Priority Questions

Dilantin- WbC

Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication. T

26.Place the steps in correct order for performing colostomy care.

a. Fitthepouchsnuglyaroundthestoma. b. Assessthecolorandappearanceofthestoma. c. Wash the skin with mild soap and rinse with warm water. d. Applyaskinbarriertoprotecttheperistomalskin. e. Drytheskincarefully. f. Don a pair of clean gloves. _____, _____, _____, _____, _____, _____ 26.ANSWERS F, B, C, E, D & A

16.You assess a 24-year-old with RA who is considering using methotrexate (Rheumatrex) for treatment. Which information is most important to communicate with the physician?

a. Thepatienthasmanyconcernsaboutthesafetyofthedrug. b. Thepatienthasbeentryingtogetpregnant. c. The patient takes a daily multivitamin tablet. d. Thepatientsaysthatshehastakenmethotrexateinthepast.

foods rich in calcium

Clients with low calcium levels should be encouraged to consume dairy products, seafood, nuts, broccoli, and spinach. Which are all good sources of dietary calcium.

Alteplase

Clot buster Alteplase is a clot buster. With patient who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug like alteplase can worsen the bleeding.

9. For a patient on the chemotherapeutic drug vincristine (Oncovin), which of the following side effects should be reported to the physician?

a. Fatigue b. Nauseaandvomiting c. Paresthesia d. Anorexia Paresthesia is a side effect associated with some chemotherapy drugs such as vincristine (Oncovin). Ideally, chemotherapy drugs should be given by nurses who have received additional training in how to safely prepare and deliver the drugs and protect themselves from exposure. The other options are a concern but the general principles of drug administration apply.

tumor

T (tumor) 0-4 signifies tumors increasing size. N (regional lymph nodes) 0-3 signifies increasing involvement of lymph nodes. M (metastasis) 0 signifies no metastasis and 1 signifies distal metastasis.

Antiviral Medications

Taking antiretroviral medications such as indinavir on a rigid time schedule is essential for effective treatment of HIV infection and to avoid development of drug resistant-strains of the virus.

Virul Lode Testing- Effectivness of Antivirul Medications

Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the ART is effective.

o2 rate greater than 4

When an oxygen flow rate is greater than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system.

Trach care precautions

When performing tracheostomy care, a sterile field is set up and sterile technique is used

women preventing UTIs

Women should avoid irritating substances such as bubble bath, nylon underwear, and scented toilet tissue to prevent urinary tract infections.

9. The (Ditropan) 5 mg by mouth three times a day after discharge. Which information would you be sure to teach this patient prior to discharge?

a. "Drinkfluidsorusehardcandywhenyouexperienceadrymouth." b. "Be sure to notify your physician if you experience a heart rate of less than 60 per minute." c. "If necessary, your physician can increase your dose up to 40 mg per day." d. "Youshouldtakethismedicationwithmealstoavoidstomachulcers." ANSWER A - Oxybutynin chloride (Ditropan) is an anticholinergic agent, which often causes an extremely dry mouth. The maximum dose is 20 mg per day. This drug can cause tachycardia as a side effect, but does not cause bradycardia. Oxybutynin chloride should be taken between meals because food interferes with absorption of the drug.

20.The nursing assistant reports to you that the patient with ARF has had a urine output of 350 mL for the past 24 hours after receiving furosemide 40 mg IV push. The nursing assistant asks you how this can happen. What is your best response?

a. "During the oliguric phase of acute renal failure, patients often do not respond well to either fluid challenges or diuretics." b. 'There must be some sort of error. Someone must have failed to record the urine output." c. "The patient with acute renal failure retains sodium and water, counteracting the action of the furosemide." d. "The gradual accumulation of nitrogenous waste products results in the retention of water and sodium." During the oliguric phase of acute renal failure, patients' urine output is greatly reduced. Fluid boluses and diuretics do not work well. This phase usually lasts from 8 to 15 days.

19.You are reviewing your client's understanding of the post-operative stapedectomy instructions that you gave several days ago. Which comment concerns you the most?

a. "I'mgoingtotakeswimminglessonsinacoupleofmonths." b. "Ihavetotakealongoverseasflightinseveralweeks." c. "I can't wait to get back to my regular weightlifting class." d. "Ihavebeencoughingalotwithmymouthopen." 19.ANSWER C - Heavy lifting should be strictly avoided after stapedectomy for at least 3 weeks. Water in the ear and air travel should be avoided for at least 1 week. Coughing and sneezing should be performed with the mouth open to prevent increased pressure.

23.The patient with a diagnosis of ARF had a urine output of 1560 mL for the past 8 hours. The LPN/LVN who is caring for this patient under your supervision asks how a patient with renal failure can have such a large urine output. What is your best response?

a. "The patient's renal failure was due to hypovolemia and we have administered IV fluids to correct the problem." b. "Acute renal failure patients go through a diuretic phase when their kidneys begin to recover and may put out up to 10 L of urine per day." c. "With that much urine output, there must have been a mistake made when the patient was diagnosed." d. "An increase in urine output like this is an indicator that the patient is entering the recovery phase of acute renal failure." Patients with acute renal failure usually go though a diuretic phase. The diuresis can result in an output of up to 10 L/day of dilute urine. During this phase, it is important to monitor for electrolyte and fluid imbalances.

17.The patient has been diagnosed with renal cell carcinoma (adenocarcinoma of the kidney). You are orienting a new nurse to the unit, who asks why this patient is not receiving chemotherapy. What is your best response?

a. "The prognosis for this form of cancer is very poor and we will be providing only comfort measures." b. "Chemotherapy has been shown to have only limited effectiveness against this type of cancer." c. "Research has shown that the most effective means of treating this form of cancer is with radiation therapy." d. "Radiofrequency ablation is a minimally invasive procedure that is the way to treat renal cell carcinoma." Chemotherapy has limited effectiveness against renal cell carcinoma.

