Reduction of Risk

After a thoracotomy, which interventions will the nurse initiate to reduce the risk of acute respiratory distress? Select all that apply 1. Allow 4 hours of rest between deep breathing and coughing exercises. 2. Splint the incision during deep breathing and coughing exercises. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours. 5. Promote incentive spirometer use several times per hour while awake.

2., & 5. Correct: Splinting helps with the ability to control pain and produce an effective cough. Incentive spirometry encourages deep inspiratory efforts, which are more effective in re-expanding alveoli than forceful expiratory efforts.1. Incorrect: They need to cough more often than every 4 hours. It is the best when this is done every 2 hours.3. Incorrect: It takes longer than a few minutes to liquefy secretions and, if the stomach is full, vomiting may occur which would put the client at risk for aspiration.4. Incorrect: After the surgery, we do not want to percuss and vibrate the incision. Besides being extremely painful, this could potentially disrupt the suture line.

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? You answered this question Incorrectly 1. Abdominal cramping 2. Lethargy 3. Salivation 4. Hypertension 5. Lacrimation 6. Miosis

1., 2., 3., 5., & 6. Correct: The signs of cholinergic crisis include Diarrhea and abdominal cramping, Urination increased, Miosis (pinpoint pupils), Bradycardia, Emesis (nausea and vomiting), Lacrimation, Lethargy, Salivation. Remember this: DUMBELLS as a mnemonic to help you recall these signs and symptoms. 4. Incorrect: Hypertension is not a sign of cholinergic crisis. Muscles get weaker so BP would go down.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider? 1. Vital lung capacity of 900 mL. 2. Breathlessness while talking. 3. Heart rate of 98 beats per minute. 4. Respiratory rate of 24 breaths per minute.

2. Correct: Breathlessness while talking indicates respiratory fatigue. Preparation for intubation needs to be made. 1. Incorrect: If the vital lung capacity drops below 800 mL, mechanical ventilation is warranted. 3. Incorrect: Imminent signs of respiratory failure include a heart rate greater than 120 beats per minute or less than 70 beats per minute. 4. Incorrect: Imminent signs of respiratory failure include a respiratory rate greater than 30 breaths per minute.

Which action by an unlicensed nursing assistant would require the nurse to intervene? You answered this question Correctly 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

4. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The nurse should do this when repositioning is needed. Prior to turning feeding back on, tube placement needs to be verified. 1. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. 2. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 3. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. This is an appropriate and safe action for the unlicensed nursing assistant to do.

T he nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? Exhibit BUN and Creatine labs are bad You answered this question Incorrectly 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular

1. Correct: All lab values are fluctuating, but those most significantly outside of normal range are the BUN and Creatinine levels, reflecting possible renal failure. The nurse would need to immediately notify the primary healthcare provider of possible complications in the client's renal system. The sodium, potassium, and glucose are within normal limits. 2. Incorrect: Several lab readings could relate to the endocrine system, but most specifically are glucose and chloride. Both these electrolytes have fluctuating levels but remain well within normal limits. Therefore, the endocrine system is not the nurse's concern at this time. 3. Incorrect: The carbon dioxide levels listed reflect venous, NOT arterial, blood. Norms for venous carbon dioxide are 23 to 29 mEq/L (milliequivalent units per liter of blood), indicating these results are all within normal levels. Although chloride could also reflect the pulmonary system, there are no irregular results in chloride levels. 4. Incorrect: Many of these elements could affect the cardiovascular system, but most specifically sodium and potassium. At present, these levels are all within normal limits, although the potassium has risen to the upper most levels of normal. If those levels continue to climb, this could become a concern; however, this would not require a call to the primary healthcare provider at this time.

A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? You answered this question Incorrectly 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Trace proteinurea

1. Correct: Facial and upper extremity edema can be a sign of pre-eclampsia, which can endanger both the mother and fetus. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. Even a slight rise in blood pressure may be a sign of preeclampsia. Left untreated, preeclampsia can lead to serious, even fatal, complications. Signs and symptoms of preeclampsia include hypertension and may include: Proteinuria; Severe headaches; Changes in vision; Upper abdominal pain; Nausea or vomiting; Decreased urine output; Thrombocytopenia; Impaired liver function; Shortness of breath; Sudden weight gain, and edema, particularly in face and hands. 2. Incorrect: Indigestion should be assessed for severity, but it is a common symptom in 3rd trimester of pregnancy. 3. Incorrect: Pedal edema should be assessed but is common in 3rd trimester of pregnancy. 4. Incorrect: Trace proteinurea is a benign sign in 3rd trimester of pregnancy.

A client is admitted to the hospital with acute exacerbation of COPD following an upper respiratory infection. His daughter found him at home, confused and in respiratory distress, a day after he developed a cold. He was placed on 4 L/min of oxygen via nasal cannula, but oxygen saturation remains at 89%. Based on this assessment, the nurse suspects that the client has developed which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Correct: Look at all the hints in this stem: COPD, upper respiratory infection, respiratory distress, confused, oxygen saturation of 89%. This client is having lung problems. So you should be able to identify the acid base imbalance as a respiratory problem, right? Yes. Why is it acidosis? Poor gas exchange! Respiratory failure, COPD, and muscular weakness can lead to respiratory acidosis. So you would expect the pH to be < 7.35, and the pCO2 to be > 45. The HCO3 would be normal. 2. Incorrect: Not alkalosis. You would expect respiratory alkalosis with a client who is hyperventilating, such as the hysterical client. The client in this question would be hypoventilating and having poor gas exchange. 3. Incorrect: Not a metabolic related acid/base imbalance. Metabolic problems do not start with a respiratory problem. Metabolic acidosis is seen with diabetic ketoacidosis or starvation. 4. Incorrect: This is not a metabolic problem but a respiratory problem. Metabolic alkalosis may be seen with prolonged vomiting and hypokalemia.

A client with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client's illness, what is most important for the nurse to do? You answered this question Correctly 1. Monitor intake and output and daily weight. 2. Allow for frequent, uninterrupted rest periods. 3. Institute seizure precautions. 4. Protect client from injury that may cause bleeding.

1. Correct: Look at the clues in the stem. Proteinuria and hematuria. When you see proteinuria what do you need to worry about? The kidneys! Protein is a great big molecule. The only way for protein to be seen in the urine is if there are holes in the glomerulus. So the kidneys are being damaged. Thus, the nurse knows that the biggest problem to "worry" about here is renal failure. The best methods for monitoring fluid status and renal status for a client are to monitor I and O and daily weights. (Also, remember that one weight doesn't mean anything. The hematuria indicates that there has already been glomerular damage.) 2. Incorrect: Systemic lupus erythematosus (SLE) is an autoimmune disease. In this disease, the body's immune system mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs. Fatigue is a major symptom so allowing for frequent, uninterrupted rest periods is important for this client but monitoring for renal failure is more acute.3. Incorrect: Seizures are a potential problem with SLE, but the ACTUAL problem depicted in the stem of the question, renal failure, takes priority. Look for the option that relates to the renal system. 4. Incorrect: Hemolytic problems can occur with SLE, but this is not the ACTUAL problem depicted in the stem of the question. The stem is indicating a renal problem, so look for a renal answer.

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

1. Correct: This client has developed signs of cardiogenic shock, one of the complications post CABG. Cardiac output is decreased, so the client needs more oxygen for the circulating blood volume. 2. Incorrect: Lowering the HOB will not help in cardiogenic shock but will actually make it harder for the heart to pump. 3. Incorrect: Poor kidney perfusion is the reason for the decreased UOP. The kidneys are trying to conserve what little volume the body has to maintain vital organ perfusion as long as possible. 4. Incorrect: Rechecking the BP will not help the problem. With the other symptoms, this BP is most likely accurate. This would only delay treatment and would not fix the problem.

