I will show you how to do manual jaw control during feedings." "An orthotic device may help with positioning during feedings." "It is possible that we may need to discuss inserting a feeding tube." (1 attempt remaining)

d/ Deep breathing and coughing exercises may be helpful, but they will not prevent aspiration. The nurse should reinforce manual jaw control and proper positioning during feeding. However, due to repeated episodes of aspiration, it is likely that the client is having significant difficulty controlling the muscles of the tongue/throat and jaw. The nurse needs to discuss the possibility of inserting a feeding tube to prevent future complications associated with repeated aspiration and weight loss. Correct! LESSON Management of Care or Coordinated Care Advocacy COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS advocacyteachingsaftey

The nurse is completing a health history of a client diagnosed with Alzheimer's disease. The nurse reviews a list of the client's medications and supplements routinely taken at home. Which treatment should be a cause for concern by the nurse? Donepezil Omega-3 fatty acids Ginkgo biloba Coconut oil

d/ Donepezil, rivastigmine, and galantamine are most commonly used in the treatment of Alzheimer's disease (AD). Complementary and integrative therapies use to treat AD include Gingko biloba (a plant extract) and omega-3 fatty acids. While there isn't sufficient research to support using these treatments, continued use won't necessarily be harmful. However, coconut oil, which is a source of caprylic acid, is a concern. While there has been limited research on Katasyn (an experimental drug containing caprylic acid), there is no scientific evidence that coconut oil is safe and effective or prevents cognitive decline. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS Alzheimer'sginkgo bilobaomega-3coconut oil

The nurse smells smoke and notices a small fire in a non-client storage area. The alarm system begins to sound. Which action should the nurse take next? Place a thermal blanket over the fire. Wait for the arrival of the fire department. Back out of the room and close the door. Extinguish the fire using an ABC fire extinguisher.

d; LESSON Safety and Infection Control Emergency Response Plan COURSE RN & PN Review KEYWORDS Firefire safetyfire extinguisher A fire in any health care facility presents great potential for harm. In this situation, there are no clients in imminent danger and the alarm has been activated. The nurse should attempt to extinguish the fire using an appropriate fire extinguisher. The ABC type is appropriate for all types of fires. Backing out of the room and closing the door may allow the fire to burn out of control. Using a blanket is not appropriate at this time. If the fire is manageable, the nurse should attempt to extinguish it and not wait for the fire department to arrive.

The emergency room nurse is evaluating a client with injuries sustained from domestic partner violence. The nurse should understand that after an acute battering incident, the batterer is most likely to respond to the client's injuries by taking which action? Be very remorseful and enter a rehabilitation program. Seek medical help for the victim's injuries. Contact a close friend and ask for help with the incident. Minimize the episode with an underestimation of the injuries. (1 attempt remaining)

d; Many batterers lack an understanding of the effects of their behavior on the person who was battered. Batterers use excessive minimization. They typically are in a state of denial about the situation, their behaviors or their intent. The other actions are not typically seen from the batterer in a domestic/partner violence incident. LESSON Psychosocial Integrity Abuse, Neglect COURSE RN Review KEYWORDS batterpartnerviolent

A client diagnosed with an acute anterior myocardial infarction is receiving nitroglycerin and heparin intravenously. The client still reports chest pain. Which action should the nurse take? a.Auscultate heart and lung sounds. b. Review and compare serial ECG strips. c. Administer antidysrhythmic drugs as indicated. d. Administer intravenous morphine sulfate as ordered.

d; Nitrates are useful for pain control due to their coronary vasodilator effects. The nurse will titrate the intravenous nitroglycerin infusion for chest pain according to standing orders, but if chest pain is unrelieved by the nitroglycerin infusion, the nurse can administer morphine intravenously (IM injections are avoided because they can alter the CPK). Morphine not only relieves pain and reduces anxiety, but also dilates the blood vessels. After giving the pain reliever, the nurse can do a more in-depth assessment of the client (auscultate heart and lung sounds, review ECGs, vital signs and labs). Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS emergencymyocardial infarctionpainprioritization

A home health nurse is teaching the parents of a pediatric client with acute spasmodic croup. Which interventions are most important to include? Antihistamines to decrease allergic responses Antibiotic therapy for 10 to 14 days Sedation as needed to prevent exhaustion Humidified air with an increase in oral fluids

d; The most important aspects of home care for a child diagnosed with acute spasmodic croup are humidified air and increased oral fluids. Humidified air helps reduce vocal cord swelling. Taking the child out into the cool night air for 10 to 15 minutes can also reduce nighttime symptoms. Adequate systemic hydration aids mucociliary clearance by keeping secretions thin and easy to remove with minimal coughing effort. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS childcroupteachhome