6. A 67-year-old client with incomplete bladder emptying caused by BPH has a new prescription for tamsulosin (Flomax). Which statement about tamsulosin is most important to include when teaching this client?

a. "Thismedicationwillimproveyoursymptomsbyshrinkingtheprostate." b. "The force of your urinary stream will probably increase." c. "Your blood pressure will decrease as a result of taking this medication." d. "Youshouldavoidmakingsuddenchangesinposition." Answer D - Because tamsulosin blocks alpha receptors in the peripheral arterial system, the most significant side effects are orthostatic hypotension and dizziness. To avoid falls, it is important that the client change position slowly. The other information is also accurate and may be included in client teaching, but is not as important as decreasing the risk for falls

6. You are supervising a new graduate RN who is orienting to the unit. The new RN asks why the patient with uncomplicated cystitis is being discharged with orders for ciprofloxacin 250 mg twice a day for only 3 days. What is your best response?

a. "Weshouldcheckwiththephysicianasthepatientshouldtakethisdrug for 10 to 14 days." b. "A 3-day course of ciprofloxacin is not the appropriate treatment for a patient with uncomplicated cystitis." c. "Research has shown that with a 3-day course of ciprofloxacin, there is increased patient adherence to the plan of care." ANSWER C - For uncomplicated cystitis, a 3-day course of antibiotics is an effective treatment, and research has shown that patients are more complaint with shorter antibiotic courses. Seven-day courses of antibiotics are appropriate for complicated cystitis, and 10-14 day courses are prescribed for uncomplicated pyelonephritis.

12.You are supervising an orienting nurse who is discharging a patient admitted with kidney stones post lithotripsy. Which statement by the nurse requires that you intervene?

a. "You should finish all of your antibiotics to make sure that you don't get a urinary tract infection." b. "Remember to drink at least 3 liters of fluids every day to prevent another stone from forming." c. "Report any signs of bruising to your physician immediately as this indicates bleeding." d. "You can return to work in 2 days to 6 weeks, depending on what your physician prescribes." 12.ANSWER C - Bruising is to be expected after lithotripsy. It may be quite extensive and take several weeks to resolve. All of the other statements are accurate for the patient after lithotripsy.

10.After arriving for your shift in the emergency department (ED), you receive change-of-shift report about all of these clients. Which one do you need to assess first?

a. A 19-year-old client with scrotal swelling and severe pain that has not decreased with elevation of the scrotum b. A 25-year-old client who has a painless indurated lesion on the glans penis c. A 44-year-old client with an elevated temperature, chills, and back pain associated with recurrent prostatitis d. A77-year-oldclientwithabdominalpainandacutebladderdistention 10.Answer A - This client has symptoms of testicular torsion, an emergency which needs immediate assessment and intervention, since it can lead to testicular ischemia and necrosis within a few hours

21.Persons at risk are the greater target population for cancer screening programs. Which asymptomatic patient(s) needs extra encouragement to participate in cancer screening? (Choose all that apply).

a. A 19-year-old white-American female who is sexually inactive for a Pap smear b. A35-year-oldwhite-Americanfemaleforanannualmammogram c. A 45-year-old African-American male for an annual prostate-specific antigen d. A49year-oldAfrican-Americanmaleforanannualfecaloccultbloodtest 21.ANSWER A, C - After age 18, females should annual Pap smears, regardless of sexual activity. African-American males should begin prostate-specific antigen testing at age 45. Annual mammograms are recommended for women over the age of 40. Annual fecal occult blood testing is recommended starting at age 50.

15.You have just received change-of-shift report about your assigned clients. In what order will you assess these clients?

a. A 22-year-old client who has questions about how to care for the drains placed in her breast reconstruction incision b. An anxious 44-year-old client who is scheduled to be discharged today after having a total vaginal hysterectomy c. A 69-year-old client who is complaining of level 5 pain (0 - 10 scale) after having a perineal prostatectomy 2 days ago d. A usually oriented 78-year-old client who has new-onset confusion after having a bilateral orchiectomy the previous day _____, _____, _____, _____ 15.Answer D, C, B, A -

7. You are acting as preceptor for a new graduate RN during her second week of orientation. For which client(s) would you assign the nursing care to the new RN under your supervision? (Choose all that apply.)

a. A 38-year-old client with moderate persistent asthma awaiting discharge. b. A63-year-oldclientwithtracheostomyneedingtrachcareeveryshift c. A 56-year-old client with lung cancer just returned from left lower tracheostomy d. A49-year-oldclientnewdiagnosisofesophagealcancer

3. Which client(s) would be best to assign to an experienced nurse in an ambulatory eye surgery center? (Choose all that apply.)

a. Aclientwhoneedspost-operativeinstructionsforcataractsurgery b. Aclientwhoneedsaneye-padandametalshieldapplied c. A client who needs home health referral for dressing changes and eye drops d. Aclientwhoneedsteachingaboutself-administrationofeyedrops ANSWERS A and C - Post-operative instructions and home health referrals should be done by an experienced nurse who can give specific details and specialized information for follow-up eye care. The principles of eye pad and shield application and of teaching the administration of eye drops are basic procedures that should be familiar to all nurses.

22.Which client(s) are appropriate to assign to the LPN/LVN, who will function under the supervision of the RN or team leader? (Choose all that apply.)

a. Aclientwhoneedspre-opteachingforuseofaPCApump b. A client with a leg cast who needs neurologic checks and PRN hydrocodone c. A client post-op toe amputation with diabetic neuropathic pain d. Aclientwithterminalcancerandseverepainwhoisrefusingmedication 22.ANSWER B, C - The clients with the cast and the toe amputation are stable clients and need ongoing assessment and pain management that are within the scope of practice for an LPN/LVN under the supervision of an RN. The RN should take responsibility for pre-operative teaching, and the terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication.