The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? You answered this question Incorrectly 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain by assessing Homan's sign.

1., 2., & 3. Correct: Assessment for VTEs is accomplished by measuring the calf and thigh daily, observing swelling, noting unusual warmth of the leg, and asking the client about pain in the calf. Prevention of VTEs include the use of sequential compression devices for bedridden clients. This device helps promote venous return. Positioning the paralyzed leg with each distal joint higher than the proximal joint will prevent dependent edema. 4. Incorrect: A trochanter roll does not prevent VTEs. They are used for the prevention of external hip rotation. 5. Incorrect: Passive range of motion exercises should be done several times a day to promote venous return and muscle tone. Once a day is not adequate. 6. Incorrect: Routinely checking the Homan's sign can actually cause a clot to dislodge. The nurse should not perform this procedure.

What nursing interventions should the nurse initiate in a client who experiences sundowning? Select all that apply 1. Limit naps. 2. Encourage TV watching in the evening. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 5. Leave the lights on at night. 6. Maintain a routine.

1., 3., 4., & 6. Correct: Sundowning occurs when the client becomes more confused and agitated in the late afternoon or evening. Behaviors commonly seen include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Limit naps because too much daytime napping may interfere with sleeping at night. Light therapy may reduce agitation and confusion so open the blinds. Caregivers should remain calm and avoid confrontation. Routine helps the client feel secure. 2. Incorrect: Watching television for this client may lead to restlessness, agitation, and confusion. Calming and more restful activities are better for the evening. 5. Incorrect: Lights should be on during the day but turned off at night (except for low lighting or nightlights so the client can see).

A child diagnosed with AIDS is scheduled for grade school immunizations. Which immunizations are safe for the nurse to administer to the child? You answered this question Incorrectly 1. MMR (measles, mumps, rubella) 2. DTaP (diphtheria, tetanus, pertussis) 3. VAR (varicella) 4. HiB (haemophilus influenza) 5. OPV (oral polio virus)

2 & 4. Correct: Children with AIDS are immunocompromised because of the HIV virus. Vaccines are crucial to provide protection against common childhood diseases. However, only vaccines which contain synthetic or inactivated viral components are acceptable for children with active AIDS. Diphtheria, tetanus, pertussis is inactive and is provided in multiple doses, starting at 2 months of age, with a booster at age 6. Haemophilus influenza is critically important since this flu virus can lead to meningitis, pneumonia or epiglottitis. This vaccine is also administered in multiple injections over a period of months, starting at 2 months, and then yearly throughout life. 1. Incorrect: The combination vaccine of measles, mumps, and rubella contains a live virus. Although research is ongoing, the Center for Disease Control (CDC) suggests while children diagnosed HIV+ may receive the vaccine, those with active AIDS should not be administered this vaccine. 3. Incorrect: Varicella is a live vaccine administered to protect children from chickenpox and the potential for shingles later in life. Though the disease and its dormancy in the body can have serious long-term effects, the vaccine is considered inappropriate for children with AIDS. 5. Incorrect: Oral polio vaccine contains the live polio virus and could be deadly to those with an immunocompromised system. The correct form of polio vaccine for AIDS clients is called IPV, or inactivated polio vaccine, and is given by injection.

A client is to be discharged following a left modified-radical mastectomy. When reviewing ADL's to be completed at home, the nurse anticipates the client will experience the most difficulty doing what tasks? You answered this question Incorrectly 1. Cooking a meal. 2. Shampooing hair. 3. Doing the laundry. 4. Vacuuming carpets. 5. Changing bed linens.

2, 3, & 5. CORRECT: The modified-radical mastectomy is a surgical approach to cancer in which the breast tissue, nipple, and axillary lymph nodes are removed but the chest muscles remain intact. Following surgery, individuals usually experience pain and stiffness when resuming normal daily activities, particularly tasks which require stretching the arm above the head. Shampooing or drying hair would be challenging, as would moving loads of heavy laundry between washer and dryer. Also difficult is changing bed sheets because it involves lifting and stretching across the bed. 1. INCORRECT: The process of cooking food can be modified in such a way the client would not need to extend the surgical arm above the head or in a painful position. 4. INCORRECT: Vacuuming carpet does not require lifting or reaching if the client uses an upright sweeper. This task should not present difficult challenges and can be completed with the non-surgical arm.

Thenurse has been assigned four clients. Who should the nurse see first? 1. A client with diabetes admitted for debridement of a foot ulcer. 2. A client with epilepsy reporting an odd smell in the room. 3. A client with exacerbation of COPD reporting dyspnea. 4. An adolescent client post appendectomy reporting pain.

2. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. 1. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. This client is not the nurse's first priority. 3. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 4. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The nurse has another priority.

A client hospitalized with a deep vein thrombosis (DVT) is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every six hours. What is the bestexplanation for the nurse to provide to the client? 1. "The medicine might make your blood much too thin." 2. "It helps us monitor and adjust the dose to work better." 3. "It is required for anyone getting heparin intravenously." 4. "The test results tell us whether the treatment is working."

2. CORRECT: The nurse has clearly stated the purpose of the frequent venipunctures in a simple and non-technical manner that answers the client's question. 1. INCORRECT: This comment by the nurse does not address the inquiry about every 6 hour bloodwork, plus the phrasing of the statement could easily frighten the client. 3. INCORRECT: This standard response does not answer the client's question about blood work nor does it provide further information about the treatment. 4. INCORRECT: The nurse's statement is vague and does not address the client's question about frequent blood work.

The nurse is instructing a client newly diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed omeprazole. What comment by the client indicates to the nurse that the teaching was successful? 1. "I should lay down after eating a big meal." 2. "Spicy food and caffeine might cause me pain." 3. "If the pain gets worse, I should take two pills." 4. "I will take the omeprazole whenever I have pain."

2. CORRECT: There are many foods and drinks that might cause discomfort for the client, particularly in the early stages of treatment. Although specific foods can vary among individuals, usually spicy foods, caffeine, and even alcohol can contribute to the burning sensation reported by clients with GERD. This statement by the client is accurate. 1. INCORRECT: Lying down after a large meal often contributes to reflux because the pressure of food permits stomach contents and acid to flow back up the esophagus, leading to heartburn and possibly regurgitation. Clients should remain upright for a period of time after eating, which allows gravity to keep acid below the level of the esophagus. 3. INCORRECT: Omeprazole is a proton-pump inhibitor which decreases stomach acid and works to heal existing ulcers. This medication is taken once daily at the same time, and should never be doubled unless ordered to do so by the primary healthcare provider. Any increase in discomfort while taking this medication should be immediately reported. 4. INCORRECT: A proton-pump inhibitor is taken once daily, usually in the morning prior to breakfast. This medication is not administered only in the presence of pain. Taking this medication consistently over time will decrease stomach acid and help heal any damaged stomach tissue.