11.The patient has urolithiasis and is passing the stones into the lower urinary tract. What is the priority nursing diagnosis for the patient at this time?

a. AcutePain b. RiskforInfection c. Risk for Injury d. FearofRecurrentStones 11.ANSWER A - When patients with urolithiasis pass stones, the stones can cause excruciating pain for up to 24-36 hours

11.A 79-year-old client who has just returned to the surgical unit following a TURP complains of acute abdominal pain caused by bladder spasms. All of these orders are listed on the client's chart. In what order will you accomplish these actions?

a. Administer acetaminophen/oxycodone 325 mg/5 mg (Percocet) 2 tablets. b. Irrigateretentioncatheterwith30-50mLofsterilenormalsaline. c. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours. d. Encourageclient'soralfluidintaketoatleast2500-3000mLdaily. 11.Answer B, A, C, D - Bladder spasms are usually caused by the presence of clots obstructing the catheter, so irrigation should be the first action taken. Administration of analgesics may help to reduce spasm. Administration of a bolus of IV fluids is commonly used in the immediate post-operative period to help maintain fluid intake and increase urinary flow. Oral fluid intake should be encouraged once you are sure that the client is not nauseated and has adequate bowel tones.

3. A client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is not responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of pain?

a. Amitriptyline(Elavil) b. Corticosteroids c. Methylphenidate (Ritalin) d. Lorazepam(Ativan)

14.A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal?

a. Fever b. Nausea c. Diaphoresis d. Abdominalcramps Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours.

13.You have just received the morning report from the night shift nurses. List the order of priority for assessing and caring for these patients.

a. Apatientwhodevelopedtumorlysissyndromearound5:00AM b. A patient with frequent reports of break-through pain over the past 24 hours c. A patient scheduled for exploratory laparotomy this morning d. Apatientwithanticipatorynauseaandvomitingforthepast24hours _____, _____, _____, _____ A, C, B, D - Tumor lysis syndrome is an emergency of electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed and prepared for surgery. A patient with breakthrough pain needs assessment and the physician may need to be contacted for a change of dose or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and antiemetics.

4. You are doing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care pan in the order each should be accomplished.

a. Applysilversulfadiazine(Silvadene)ointment. b. Obtainaerobicandanaerobicwoundcultures. c. Administer morphine sulfate 10 mg IV. d. Debridewoundofescharusinggauzesponges. _____, _____, _____, _____ ANSWER C, D, B, A -

9. You interventions for the patient with CTS. Which action requires that you intervene immediately?

a. Arrangethepatient'slunchtrayandcutthemeat. b. Providewarmwaterandassistthepatientwithabath. c. Replace the patient's splint in hyperextension position. d. Remindthepatientnottoliftveryheavyobjects. ANSWER C - When a patient with CTS has a splint used for immobilization of the wrist, it is placed either in the neutral position or in slight extension

8. You are preparing to give an enteral feeding through a nasogastric tube. Place the steps in the correct order.

a. Assessforbowelsounds. b. AuscultatetubeplacementandcheckpH. c. Flush the tube with water. d. Reflushthetubewithwater. e. Administerthefeeding. f. Check for residual volume. _____, _____, _____, _____, _____, _____ ANSWERS A, B, F, C, E & D -

15.You are preparing to insert an intermittent catheter into a male patient to assess for post-void residual urine. Place the following steps I correct order.

a. Assistpatienttothebathroomandaskhimtoattempttovoid. b. Retracttheforeskinandholdthepenisat60to90-degreeangle. c. Open the catheterization kit and put on sterile gloves. d. Lubricatethecatheterandinsertitthroughthemeatusofthepenis. e. Positionthepatientsupineinbedorwithheadslightlyelevated. f. Drain all urine present in the bladder into the container. g. Cleansetheglanspenisstartingatthemeatusandworkingoutward. h. Remove the catheter, clean the penis, and measure the amount of urine returned. _____, _____, _____, _____, _____, _____, _____, _____ 15.ANSWER A, E, C, B, G, D, F, H -

1. The experienced LPN/LVN, under the supervision of the team leader RN, is providing nursing care for a client with a respiratory problem. Which of the following actions are appropriate to the scope of practice for an experienced LPN/LVN? (Choose all that apply.)

a. Auscultatebreathsounds b. AdministerMDI(multidose)inhaler)medications c. Complete in-depth admission assessment d. Checkoxygensaturationusingpulseoximetry e. Initiatenursingcareplan f. Evaluate client's technique for using MDIs A, B, D - The experienced LPN/LVN is capable of gathering data and observations including breath sounds and pulse oximetry. Administering medications, such as MDIs, is within the scope of practice for the LPN/LVN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a client's abilities require additional education and skills.

10.You are working in the ED caring for a patient who was just admitted with left anterior chest pain, possible unstable angina or myocardial infarction. Which nursing activity will you accomplish first?

a. Auscultateheartsounds. b. Administersublingualnitroglycerin. c. Insert an IV catheter. d. Obtainabriefpatienthealthhistory. The priority for a patient with unstable angina or myocardial infarction is treatment of pain.

2. You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? (Choose all that apply).

a. Avoidfoodsthatcontaintyramine,suchasalcoholandagedcheese. b. AvoiddrugssuchasTagamet,nitroglycerinandNifedipine. c. Abortive therapy is aimed at eliminating the pain during the aura. d. Apotentialsideeffectofmedicationsisreboundheadache. e. Complementarytherapiessuchasrelaxationmaybehelpful. f. Continue taking estrogen as prescribed by your physician.

17.You are working in the PACU caring for a 32-year-old client who has just arrived after having a dilation and curettage (D & C) to evaluate infertility. Which assessment data are of most concern?

a. Bloodpressure162/90 b. Perinealpadsaturatedafterfirst30minutes c. O2 saturation 91% - 95% d. Sharp,continuouslevel8/10abdominalpain 17.Answer D - Cramping or aching abdominal pain is common after D & c; however, sharp, continuous pain may indicate uterine perforation, which would requires immediate notification of the physician. The other data indicate a need for ongoing assessment or interventions. Transient blood pressure elevation may occur due to the stress response after surgery. Bleeding following the procedure is expected, but should decrease over the first 2 hours. And while the oxygen saturation is not at an unsafe level, interventions to improve the saturation should be accomplished

17.You assess a patient who has just returned to the recovery area after having a coronary arteriogram. Which of these data is of most concern?

a. Bloodpressureis144/78. b. Pedalpulsesarepalpableat+1. c. Left groin has a 3-cm ecchymotic area. d. Apicalpulseis122andregular. The most common complication after coronary arteriogram is hemorrhage and the earliest indication of hemorrhage is an increase in heart rate.

20.When assessing a client with cervical cancer who had a total abdominal hysterectomy yesterday, you obtain the following data. Which information has the most immediate implications for planning the client's care?

a. Finecracklesareaudibleatthelungbases. b. Client'srightcalfisswollenandtender. c. Client is using the PCA every 15 minutes. d. Urineinthecollectionbagisamberandclear. 20.Answer B - Right calf swelling indicates the possible presence of deep vein thrombosis. This will change the plan of care, since the client should be placed on bedrest, while the usual plan is to ambulate the client as soon as possible after surgery.

26.Three days after having a pelvic exenteration procedure, a client suddenly complains of a "giving" sensation along her abdominal incision. You check under the dressing and find that the wound edges are open and loops of intestines are protruding. Which action should you take first?

a. Call the client's surgeon and report that wound evisceration has occurred. b. Coverthewoundwithsaline-soakeddressings. c. Don sterile gloves and gently replace the intestine back in the wound. d. Checktheclient'sbloodpressureandheartrate 26.Answer D - Wound dehiscence or evisceration may cause shock, so the first action should be to assess the client's blood pressure and heart rate. The next action should be to ensure that the abdominal contents remain moist by covering the wound and loops of intestine with dressings soaked with sterile normal saline.

26.You are ambulating a cardiac surgery patient who has telemetry cardiac monitoring when another staff member tells you that thepatient has developed a supraventricular tachycardia with a rate of 146 beats per minute. In which order will you take these actions?

a. Callthepatient'sphysician. b. Havethepatientsitdown. c. Check the patient's blood pressure. d. Administeroxygenbynasalcannula.

11.As charge nurse you assign the nursing care of a patient who has just returned form open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which of the following instructions will you provide for the LPN/LVN? (Choose all that apply.)

a. Checkthepatient'svitalsignsevery15minutesinthefirsthour. b. Checkthedressingfordrainageandtightness. c. Elevate the patient's hand above the heart. d. Thepatientwillnolongerneedpainmedication. e. Checktheneurovascularstatusofthefingerseveryhour. 11.ANSWERS A, B, C & E - Post-operatively, patients with OCTR surgery have pain and numbness. Their discomfort may last for weeks to months. All of the other directions are appropriate to the post-operative care for this patient. It is important or monitor for drainage, tightness, and neurovascular changes. Raising the hand/wrist above the heart reduces the swelling form surgery, and this is often done for several days

7. While working on the surgical unit, you are assigned to care for a client who has just returned to the surgical unit after a TURP. You assess the client and obtain these data. Which finding will require the most immediate action?

a. Client'sbloodpressurereadingis153/88. b. Client's catheter is draining bright red blood. c. Client is not wearing anti-embolism hose. d. Clientiscomplainingofabdominalcramping. Answer B - Hemorrhage is a major complication after TURP and should be reported to the surgeon immediately.

Patients with acute renal failure usually go though a diuretic phase. The diuresis can result in an output of up to 10 L/day of dilute urine. During this phase, it is important to monitor for electrolyte and fluid imbalances.

a. Clienttellsyouthathealwayshastroublestartinghisurinarystream. b. Client'schartshowsanelevatedprostate-specificantigen(PSA)level. c. Client is restless and his bladder is palpable above the symphysis pubis. d. Client says he has not voided since having a glass of juice 4 hours ago. Answer C - A palpable bladder and restlessness are indicators of bladder distention, which would require action (such as insertion of a catheter) in order to empty the bladder.

17.The LPN/LVN, under your supervision, is providing nursing care for a patient with GBS. What observation would you instruct the LPN/LVN to report immediately?

a. Complaintsofnumbnessandtingling b. Facialweaknessanddifficultyspeaking c. Rapid heart rate of 102 beats per minute d. Shallowrespirationsanddecreasedbreathsounds The priority interventions for the patient with GBS are aimed at maintaining adequate respiratory function.

17.You are caring for an obese post-operative client who underwent surgery for bowel resection. As the client is moving in bed, he states, "Something popped open." Upon examination you note wound evisceration. Place the following steps in order for handling this complication.

a. Covertheintestinewithsterilemoistenedgauze b. Staycalmandstaywiththeclient. c. Monitor the vital signs especially BP and pulse. d. Haveacolleaguegathersuppliesandcontactthephysician. e. Puttheclientintosemi-Fowler'swithkneesslightlyflexed. f. Prepare the client for surgery as ordered. _____, _____, _____, _____, _____, _____ 17.ANSWERS B, D, E, A, C & F

17.An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone (Deltasone) 20 mg daily for 4 hours. Which of these medical orders should you question?

a. Discontinueprednisoneaftertoday'sdose. b. Administerfirstdoseofvaricellavaccine. c. Check patient's C-reactive protein (CRP). d. GiveIbuprofen(Advil)800mgevery6hours. The varicella (chickenpox) vaccine is a live-virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone.