Which client should the nurse assign to a room closest to the nurse's station? You answered this question Correctly 1. A multigravida admitted with a new diagnosis of gestational diabetes 2. A primigravida admitted with a diagnosis of placenta previa 3. A primigravida admitted with a diagnosis of complete abortion 4. A pregestational diabetic admitted for glycemic control

2. Correct: A client with a diagnosis of placenta previa is at high risk for bleeding and must be monitored closely. Placenta previa is a complication of pregnancy in which the placenta is either partially or wholly inserted in the lower uterine wall and blocks the cervix. It is the leading cause of antepartum hemorrhage. Clients with this complication will have to have a C-section to prevent harm to the mother and fetus from bleeding. 1. Incorrect: This client's primary needs are monitoring and education. While important to educate this client to ensure the health of the mother and fetus, this does not take priority over monitoring a client that is at risk for hemorrhage. 3. Incorrect: All the products of conception are expelled with a complete abortion, and she is at low risk for hemorrhage. 4. Incorrect: This client's primary needs are monitoring and education and are not priority over a client that is at risk for hemorrhage.

The nurse is irrigating an acid chemical burn on a client's arm. Which would indicate to the nurse that irrigation can be stopped? 1. Client's pain rating has decreased from 6 to 2 on a 0 to 10 pain scale. 2. The pH value of the runoff solution is 7.0. 3. Client reports a burning sensation in the affected arm. 4. Capillary refill is less than 2 seconds in the affected arm.

2. Correct: A pH of 7 is nonacidic, so the solution's pH indicates that the acid chemical has been removed 1. Incorrect: Pain could indicate acid is still present. 3. Incorrect: A burning sensation may indicate acid is still present. 4. Incorrect: Capillary refill is not an indication that all acid has been removed.

The nurse assesses a client post thyroidectomy for complications by performing which assessment? You answered this question Correctly 1. Accucheck 2. Chovostek's 3. Ballottement 4. Ice water colonic

2. Correct: A positive Chovostek's and Trousseau's is indicative of tetany and low calcium. This can occur when a couple of parathyroids are accidently removed when the thyroid is removed. 1. Incorrect: Accucheck assesses for blood glucose levels, which is not the problem post thyroidectomy. 3. Incorrect: This assessment technique is used in examining the abdomen when ascites is present. It is done by palpating the abdomen to detect excessive amounts of fluid (ascites). 4. Incorrect: If you have never heard of it, no one else has either. The phrase implies using ice water to cleanse the colon and this would never be a good thing, especially for someone post thyroidectomy that would be intolerant to extremes in temperature.

A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis, and a 10 pound weight loss over the past month. The primary healthcare provider orders an antiemetic and daily mouthwashes. When the home care nurse evaluates the client one week later, what change described by the client would best indicate improvement? 1. Eating three meals daily. 2. Weight gain of two pounds. 3. No further mouth pain. 4. Improved skin turgor.

2. Correct: Chemotherapy typically causes gastrointestinal disturbances severe enough to interfere with a client's ability to eat or absorb nutrients. A ten pound weight loss over one month is significant but expected because of the reported vomiting and stomatitis. A weight gain of two pounds in a week would be the best specific indicator of improvement. 1. Incorrect: The ability to eat three meals daily does not mean that the client is actually absorbing those nutrients successfully. This option suggests that the antiemetic is working well, but there is not enough evidence to demonstrate significant client improvement. 3. Incorrect: The client's denial of any further mouth pain signifies that the mouthwashes have decreased mouth inflammation and stomatitis. While this is a positive change in the client's condition, it is not the best evidence noted by the nurse. 4. Incorrect: Skin turgor specifies the hydration status of a client. Since this client had previously been vomiting, improved skin turgor would indicate the antiemetic is working well and the client is able to retain fluids. While this is a positive change, it is not the most significant indicator of client improvement.

A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible.

2. Correct: Each finger must be wrapped individually to prevent webbing. If not done appropriately the client could develop contractures and lose functional use of the hand. 1. Incorrect: No debridement is needed if dressing changes are done as ordered. 3. Incorrect: Blisters should be left intact so as not to create an open wound and an environment for infection to easily start. 4. Incorrect: This is not appropriate at this time and is not the most important option for the nurse to do to properly care for the wound and enhance healing.

A client reports to the nurse, "I just do not feel well. Something is wrong." The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next? You answered this question Correctly 1. Administer PRN anxiolytic. 2. Connect to oxygen saturation monitor. 3. Reassure the client that everything is okay. 4. Instruct on relaxation technique.

2. Correct: Everything is pointing toward hypoxia. Look at HR and RR. This data is telling you that the client is restless and has tachycardia...think hypoxia FIRST when you see these 2 symptoms. 1. Incorrect: Anxiolytic medications are used to treat anxiety, however, in a client with hypoxia, this would decrease the respiratory rate so much that respiratory arrest could occur. Don't be a killer nurse. 3. Incorrect: This would be incorrect because everything is not okay. Remember, you must pick an answer that fixes the problem. This choice ignores it. 4. Incorrect: This will not fix the problem and is unsafe. The client is hypoxic, and this would make you a killer nurse.

The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post procedure? You answered this question Correctly 1. Fowler's 2. Right side 3. Left side 4. Prone

2. Correct: How do you stop bleeding from a puncture site? With pressure, right? Yes. So where is the liver? In the right upper abdomen under the rib cage. So position the client on the right side so that pressure is applied to the liver's puncture site. Then apply pressure with a sand bag or rolled up towel. This will help to stop bleeding. 1. Incorrect: This will not help control the bleeding. Pressure needs to be applied to the liver, so we want the liver coming forward toward the abdominal wall and pressure to be applied with a sand bag or rolled up towel. 3. Incorrect: The liver is on the right, not the left. Without the liver next to the abdominal wall, pressure cannot be exerted on the liver's puncture site. 4. Incorrect: We don't turn client onto abdomen. You will not be able to assess for bleeding with the client in this position.

A client diagnosed with systemic lupus erythematosus (SLE) has been started on hydroxychloroquine sulfate to decrease joint pain and swelling. What statement by the client indicates to the nurse the medication teaching has been effective? You answered this question Correctly 1. "I will be prone to infections while on this medication." 2. "I need to see my eye doctor at least once every year." 3. "I might develop a red rash on my nose and cheeks." 4. "I can stop this medicine after my symptoms are gone."

2. Correct: Hydroxychloroquine sulfate(Plaquenil) is in the category of DMARDs (disease modifying anti-rheumatic drug) and was originally developed to treat or prevent malaria. When taken once or twice daily, this medication reduces swelling and joint pain while also decreasing skin problems in Lupus clients. Though there are relatively few side effects, the most serious is retinal toxicity which requires treatment by an ophthalmologist. It is imperative for clients on this medication to have an eye examination every 6 to 12 months. 1. Incorrect: This medication is an antimalarial which has been shown to decrease pain from arthralgia in clients with SLE. Minimal side effects are generally limited to gastrointestinal disturbances such as nausea or diarrhea. This medication does not increase the client's risk of infection at all. 3. Incorrect: Clients with SLE frequently develop the classic red "butterfly rash" across the nose and cheeks which becomes worse when exposed to the sunlight. This symptom occurs because of the disease process and is not related to any medications the client may be taking. 4. Incorrect: There are several categories of medications used to treat SLE; however, none of them should be stopped suddenly. The disappearance of symptoms generally indicates the medication regime is working well, and the client should never suddenly discontinue any medicine unless instructed to do so. Abruptly stopping this drug increases the risk of an exacerbation of symptoms such as nephritis or vasculitis.

The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? 1. I'll have to take a strong laxative the morning of the test. 2. I'll have to drink contrast while x-rays are taken. 3. I'll have a CT scan after I'm injected with a radiopaque contrast dye. 4. I'll have an instrument passed through my mouth to my stomach.