25.You are administering vancomycin (Vancocin) 500 mg IV to a client with PID when you notice that the client's neck and face are becoming flushed. Which action should you take next?

a. Discontinuethevancomycin. b. Slowtherateofthemedicationinfusion. c. Obtain an order for an antihistamine. d. Checktheclient'stemperature. 25.Answer B - "Red man syndrome" occurs when vancomycin is infused too quickly. Because the client needs the medication to treat PID, the vancomycin should not be discontinued. Antihistamines may help decrease the flushing but vancomycin should be administered over at least 60 minutes

14.A client admitted to the ED complains of itching of the trunk and groin. You note the presence of multiple reddened wheals on the chest, back, and groin. Which question is most appropriate to ask next?

a. Doyouhaveafamilyhistoryofeczema? b. Haveyoubeenusingsunscreenregularly? c. How do you usually manage stress? d. Areyoutakinganynewmedications? 14.ANSWER D - Wheals are frequently associated with allergic reactions, so asking about exposure to new medications is the most appropriate question for this client.

22.The client with acute respiratory distress syndrome (ARDS) is receiving oxygen by non-rebreather mask, but arterial blood gases still show poor oxygenation. As the nurse responsible for this client's care, you anticipate which physician's orders?

a. Endotracheal intubation and mechanical ventilation b. ImmediateapplicationofCPAPtoclient'snoseandmouth c. Intravenous furosemide (Lasix) 100 mg IV push stat d. CallaCODEforrespiratoryarrest. A non-rebreather mask can deliver up to 95% oxygen. When the client's oxygenation status does not respond to oxygenation at this high a concentration, this is refractory hypoxemia. Usually at this stage, the client isworking very hard to breathe and may go into respiratory arrest unless intubation and mechanical ventilation are provided to decrease the client's work of breathing.

12.You are teaching the client and family how to do colostomy irrigation. Place the information in the correct order.

a. Hangthecontainerataboutshoulderheight. b. Allowthesolutiontoflowslowlyandsteadilyfor5-10minutes. c. Put 500 - 100 mL of lukewarm water in the container. d. Allow30-45minutesforevacuation. e. Lubricatethestomaconeandgentlyinsertthetubingtipintothestoma. f. Clean, rinse, and dry skin, and apply a new drainage pouch. _____, _____, _____, _____, _____, _____ 12.ANSWERS C, A, G, E, B, D, F - Prepare the warm water (cold water can cause cramping) and hang the container at shoulder height (hanging the container too high or too low will alter the rate of flow). Put on a pair of clean gloves to protect your hands from colostomy secretions. Lubricating the stoma and gently inserting will allow the water t flow into the stoma. A slow and steady flow prevents cramps and spillage. Adequate time allows for complete evacuation. Careful attention to the skin prevents breakdown.

16.While transferring a dirty laundry bag, a nursing assistant sustains a puncture would to the finger from a contaminated needle. The unit has several clients with hepatitis and AIDS; the source is unknown. Prioritize the instructions that you, as charge nurse, should give to the assistant.

a. Havebloodtest(s)drawnprotocol. b. Completeandfileanincidentreport. c. Perform a thorough aseptic Handwashing. d. Reporttotheoccupationalhealthnurse. e. Followupforresultsandcounseling. f. Begin prophylactic drug therapy. _____, _____, _____, _____, _____, _____ 16.ANSWERS C, D, B, A, F & E -

12.Before giving a beta-adrenergic blocker glaucoma agent, you would notify the physician if the client discloses a history of what condition?

a. Hypertension b. Tachycardia c. Rheumatoid arthritis d. Bradycardia ANSWER D - All beta-adrenergic blockers are contraindicated in bradycardia. Alpha-adrenergic agents can cause tachycardia and hypertension. Carbonic anhydrase inhibitors should not be given to clients with rheumatoid arthritis who are taking high doses of aspirin

28.When assessing a 22-year-old client who was admitted 3 days ago with multiple rib fractures and pulmonary contusions after a motor vehicle accident, you find that the client has shallow respirations at a rate of 38. He says he feels "dizzy and scared." His oxygen saturation is 90% with the oxygen at 6 L/minute per nasal cannula. Which action is most appropriate?

a. Increases the flow rate on the oxygen to 10 L/minute and reassess the client after about 10 minutes. b. Assist the client to se the incentive spirometer and splint his chest using a pillow while he coughs. c. Administer the ordered morphine sulfate to the client to decrease his anxiety and reduce the hyperventilation. d. Place the client on a non-breather mask at 95%-100% F102 and call the physician to discuss the client's status. The client's history and symptoms suggest that he may be developing ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an FiO2 of 40%. This is achieved with the O2 flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful.

22.A 59-year-old woman who had a total abdominal hysterectomy and bilateral salpingo-oophorectomy 3 days ago is complaining of flank pain and a burning sensation with urination. Her total urine output during the previous 8 hours was 210 mL. The client's temperature is 101.30 F. You call the physician to report this information and receive these orders. Which will you implement first?

a. InsertstraightcatheterPRNforoutputlessthan300mL/8hours. b. Administeracetaminophen(Tylenol)650mgorally. c. Send urine specimen to laboratory for culture and sensitivity. d. Administerceftizoxime(Cefizox)1gIVevery12hours. 22.Answer A - The client has symptoms of a urinary tract infection. Inserting a straight catheter will enable you to obtain an uncontaminated urine specimen for culture and susceptibility testing before the antibiotic is started.