2. Correct: In an upper GI series (sometimes called a barium swallow test), the client swallows barium contrast while x-rays are taken. 1. Incorrect: Laxatives are taken the night before a colonoscopy to ensure stool is cleared from the colon. Waiting to take the laxative the morning of the test would be ineffective and uncomfortable for the client. 3. Incorrect: Radiopaque dye injected before a CT (computed tomography) scan is not part of a GI series. This would be a totally different diagnostic test from the upper GI. 4. Incorrect: In a gastroscopy (sometimes called a gastric endoscopy), a scope is passed through the mouth to the stomach to visualize the inner lining of the upper GI tract.

A client with a diagnosis of endocarditis and a new peripherally inserted cential catheter (PICC) line has been discharged home to receive daily intravenous antibiotics for six more weeks. The home health nurse is making an assessment visit today. What instruction by the nurse is most important initially? You answered this question Incorrectly 1. Take antibiotics before dental procedures. 2. Brush and floss teeth at least twice daily. 3. Report any flu like symptoms immediately. 4. Include rest periods throughout the day.

2. Correct: Poor dental hygiene is one of the chief causes of endocarditis in adults, leading to growth of vegetation on heart valves, emboli, strokes, or even death. Instructions on proper oral care is considered primary or preventative teaching and encourages the client to take an active role in personal health care. Decreasing mouth bacteria or disease will decrease the potential for a reoccurrence of endocarditis. 1. Incorrect: Although primary healthcare providers may order antibiotics prior to a dental visit, it depends on what procedure the dentist is going to perform. Invasive mouth procedures where bleeding is likely generally require pre-visit antibiotics. However, this is not the most important information by the nurse initially. 3. Incorrect: Flu like symptoms are an indication of a possible exacerbation or reoccurrence of endocarditis. The client would be instructed to report such signs as fever, chills, malaise, or night sweats immediately to the primary healthcare provider. While it is important for the client to understand what to report, preventative measures are more important at this time. 4. Incorrect: Infection within the heart is very serious and, despite aggressive treatment, may have lasting effects on the client's cardiovascular system. Decreasing the workload of the heart during treatment and recovery time would certainly assist with the healing process. However, the need for frequent rest periods throughout the day is determined by a variety of factors, such as the client's age and morbidity factors, general health, amount of damage to the heart, and response to antibiotics. Rest is not the most important instruction the nurse must present initially.

Which nursing intervention should the nurse implement when administering a medication through a nasogastric (NG) tube? You answered this question Correctly 1. Place the client in a high-Fowler's position for medication administration. 2. Flush the tubing between administering medications 3. Turn the client onto their left side after medication administration. 4. Mix the medication directly into the tube feeding

2. Correct: The NG tube should be flushed with appropriate facility approved amount of fluid between medications. The amount of the flushing solution should be added to the intake amount. 1. Incorrect: Semi-Fowler's position is the position of choice for administering tube feedings. This position helps prevent aspiration and promotes digestion. The volume of fluid administered with medication administration is usually much smaller than with tube feedings, so high-Fowler's is not required. 3. Incorrect: The left side position slows gastric emptying, which could lead to aspiration. The right side is the position that best promotes gastric emptying. 4. Incorrect: Do not mix medications in the enteral feeding solution. The tube feeding rate may be prescribed at different rates or the tube feeding can be held for a designated time. The proper administration of the medication could not be determined.

Question 2: What preoperative information should the nurse provide to the client who is scheduled for an exercise stress test tomorrow morning? 1. Eat a light breakfast two hours before the test. 2. Dress in loose, comfortable clothing. 3. Take nitroglycerin dose 15 minutes prior to test. 4. Limit drinks with caffeine to 8 ounces (240 mL) within 12 hours.

2. Correct: The client should dress in loose, comfortable clothing the day of the test because the stress test consists of intense exercise. 1. Incorrect: Don't eat or drink anything except water for 4 hours before the test. The fullness from a meal makes it difficult to perform the stress test. 3. Incorrect: Clients are asked to hold beta-blockers, calcium channel blockers, and nitroglycerin medicines prior to a stress test. These medications either increase or slow down the heart rate, which can affect the test. 4. Incorrect: The client should avoid products containing caffeine for 24 hours prior to the stress test. Caffeine increases the heart rate and can affect the results of the test.

Following escharotomy of a circumferential burn to the arm, which assessment is the best indicator when evaluating the effectiveness of this procedure? 1. Decreased pain in the extremity 2. Prompt capillary refill < 2 seconds after blanching 3. Bleeding at the site of the incision 4. Ability of the client to wiggle his/her fingers

2. Correct: The objective of creating an incision through the eschar is to relieve the pressure and restore circulation. If nail beds blanch and refill promptly, blood is flowing into the limb. 1. Incorrect: Decreased pain is not an indicator of circulation to a limb. It's a good thing, but is not a definitive evaluation of circulation. 3. Incorrect: Bleeding would indicate that circulation was improved in the incision area, but to assure improved circulation of the total arm, capillary refill is the best assessment. 4. Incorrect: Movement (motor) is a neurological check, and the right answer will involve a circulatory (vascular) check!

After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? You answered this question Correctly 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

2. Correct: This is an oxygen therapy safety precaution that the nurse should implement after applying oxygen. It is also the only correct and safe option in the question. 1. Incorrect: The bi-nasal prongs would mean that the oxygen is going in through the nose. Breathing deeply through the mouth and out through the nose would not increase oxygenation for a client having chest pain and would disrupt the flow of oxygen through the nose. 3. Incorrect: The nurse should avoid using petroleum products where oxygen is in use because they are flammable. 4. Incorrect: These client actions have nothing to do with oxygen administration and would cause more distress to the client with chest pain.

After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the central line catheter. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.

2. Correct: This is the most important information that needs to be documented. This information would be important in determining if a potential safety issue/complication could occur as a result of the PICC line being removed or a portion of the line breaking off before removal. 1. Incorrect: This is not the most important information that needs to be documented. There are no client safety issues with charting the client's tolerance of the procedure. 3. Incorrect: This would be charted so the intake and output could be calculated. This is not the most important data that needs to be documented related to the removal of the PICC line. 4. Incorrect: This would need to be documented because a dressing is applied to the insertion site after removal. However, this is not the most important data that would need to be documented after this procedure.

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? You answered this question Correctly 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

2. Correct:The greatest risk to clients following a transplant is the chance of infection from any source since the client is severely immune-compromised for an extended period of time. There are numerous precautions necessary to avoid bacteria, but one area of concern is food storage, preparation, and consumption. Raw fruits with no skin to peel, such as strawberries, and raw vegetables like broccoli and cauliflower, present a serious risk for bacterial contamination and should not be consumed by new transplant clients. 1. Incorrect: Precise mouth care is vital following a bone marrow transplant; however, rinsing a toothbrush in alcohol is unsafe. Any residual alcohol would cause irritation and trauma to gum tissue, placing the client at risk for mouth inflammation and infection. Clients are instructed to brush teeth twice daily with a soft bristle brush, using a fluoride toothpaste. Some clients are instructed to soak the toothbrush once weekly in a special bleach solution, then rinse in hot water, while others need to replace the toothbrush weekly, based on lab test results. 3. Incorrect: Standing water of any type quickly builds up bacteria, including flower vases and vaporizers. Although bottled water may seem a safe choice, after that bottle is opened, bacteria begins to quickly build up, even if the bottle is recapped. Any water standing more than 15 minutes is considered old and must be thrown out. 4. Incorrect: With bone marrow transplant clients, it will be months before the body begins to stabilize and produce normal blood cells. Bruising and low platelet counts are to be expected for a period of time. When clients develop bruising, the approved treatment is cold compresses or ice packs applied for 15 minutes a couple times per day, and never a heating pad. Additionally, the healthcare provider should be notified so that a current platelet count can be obtained.

he nurse is planning care for a client admitted with a diagnosis of new onset myasthenia gravis. Which nursing interventions should the nurse include in order to decrease the risk of aspiration? You answered this question Correctly 1. Provide thin liquids such as water with meals. 2. Offer small bites of food. 3. Allow client to rest between each bite of food. 4. Offer small meals in the morning and larger meals in the evening. 5. Position client upright with head tilted slightly back when eating. 6. Provide meals 30 minutes before administration of cholinesterase inhibitor medication.

2., & 3. Correct: Offer the client small bites and instruct to chew well, eat slowly, swallow after each bite, and swallow frequently. Allow the client to rest while chewing and in between bites to restore strength. 1. Incorrect: Provide highly viscous foods and thickened liquids that are easy to chew and swallow. Thin liquids are more likely to cause aspiration. 4. Incorrect: Offer large meals in the morning and small meals in the evening. The client is more fatigued as the day progresses, so a smaller meal is best in the evening. 5. Incorrect: Position the client upright with head slightly forward when eating and drinking, using compensatory maneuvers (chin tuck, head turn) as necessary. 6. Incorrect: Adjust the client's eating schedule to optimize medication efficacy. Typically, meals should be taken during periods of optimal strength (such as during the earlier part of the day, 30 minutes after administration of cholinesterase inhibitor medications, or after rest periods).

A gunshot victim is brought by ambulance to the emergency room with an open pneumothorax. A bio-occlusive dressing to the chest. The nurse then notes increased dyspnea and sub-q emphysema in the client. What is the nurse's priority action? You answered this question Correctly 1. Prepare client for insertion of chest tube. 2. Apply a non-rebreather with 100% oxygen. 3. Loosen one side of the bio-occlusive dressing. 4. Obtain a tracheostomy kit and call the surgeon.

3. CORRECT: An open pneumothorax, also referred to as a sucking chest would, allows outside air to rush into the chest cavity. Because outside air has greater pressure than intrathoracic air, the pressure builds up quickly creating a mediastinal shift that collapses all structures in the thoracic cavity. This is referred to as a tension pneumothorax and can be caused by securing all four sides of the bio-occlusive dressing. The nurse should check to see that the dressing is loose on one side. If it is not, one side of the dressing must be released to allow the air to escape from the chest. 1. INCORRECT: Although this client will ultimately need a chest tube to remove the air that entered the chest cavity, this is not the nurse's priority action. 2. INCORRECT: A dyspneic client may certainly need supplemental oxygen; however, there are not enough parameters provided to determine whether the client is truly hypoxic. 4. INCORRECT: An emergency tracheostomy is not the initial treatment for dyspnea or sub-q emphysema. Such an invasive procedure would be used only in a life-threatening situation.

During day shift, staff notifies the nurse that an elderly client seems slightly confused and has become incontinent. Upon assessing the client, the nurse notes an increased pulse with blood pressure lower than normal. What action by the nurse takes priority? 1. Call primary healthcare provider stat. 2. Notify family that client is confused. 3. Have staff collect a urine specimen. 4. Apply oxygen at 2/L via nasal cannula.

3. CORRECT: In the elderly, symptoms of urinary tract infections (UTIs) may vary from standard manifestations usually seen in younger client. An older client may initially show neurologic signs such as confusion or falls in addition to frequency, incontinence or lower abdominal pain. Those clients with recurring UTIs may even have a standing prescription written for a urinalysis anytime confusion is noted. 1. INCORRECT: Although the primary healthcare provider will need to be notified about the changes occurring with the client, the nurse should focus on addressing current client needs, including assessing and stabilizing the client if necessary. 2. INCORRECT: The nurse will definitely notify the family when a diagnosis of urinary tract infection is confirmed; however, there is no need to report the confusion to the family until all data has been collected and the primary healthcare provider has determined the outcome. 4. INCORRECT: There is no indication of any respiratory issues requiring the nurse to provide oxygen for the client.

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? You answered this question Incorrectly 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.

3. CORRECT: Rheumatoid arthritis is an autoimmune disease that affects not only body joints but also organs of the body. Receiving methylprednisolone as treatment further suppresses the immune system, making the client even more at risk of infection. Restricting visitors with colds, respiratory problems and other infectious processes is the best method to protect the client. 1. INCORRECT: The question states the diagnosis is rheumatoid arthritis, but there is no indication the client is unsteady or needs to be on "Fall Precautions". Although the client is fatigued and has brittle bones, there is no evidence the client needs assistance ambulating. A sign is not necessary. 2. INCORRECT: Most facilities have policies to change an IV site at specific intervals, usually every three days. Changing the site daily exposes the client to an increased chance of infection from the invasive procedure. Steroids do not irritate veins and do not require frequent site changes. 4. INCORRECT: There is no rationale for contact precautions since the client's disease process is not contagious. The main concern is to protect the client from other individuals.

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? You answered this question Correctly 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

3. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. 1. Incorrect: A lumbar puncture involves removing cerebral spinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. 2. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Although this will require assessment, this client is not the priority at this time. 4. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catherization. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication.

Following surgery, a client has an indwelling urinary catheter attached to a collection bag. The nurse empties the collection bag at 0900. At the change of shift at 1500, the collection bag contains 100 mL of urine. The system has no obstructions to urinary flow. What would be the nurse's most appropriate initial response? 1. Elevate the head of the client's bed. 2. Start giving the client 8 ounces of oral fluid per hour. 3. Check circulation and take the vital signs of the client. 4. Continue monitoring, because this is an expected finding.

3. Correct: A urine output (U/O) of 100 mL over a 6 hour period is dangerously low. This client could be experiencing hypovolemic shock. In clients who are "shocky", the kidneys stop making urine to try to hold on to what little volume the body has left. The nurse is checking the vital signs for low BP and increased HR, indicators of hypovolemic shock. Also, when the urine output is this low, the client is at risk for renal failure. 1. Incorrect: Elevating the head of the client's bed is a good choice when the client is having difficulty breathing, but not here. Raising the HOB will cause the BP to drop lower. Clients in shock should be supine. 2. Incorrect: Normally, pushing fluids is a good choice if the urine output were low. 100 mL over six hours requires more aggressive treatment to combat shock. 4. Incorrect: This is not an expected finding. Urine output less than 240 mL in an eight hour time frame should alert the nurse to a serious problem such as shock.

A client who has had a stroke presents with lethargy, facial droop, and slurred speech. The client has a history of gastroesophageal reflux disease (GERD). From this history, what does the nurse recognize as an increased risk for this client? 1. Diminished colonic motility 2. Esophageal hemorrhage 3. Aspiration pneumonia 4. Stress ulcers

3. Correct: Anyone who has had a stroke is at risk for aspiration, especially with a history of reflux disease. It is important to remember that the stomach is full of acid. When aspiration of this acid occurs, it causes irritation to the lung tissue. The client can develop a severe pneumonitis. That's what could kill the client, so this answer takes priority. 1. Incorrect: Diminished colonic motility may become a problem, but aspiration pneumonia is more acute. Remember airway, breathing, and circulation will take priority. 2. Incorrect: Esophageal hemorrhage is seen with esophageal varices, not reflux disease. 4. Incorrect: GERD is not associated with increased risk for stress ulcers, but GERD can also lead to strictures and/or precancerous lesions called Barrett's esophagus.