9. The day after having a radical prostatectomy, your client has many blood clots in the urinary catheter and states he has frequent bladder spasms. You notice occasional urine leakage around the catheter at the urinary meatus. The client says that his right calf is sore and complains that he feels short of breath. Which action will you take first?

a. Irrigatethecatheterwith50mLofsterilesaline. b. Administeroxybutynin(Ditropan)5mgorally. c. Dorsiflex the foot to check for Homan's sign. d. Obtainanoxygensaturationusingpulseoximetry. Answer D - It is important to assess oxygenation because the client's shortness of breath may indicate a pulmonary embolus, a serious complication of TURP. Dorsiflexion of the foot should not be done if a deep vein thrombosis is suspected, since this may dislodge thrombus. The other activities are appropriate, but are not as high a priority as ensuring that oxygenation is adequate

16.At 10:00 AM, a patient receives a new order for transesophageal echocardiography (TEE) ass soon as possible. Which action will you take first?

a. MakethepatientNPO. b. Teachthepatientabouttheprocedure. c. Start an intravenous line. d. Attachthepatienttoacardiacmonitor

4. The disease progress of cancers, such as cervical or Hodgkin's, can be classified according to a clinical staging system. Place the description of stages 0-IV in the correct order.

a. Metastasis b. Limitedlocalspread c. Cancer in situ d. Tumorlimitedtotissueoforigin e. Extensivelocalandregionalspread _____, _____, _____, _____, _____ ANSWER C, D, B, E, A - This classification system is based on the extent of the disease rather than the histological changes, Stage 0: cancer in situ, stage I: tumor limited to tissue of origin, stage II: limited local spread, stage III: extensive local and regional spread, stage IV: metastasis.

18.When developing the plan of care for a home health client who has been discharged after a radical prostatectomy, which activities will you delegate to the home health aide? (Choose all that apply.)

a. Monitortheclientforsymptomsofurinarytractinfection. b. Helptheclienttoconnectthecathetertothelegbag. c. Assess the client's incision for appropriate wound healing. d. Assisttheclienttoambulateforincreasingdistances. e. Helptheclientshoweratleasteveryotherday. 18.Answer B, D, E - Assisting with catheter care, ambulation, and hygiene is included in home health aide education and would be expected activities for this staff member.

23.An 86-year-old woman had an anterior and posterior colporrhaphy (A and P repair) several days ago. The client has been unwilling to ambulate or cough effectively. Her retention catheter was discontinued 8 hours ago. Which information obtained during your assessment has the most immediate implications for her care?

a. Oral temperature is 100.70 F. b. Abdomenisfirmandtendertopalpationabovethesymphysispubis. c. Breath sounds are decreased with fine crackles audible at both bases. d. Apicalpulseis86andslightlyirregular. 23.Answer B - After an A and P repair, it is essential that the bladder be empty to avoid putting pressure on the suture lines. The abdominal firmness and tenderness indicate that the client's bladder is distended

10.The patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What key point will you be sure to teach the patient?

a. Painandnumbnesswillbeexperiencedforseveraldaystoweeks. b. Immediatelyaftersurgery,thepatientwillnolongerneedassistance. c. After surgery, the dressing will be large with dots of drainage d. Aftersurgery,thepainandparesthesiawillnolongerbepresent. 10.ANSWER A - Post-operative pain and numbness occur for a longer period of time with endoscopic carpal tunnel release than with the open procedure. Patients often need assistance post-operatively, even after they are discharged. The dressing from the endoscopic procedure is usually very small and there should not be a lot of drainage

16.Which physical assessment finding should be reported to the physician?

a. Pearlygrayorpinktympanicmembrane b. Dense,whitishringatthecircumferenceofthetympanum c. Bulging red or blue tympanic membrane d. Aconeoflightattheinnermostpartofthetympanum 16.ANSWER C - A bulging red or blue tympanic membrane is a possible sign of otitis media or perforation.

5. You are supervising an RN who has pulled from the medical-surgical floor to the emergency department (ED). The nurse is providing care for a client admitted with anterior epistaxis (nosebleed). Which of these directions will you clearly provide to the RN? (Choose all that apply.)

a. Positiontheclientsupineandturnedonhisside. b. Applydirectlateralpressuretothenosefor5minutes. c. Maintain universal body substance precautions. d. Applyiceorcoolcompressestothenose. e. Instructtheclientnottoblowthenoseforseveralhours. B, C, D, E - The correct position for a client with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and prevent possible aspiration

25.A client is admitted through the emergency department for a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Choose all that apply.)

a. Preparationforsurgery b. Bariumenema c. NG tube insertion d. Abdominalx-ray e. IVfluids 25.ANSWERS A, C, D & E - Strangulated intestinal obstruction is a surgical emergency. NG tube is for decompression of the intestine. Abdominal x-ray is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and delivery of medication. Barium enema is not ordered if perforation is suspected.

9. The experienced LPN/LVN reports that a client's blood pressure and heart rate have decreased and that when the face is assessed, one side twitches. What action should you take at this time?

a. Reassesstheclient'sbloodpressureandheartrate b. Reviewtheclient'smorningcalciumlevel c. Request a neurologic consult today d. Checktheclient'spapillaryreactiontolight A positive Chvostek's sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The LPN/LVN is experienced and possesses the skills to take accurate vital signs.

20.Place the steps for removal of a foreign body from the ear canal in the correct order.

a. Referfortreatmentofexternalotitis. b. Inspectthetympanicmembranefortrauma. c. Obtain history for type of object. d. Chooseappropriatefluidforirrigationorinstillation. e. Assess,forpossibilityofperforation. _____, _____, _____, _____, _____ 20.ANSWERS C, E, D, B & A - The type of foreign body (e.g. insect, bean, bead) will determine the next steps. If there is a live insect, instill oil. Vegetable or insect matter will swell if water is used for irrigation. Tightly wedged objects like beads are difficult to flush. If perforation is suspected or if the object is not easily removed, the nurse should not attempt irrigation or instillation. Check for trauma after the object is removed. If trauma occurred, the client should be referred for antibiotics to prevent infection.

3. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for the LPN/LVN being supervised by the nurse? (Choose all that apply.)

a. Remindclienttoavoidcommercialmouthwashes. b. Encourage mouth rinsing with warm saline. c. Assess lips, tongue, and mucous membranes d. Providemouthcareevery2hourswhileclientisawake e. Seekdietaryconsulttoincreasefluidsonmealtrays.

19.You are working in the ED when a client with possible toxic shock syndrome (TSS) is admitted. The physician has given all of these orders. Which one will you implement first?

a. Removeclient'stampon. b. Obtainbloodculturesfromtwosites. c. Give O2 at 6 L/minute. d. Infusenafcillin(Unipen)500mgIV. 19.Answer A - Because the most likely source of the bacteria causing the TSS is the client's tampon, it is essential to remove it first. The other actions should be implemented in the following order: administer oxygen (essential to maximize O2 delivery to tissues), obtain blood cultures (best obtained prior to initiating antibiotic therapy to obtain accurate culture and susceptibility results), and infuse nafcillin (rapid initiation of antibiotic therapy will decrease bacterial release of toxins).

13.You are caring for a client with a nasogastric (NG) tube. Which task can be delegated to the experienced nursing assistant?

a. RemovetheNGtubeperphysicianorder. b. Securethetapeiftheclientaccidentallydislodgesthetube. c. Disconnect the suction to allow ambulation to the toilet. d. Reconnectthesuctionaftertheclienthasambulated. 13.ANSWER C - Disconnecting the tube from suction is an appropriate task to delegate. Suction should be reconnected by the nurse, so that correct pressure is checked. If the nursing assistant is permitted to reconnect the tube, the RN is still responsible for checking that the pressure setting is correct. During removal of the tube, there is a potential for aspiration, so the nurse should perform this task. If the tube is dislodged, the nurse should recheck placement before it is secured

3. You patient with Paget's disease. Which finding indicates that the physician should be notified?

a. Thepatienthasbowingofbothlegsandthekneesareasymmetric. b. Thebaseofthepatient'sskullisinvaginated(platybasia). c. The patient is only 5 feet tall and weighs 120 pounds. d. Thepatient'sskullissoft,thick,andlargerthannormal. ANSWER B - Platybasia (basilar skull invagination) causes brain stem manifestations that threaten life. Patients with Paget's disease are usually short and often have bowing of the long bones that results in asymmetric knees or elbow deformities. Their skull is typically soft, thick and enlarged.

1. You give an intradermal injection of allergen to a patient who is undergoing skin testing for allergies. A few minutes later, the patient complains about feeling anxious, short of breath, and dizzy. You notice that the patient has reddened blotches on the face and arms. All of these therapies are available on your emergency cart. Which action should you take first?

a. Startoxygenat4L/minusinganasalcannula. b. ObtainIVaccesswithalarge-boreIVcatheter. c. Administer epinephrine (Adrenalin) 0.3 mL subcutaneously d. Givealbuterol(Proventil)withanebulizer Epinephrine given rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but generally is administered using a non-rebreather mask at 90%-100%

14.In monitoring patients who are at risk for spinal cord compression related to tumor growth, what is the most likely early manifestation?

a. Sudden-onsetbackpain b. Motorloss c. Constipation d. Urinaryhesitancy Back pain is an early sign occurring in 95% of patients. The other symptoms are later

24.While you are orienting a new RN to the medical-surgical unit, you observe the orientee accomplishing all of the following actions while caring for a client with severe pelvic inflammatory disease (PID), who has been admitted to the hospital for administration of IV antibiotics. Which one will require that you intervene most quickly?

a. The new RN tells the client she should avoid using tampons in the future. b. ThenewRNofferstheclientanicepacktodecreaseherabdominalpain. c. The new RN positions the client flat in bed while helping her take a bath. d. The new RN teaches the client she should not have intercourse for 2 months. 24.Answer C - The client should be positioned in a semi-Fowler's position to minimize the risk of abscess development higher in the abdomen. The other actions also require correction, but not as rapidly. Tampon use is not contraindicated after an episode of PID, although some sources recommend not using tampons during the acute infection. Heat application to the abdomen and pelvis is used for pain relief. Intercourse is safe a few weeks after effective treatment for PID

29.During the initial post-operative assessment of a patient who has just transferred to the post-anesthesia care unit (PACU) after repair of an abdominal aortic aneurysm, you obtain all of these data. Which has the most immediate implications for the patient's care?

a. Thearteriallineindicatesabloodpressureof190/112. b. ThemonitorshowssinusrhythmwithfrequentPACs. c. The patient does not respond to verbal stimulation d. Thepatient'surineoutputis100mLofamberurine. Elevated blood pressure in the immediate post-operative period puts stress on the graft rupture and/or hemorrhage, so it is important to lower the blood pressure quickly.

4. You are evaluating an HIV-positive patient who is receiving IV pentamidine (Pentam) as a treatment for Pneumocystis carinii pneumonia. Which information is most important to communicate to the physician?

a. Thebloodpressuredecreasedto104/76duringadministration. b. Thepatientiscomplainingofpainatthesiteoftheinfusion. c. The patient is not taking in an adequate amount of oral fluids. d. Bloodglucoseis55mg/dLafterthemedicationadministration. Pentamidine can cause fatal hypoglycemia, so the low blood glucose level indicates a need for a change in therapy. The low blood pressure suggests that the IV infusion rate may need to be slowed.