A client's membranes spontaneously rupture at 10 cm dilation and +2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action? You answered this question Correctly 1. Emergency cesarean delivery 2. Immediate high forceps delivery 3. Equipment for immediate suctioning of the newborn 4. Administration of IV oxytocin

3. Correct: Green stained fluid indicates fetal passage of meconium. The fetus must be suctioned by the healthcare provider when the head is still on the perineum and before the baby takes its first breath. This will remove any particulate matter from the meconium that may cause aspiration. 1. Incorrect: Delivery will probably occur soon and vaginal delivery is preferable to cesarean. This is an unrealistic and inappropriate action for this client. 2. Incorrect: High forceps are never indicated and would not provide safe delivery for the baby. The concern is the meconium stained fluid and potential aspiration for the baby. 4. Incorrect: The meconium passage is an indicator of fetal stress, and increased uterine contractions may stress the fetus further. This would not be safe for the baby or the mother at this stage of labor.

The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.

3. Correct: Look at the clues: full thickness wound, small amount of blood, wet to dry dressing. With a full thickness wound there is destruction of the epidermis, dermis, and subcutaneous tissues going down to the bone. ​So you would expect to see a small amount of blood or drainage wouldn't you? Yes. This is expected. Simply document this normal finding. 1. Incorrect: Is there really anything to worry about in this situation? No, so you do not need to notify healthcare provider. Now, with most questions on NCLEX there is something to worry about but just not with this one. 2. Incorrect: No, bleeding is not a sign of infection which is what you would be worried about if you got a wound culture. 4. Incorrect: Probably not, just a sign of blood flow in healing wound. Wet to dry dressing helps to debride the wound. So if you remove the dressing will debridement occur? No.

A client is returned to the surgical unit following gastric/esophageal repair of a hiatal hernia, with an IV, NG tube to suction, and an abdominal incision. To prevent disruption of the esophageal suture line, what is most important for the nurse to do? 1. Assess the wounds for drainage. 2. Give ice chips sparingly. 3. Maintain the patency of the NG tube. 4. Monitor for the return of peristalsis.

3. Correct: Maintain the patency of the NG tube. On ANY post-op client, the nurse is responsible for preventing disruption of the suture line. (Disrupture of any suture line, since disruption could be life-threatening.) The nurse is responsible for keeping the NGT patent to prevent accumulations of gastric secretions and blood in the stomach. Accumulation of fluid in the stomach can cause pressure on the suture line and places the client at risk for disruption of the suture line and hemorrhage. The nurse knows NEVER to allow pressure or stretching on suture lines. 1. Incorrect: Assessing the wound for drainage is important, but when there is something more life-threatening, that is the priority answer. Disrupting the sutures is more life-threatening. 2. Incorrect: This person is ABSOLUTELY NPO. Giving ice chips is contraindicated as it could disrupt the suture lines. 4. Incorrect: It is important to monitor for return of peristalsis, but this is not life-threatening.

Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority? You answered this question Correctly 1. Remove any exudate around eyes with warm water. 2. Instill exact number of drops into lower conjunctival sac. 3. Instruct client to look upward when drops are instilled. 4. Avoid dropping the medication directly on the cornea.

4. CORRECT: The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems if meds were dropped onto the cornea. 1. INCORRECT: It is important to clean away any exudate prior to instilling eye drops to maintain aseptic technique and decrease chance of infection. Though this is an important action, there is another task which takes priority. 2. INCORRECT: Instilling the exact number of drops is appropriate when implementing written prescriptions from the primary healthcare provider. This is an important nursing action but not the priority. 3. INCORRECT: Instructing the client to look upward helps prevent drops from running out of the eye but there is another issue more important.

The parents of a child hospitalized with cystic fibrosis have been given discharge instructions. The nurse knows that teaching has been successful when the parents make what statement? You answered this question Correctly 1. "Our child will need to have a gluten free diet." 2. "The enzymes should be given at bedtime daily." 3. "Salt needs to be decreased in our child's diet." 4. "We need to prepare high calorie, high fat meals."

4. Correct: Cystic fibrosis is an inherited disorder in which abnormally viscous secretions affect the respiratory and digestive systems. Because the client is unable to absorb nutrients, several dietary adaptations are crucial, including frequent small meals along with digestive enzymes to help the client process food. The meals should be high calorie, high fat with increased amounts of sodium to help stabilize fluids. 1. Incorrect: A gluten free diet is not associated with cystic fibrosis. This special diet is generally required for clients with Celiac disease and certain food allergies, although clients with either of these diseases will need the addition of fat soluble vitamins A, D, E and K. This statement by the parents indicates the need for further teaching. 2. Incorrect: Pancreatic digestive enzymes, such as Creon or Pancreaze, must be given with every meal or snack in order to help the digestive system absorb nutrients properly. Because clients with cystic fibrosis need frequent small meals throughout the day, digestive enzymes must also be provided throughout the day with any food. 3. Incorrect: Clients with cystic fibrosis lose abnormally large amounts of salt in sweat, and the glands are unable to reabsorb needed sodium into the body system. Rapid dehydration is common due to decreased sodium levels, which are exacerbated during exercise or hot weather. These clients are encouraged to increase salt intake.

The edrophonium (Tensilon) test has been prescribed for a client. Which statement by the client would indicate to the nurse that the client understands this test? 1. "This medication will be given to me as an IM injection immediately after my muscles are tired." 2. "This test will determine if I have multiple sclerosis." 3. "The test is positive if my muscles do not get stronger after injection with this medication." 4. "I will be asked to perform a repetitive movement to test my muscles."

4. Correct: If the primary healthcare provider suspects myasthenia gravis (MG), the client will be asked to perform a repetitive movement to test a group of muscles. 1. Incorrect: The medication is given IVP after the muscle group has become fatigued. 2. Incorrect: The edrophonium (Tensilon) test is used to diagnose myasthenia gravis. 3. Incorrect: A person tests positive for MG if their muscles get stronger after being injected with edrophonium (Tensilon).

A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider.

4. Correct: In this case, there is nothing on the list the nurse can do to fix the problem. The primary healthcare provider must be notified immediately. Anticipate that the client will be returning to surgery because these are symptoms of an arterial problem that needs to be addressed immediately. 1. Incorrect: Arterial circulation is improved by lowering the extremity. Remember to raise venous problems; lower arterial problems. These signs/symptoms indicate an acute, emergent change in the client's condition. In this case, the nurse is "worried" the client will lose the extremity. There is nothing the nurse can do to fix the problem, so calling the primary healthcare provider is the best answer. 2. Incorrect: Assessing the pulses is delaying treatment and does not fix the problem. In this question you have only 1 option, so you must go with what is best for the client. 3. Incorrect: Increasing the IV rate does nothing to fix the problem, and you have only 1 chance in this question to show the NCLEX lady that you are a safe nurse.

A term primipara is admitted in active labor and with rupture of membranes. Her last vaginal exam one hour ago revealed that she was dilated to 6 centimeters, 100% effaced, and at -1 station. The client calls out "My belly really hurts. I feel like I have to have a bowel movement!" Which action should the nurse perform first? 1. Offer her a bedpan. 2. Call the primary healthcare provider. 3. Prepare for epidural administration. 4. Perform a sterile vaginal exam.

4. Correct: Labor can progress rapidly even in a primipara. As the fetal presenting part descends, pressure is placed on the rectum and many women report that it feels as though they need to have a bowel movement. The symptoms described indicate that the client has fully dilated and is at +1 or better station, and delivery may be imminent. 1. Incorrect: The nurse should first determine labor progress with a vaginal exam since this complaint is a common symptom of labor progressing and the fetus descending through the birth canal. Often, the client has had an enema to cleanse the colon prior to delivery so there usually is no fecal material present. 2. Incorrect: First determine labor progress with a vaginal exam. This might be necessary later, but is not the first action to perform. 3. Incorrect: First determine labor progress with a vaginal exam prior to preparing the client for anesthesia.

An expectant HIV positive client asks why zidovudine (ZDV) must be continued throughout the pregnancy. What is the best explanation by the nurse? You answered this question Correctly 1. "The medication permits safe breastfeeding after delivery." 2. "It protects you against other infections during pregnancy." 3. "This drug prevents transmission of HIV to your partner." 4. "ZDV decreases the chance the baby will contract HIV."

4. Correct: New advances in the treatment of HIV have decreased the chances of transmitting the HIV virus from mother to fetus from 25% without treatment to less than 2 % with treatment. Several HIV medications have been shown to be safe for both the fetus and mother, including ZDV. The nurse is presenting the most complete, accurate information with this statement. 1. Incorrect: Even with treatment, most primary healthcare providers discourage breast-feeding after birth since the HIV virus has been shown to be transmitted through breast milk. The use of ZDV or other antiviral medications cannot completely eradicate the virus from breast milk, though some pediatricians allow breastfeeding under certain circumstances. 2. Incorrect: The use of antiviral medications, including ZDV, does not protect the client from contracting other acquired infections. The medication is strictly for the purpose of decreasing the chances of passing HIV to the fetus, and requires the mother to precisely follow the dosing regime and other healthy habits to increase its effectiveness. 3. Incorrect: While the use of antiviral medications during pregnancy can decrease the chances of the mother passing the virus to the fetus, the medication does not prevent transmission of the disease to the client's partner. This statement is incorrect.

A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? 1. Inspect the catheter tubing for obstruction. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.

4. Correct: The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow to prevent further bladder distention. Bladder distention is one of the main causes of hemorrhage in the fresh post op period. 1. Incorrect: The next action is to check the external system for kinks or obstruction to assess if this is the cause of the decreased urine output. Obstruction of the catheter tubing can also cause bladder distention. 2. Incorrect: After the external system is checked for kinks or obstruction, and the client's urine output doesn't change, then the catheter is irrigated with 30 to 50 mL of normal saline using a large piston syringe. However, irrigating a new post-op client is not the safest or first action for the nurse. 3. Incorrect: Of the options listed here, this is the last intervention. If the obstruction is not resolved after irrigating the system, the primary healthcare provider must be notified.

The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities? You answered this question Correctly 1. Ask the client to lie down and place the stockings on the legs. 2. Ask the client to sit on the bedside and place the stockings on the legs. 3. Tell the client that the nurse will return later to assist with the application. 4. Elevate the extremities in bed for 30 minutes before application.

4. Correct: The client should have extremities elevated to encourage venous return and reduce the risk of swelling before the stockings are applied.1. Incorrect: To place the stockings on immediately will cause further venous stasis and swelling.2. Incorrect: The extremities should be elevated for a period of time before application.3. Incorrect: This instruction alone does not give the client adequate information about the need to keep the lower extremities elevated before applying the stockings.

A nurse is triaging a 2 year old child in the pediatric emergency department. The nurse notes that the child will not lie down and is consistently drooling. A croaking sound is heard on inspiration. What is the priority nursing intervention? 1. Examine the oral pharynx using a tongue depressor. 2. Administer a sedative so the child can be examined. 3. Have a second nurse hold the child down for the assessment. 4. Notify the primary healthcare provider immediately.

4. Correct: This is the safest answer. The child could suddenly obstruct the airway upon examination of throat. 1. Incorrect: If it looks like epiglottitis, do not examine as this could cause sudden airway obstruction which could be fatal. 2. Incorrect: The client is having trouble breathing, so do not sedate the client. Sedatives would depress the respirations more and potentially cause the client to go into respiratory arrest. Remember, the NCLEX® lady does not want you to be a killer nurse. 3. Incorrect: This will cause more respiratory and emotional distress to the child. This is an unsafe answer.

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? You answered this question Incorrectly 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

4. Correct: This position will decrease pressure on the suture line and abdomen. 1. Incorrect: Sims' is a semi-prone position where the client assumes a posture halfway between the lateral and prone positions. If you place the client in this position the bowel contents can protrude out of the wound even more. 2. Incorrect: In this position the client's head and shoulders are slightly elevated on a small pillow. This does not ease the tension as much as supine with HOB elevated 15 degrees and knees and hips flexed. 3. Incorrect: Turning the client on their side will allow the abdominal contents to protrude out of the wound even more.

Two hours post chest tube insertion, the nurse notes 100 mL of dark bloody drainage in the collection chamber of the closed drainage unit (CDU). What action should the nurse take? 1. Document the findings. 2. Notify the primary healthcare provider. 3. Decrease the amount of suction. 4. Use a padded hemostat to clamp the chest tube.

1. Correct: A chest tube is inserted to remove air, blood, or exudate from the pleural space. So 100 mL of dark bloody drainage would not be unusual over the first two hours after insertion. Drainage may range from 100 to 300 mL/hr within the first 2 hours. Documentation is required and continued hourly follow-up. 2. Incorrect: It is not necessary to notify the primary healthcare provider at this time. There is nothing in the stem to indicate that the client is in distress. 3. Incorrect: Suction does not need to be decreased or increased. You want just enough suction to have gentle continuous bubbling in the suction control chamber. 4. Incorrect: You only clamp the chest tube as a last resort and only long enough to find a leak in the system. Clamping a chest tube is dangerous and can lead to a tension pneumothorax.

When assessing for the development of an infection following the application of a plaster cast to the leg, the nurse should teach the client to observe for the presence of which sign of infection? You answered this question Correctly 1. Hot spots 2. Cold toes 3. Warm toes 4. Paresthesia

1. Correct: Hot spots is the best answer. Redness and increased warmth are indicators of localized infection. If the cast covers the extremity, redness cannot be visualized, but the client can feel more warmth (a "hot spot") in an area becoming infected. 2. Incorrect: "Cold toes" is a neurovascular check, not an indication of infection. 3. Incorrect: "Warm toes" is a neurovascular check, not an indication of infection. 4. Incorrect: Paresthesia is a neurovascular check, not an indication of infection.

The nurse is working in the term nursery. Which task should be performed first on a newborn? 1. Prepare the circumcision equipment for a two day old newborn. 2. Assess the five minute APGAR of a newborn. 3. Perform the gestational age assessment on a 30 minute old newborn. 4. Obtain a blood sample for metabolic testing on a 24 hour old newborn.

2. Correct: The APGAR is done to determine whether a newborn needs help breathing or is having heart trouble. It looks at the newborn's breathing effort, HR, muscle tone, reflexes, and skin color and is the most important initial assessment for a newborn. 1. Incorrect: This task is not emergent and can be performed later at an appropriate time. 3. Incorrect: This task is not emergent and can be performed later at anytime during the transition stage of the newborn's nursery care. 4. Incorrect: This task is not emergent and can be performed at anytime between 24 hours and 7 days old. Typically it is done before the newborn is discharged home.