19.A patient with systemic lupus erythematosus (SLE) is admitted to the hospital for evaluation and management of acute joint inflammation. Which information obtained in the admission laboratory testing concerns you most?

a. Thebloodureanitrogen(BUN)leveliselevated. b. TheC-reactiveprotein(CRP)levelisincreased. c. The anti-nuclear antibody (ANA) test is positive. d. Thelupuserythematosus(LE)cellprepispositive. A high number of patients with SLE develop nephropathy

19.An outpatient seen in the clinic for follow-up after being diagnosed with contact dermatitis caused by poison ivy has been taking prednisone (Deltasone) 30 mg daily. You evaluate the client for adverse medication effects. Which information is of most concern?

a. Theclient'sbloodglucoseis136mg/dL b. Theclientstates,"Iameatingallthetime." c. The client complains of epigastric pain. d. Theclient'sbloodpressureis148/84 19.ANSWER C - Epigastric pain may indicate that the client is developing peptic ulcers, which require collaborative interventions such as the use of antacids, H2 receptor blockers (e.g., famotidine [Pepcid]), or proton pump inhibitors (e.g., esomeprazole [Nexium]

18.You are caring for a post-operative cholecystectomy client. What should be reported immediately to the physician?

a. Theclientcannotvoid4hourspost-operatively. b. Theclientreportsshoulderpain. c. The client reports severe RUQ tenderness. d. Output does not equal input for the first few hours. 18.ANSWER C - RUQ is a sign of hemorrhage or bile leak. Ability to void should return within 6 hours post-operatively. Right shoulder pain is related to unabsorbed CO2 and will resolve by placing the client in the Sims' position. Output that does not equal input after surgery for the first several hours is expected.

17.You obtain the following data about a client admitted with multiple myeloma. Which information has the most immediate implications for the client's care?

a. Theclientcomplainsofchronicbonepain. b. Theblooduricacidlevelisveryelevated. c. The 240hour urine shows Bence-Jones protein. d. Theclientisunabletoplantarflexthefeet. The lack of plantar flexion may indicate spinal cord compression, which should be evaluated and treated immediately by the physician

5. You obtain all of these assessment data about your client with continuous bladder irrigation (CBI) after a transurethral resection of the prostate (TURP). Which information indicates the most immediate need for nursing intervention?

a. Theclientstateshefeelsacontinuousurgetovoid. b. Thecatheterdrainageislightpinkwithoccasionalclots. c. The catheter is pulled taut and taped to the client's thigh. d. Theclientcomplainsofpainfulbladderspasms. Answer D - The bladder spasms may indicate that blood clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 - 50 mL of saline using a piston syringe.

8. You incontinence. For which patient will a bladder-training program be an appropriate intervention?

a. Thepatientwithfunctionalincontinenceduetomentalstatuschanges b. The patient with stress incontinence due to weakened bladder neck support c. The patient with urge incontinence and abnormal detrusor muscle contractions d. The patient with transient incontinence due to inability to get to toileting facilities ANSWER C - As long as they are alert, aware, and able to resist the urge to urinate, patients with urge incontinence can be taught to control their bladder by starting a schedule for voiding, then increasing the intervals between voids. Patients with functional incontinence related to mental status changes or loss of cognitive function will not be able to follow the bladder-training program. The patient with stress incontinence is better treated with exercises such as pelvic kegal

11.A client is admitted to the intensive car unit (ICU) with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the most immediate implications for the client's care?

a. Thereisnopalpableradialorpedalpulse. b. Theclientcomplainsofchestpain. c. The client's oxygen saturation is 87% d. Thereismottlingofthehandsandfeet. Because the decrease in oxygen saturation will have the greatest immediate effect on all body systems, improvement in oxygenation should be the priority goal of care

3. You are preparing to administer TPN through a central line. Place the steps for administration in the correct order.

a. Useaseptictechniquewhenhandlingtheinjectioncap. b. ThreadtheINtubingthroughaninfusionpump. c. Check the solution for cloudiness or turbidity. d. Connectthetubingtothecentralline. e. Selectthecorrecttubingandfilter. f. Set infusion pump at prescribed rate. _____, _____, _____, _____, _____, _____ ANSWERS C, E, B, A, D & F

17.You are taking histories from several clients who report vertigo. Which client report concerns you the most?

a. Vertigowithhearingloss b. Episodicvertigo c. Vertigo without hearing loss d. "Merry-go-round"vertigo ANSWER C - Vertigo without hearing loss should be further assessed for nonvestibular causes, such as cardiovascular or metabolic.

tetracycline

avoid sun and dairy products milk, decreases obsorbation

12.You are preparing the post-operative CTS patient for discharge. Which information is important to provide to this patient?

b. Handmovementswillberestrictedfor4-6weeksaftersurgery.

fibrinolytic therapy

done to reverse tissue damage after onset of chest pain, but tissue is reversable only if therapy is started within 6 hrs of chest pain. if chest pain lasts more than 6 hrs than damage will be irreversable and fibrinolytic theraphy is useless

post abdominal hysterectoy ambulate asap

dvt changes plan of care

Roferon

given for treatment of Hep C. - Nausea and vomiting are common adverse effects of interferon alfa-2a, but continued vomiting should be reported to the physician because dehydration may occur. The medication may be given by either the subcutaneous or intramuscular route. Flu-like symptoms such as a mild temperature elevation, headache, muscle aches, and anorexia are common after initiating therapy but tend to decrease over time.

urineanalysis & cystoscopy

urineanalysis contains wbc & rbc and cystoscopy diagnosis cystitis

post surgery voiding and bowl sounds

voiding comes back after 6 hrs absent bowl sounds for 24-48 hrs