Which signs/symptoms should the nurse assess for when caring for a client diagnosed with bulimia nervosa? Select all that apply 1. Increased thirst 2. Muscle cramps 3. Blurred vision 4. Tingling of lips 5. Constipation

2., 4., 5. Correct: The typical abnormalities associated with bulimia are hypokalemia and metabolic alkalosis because of the binging and purging process. This leads to muscle cramps, weakness, fatigue, constipation, and arrhythmias are all symptoms of this electrolyte and acid-base imbalance. Hypokalemia leads to metabolic alkalosis.1. Incorrect: Increased thirst is a sign of hyperglycemia and would not be the concern with someone that is purging. This client would be more likely to be hypoglycemic instead. 3. Incorrect: Blurred vision is a sign of hyperglycemia because of the effect of too much glucose in the small vessels of the eye. Microvascular damage is one of the biggest concerns with hyperglycemia; the bulemic client would be hypoglycemic.

A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a myocardial infarction(MI)? 1. I became dizzy when I stood up. 2. I was nauseated and began vomiting. 3. The pain started in my chest and stopped after I sat down. 4. The pain was not relieved after taking 3 nitroglycerine tablets.

3. Correct: Chest pain brought on by exercise and stopped with rest is the hallmark of angina. If it were an MI, the pain would continue even with rest or position changes. 1. Incorrect: This indicates orthostatic hypotension which is not definitive for angina or MI. 2. Incorrect: Vomiting is a symptom of an MI not angina and is a bad sign related to the acute pain from the MI. This type of pain stimulates the vagus nerve, which causes the heart rate, BP and cardiac output to decrease and this is never good with a heart client. 4. Incorrect: This is the picture of MI, not angina

Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? Select all that apply 1. Ecchymosis 2. Bleeding gums 3. Palpable spleen 4. Pain 5. Petechiae

1., 2., 3., & 5. Correct: The word thrombocytopenia means low platelets. Any client with low platelets is at risk for bleeding, which is indicated by ecchymosis (bruising), bleeding gums, and petechiae (red to purple dots on the skin, 1-3 mm in size). Spleen and liver are often slightly palpable.4. Incorrect: Pain is not associated with ITP unless there are other associated problems. However, the stem of the question gave no indication that other problems exist.

A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? You answered this question Correctly 1. Respiratory 2. Cardiac 3. Airway 4. Neurological

3. Correct: A fire in an enclosed area causes concern for carbon monoxide poisoning. In addition to the burns to the chest, there is the added potential for airway damage. 1. Incorrect: Important to assess respiratory status but not before airway. 2. Incorrect: Important to assess cardiac, but not #1. 4. Incorrect: This assessment would be done, but not #1.

A nurse is caring for a client on the second day after a thoracotomy. The client reports incisional pain. The nurse assesses the client and evaluates the vital signs. Based on the data documented in the chart, what action should the nurse take first? Exhibit Nursing Note: Client reports incisional pain as 8/10. Wound is clean and dry, without redness, edema, or drainage. Shallow respirations noted at 24/min. Adventitious lung sounds noted in bilateral bases. Vital Signs: Oral temperature 100º F/37.8ºC Heart rate 92/min and regular BP 130/80 Respirations 24/min 1. Have client cough and deep breathe. 2. Administer acetaminophen for fever 3. Administer the prescribed analgesic 4. Assist the client to ambulate.

3. Correct: The client described in this question is post thoracotomy. With ANY post-op client, the number one concern, especially as a brand new nurse, is preventing pneumonia. A thoracotomy is very painful and the client is unlikely to breathe deep unless the pain is relieved. Temperature of 100º F/37.8ºC, HR 92, respirations 24, bilateral crackles (indicating atelectasis) all reveal this client is heading for pneumonia. 1. Incorrect: Coughing and deep breathing exercises are exactly what the client needs, but the client will not cough and deep breathe if it hurts. Give pain medication first. 2. Incorrect: Acetaminophen is not potent enough to relieve pain. The goal is to "fix the problem". The problem is that the client is not properly deep breathing due to pain. 4. Incorrect: Assisting the client to ambulate is a good idea, but the nurse has to fix the problem, and the problem is that the client is not deep breathing.

When planning post procedure care for a client who is having a barium enema, what must the nurse include? You answered this question Incorrectly 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet

3. Correct: The client must expel the barium post procedure. If the barium is not eliminated, it can harden in the colon and cause an obstruction. 1. Incorrect: It is not standard practice to place clients on a cardiac monitor after a barium enema. 2. Incorrect: Monitoring urine output has nothing to do with this procedure and does not answer the specific question related to this diagnostic procedure. 4. Incorrect: Reordering the client's diet is important but is not as life-threatening as a bowel obstruction.

The lactation consultant is preparing to make rounds on the breastfeeding clients on the Labor, Delivery, Recovery, Postpartum (LDRP). Which client should the consultant see first? You answered this question Incorrectly 1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. 2. The mother who stated that her newborn sucks in short bursts and has audible swallowing. 3. The mother who reported blisters on her nipples and pain whenever the newborn latches on. 4. The mother who stated that her baby was so good that she has to wake him for each feeding.

4. Correct: A baby who is so sleepy that he doesn't wake on his own for feeding is at high risk for dehydration and malnourishment. This newborn needs further evaluation and close monitoring to prevent serious complications. 1. Incorrect: This is a normal finding for a breastfeeding mother and is not the priority concern for the consultant.2. Incorrect: This is a normal finding for a breastfeeding mother and is not the priority concern for the consultant. 3. Incorrect: Blisters and pain are concerns that need to be assessed, but the sleepy baby situation has first priority. This would be the next client for the consultant to see, but not the first.

Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome

4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult with both of these risk factors together, this one is the highest risk for cancer. 1. Incorrect: Although smoking is a known environmental carcinogen, this one risk factor alone is not the highest risk. 2. Incorrect: These are known environmental carcinogens, but do not rank as highly as aging and immune deficiency. 3. Incorrect: Birth defects are not a risk factor for cancer.

An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and unstable vital signs. What should the nurse do first? You answered this question Correctly 1. Decrease rate of IV fluids. 2. Neurovascular checks of affected leg. 3. Elevate the head of the bed. 4. Call the active response team.

4. Correct: The client is exhibiting symptoms of a fat embolism, particularly with the petechial rash on his chest and severe shortness of breath. Due to his age, high risk behaviors with contact sports, and the large long bone fracture, he is the classic example of a client that may experience a fat embolus. This constitutes a medical emergency and activation of the response team. 1. Incorrect: This does not affect breathing here and will do nothing to resolve the fat embolism. 2. Incorrect: Neurovascular checks of the leg will not help the client's breathing and are not the first priority for the nurse. 3. Incorrect: The nurse may elevate HOB to assist with breathing unless client is hypotensive. Either way, this is not the best first answer.

A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.

3. Correct: The postoperative client with a total hip replacement is at risk for thromboembolism and fat emboli which can travel to the lungs and cause respiratory distress. Without proper turning, coughing, and deep breathing, pneumonia and atelectasis may occur. So preventing respiratory complications is high on the priority list. Remember the ABCs - airway, breathing, then circulation. Preventing respiratory complications is the highest priority because of the possibility of sudden death from the complications of deep vein thrombosis and pulmonary embolism. 1. Incorrect: This client is at risk for hemorrhage and/or hematoma formation related to surgical trauma to blood vessels (the hip is a very vascular area) and use of anticoagulants or antiplatelet agents before and after surgery. So the nurse will need to monitor for shock caused by loss of volume. The nurse should monitor drains, wound dressings, and intake and output. But remember, Airway and Breathing take priority. 2. Incorrect: Dislocation of the prosthesis is another complication to worry about. It will cause pain and possible deformity and is very important, but airway is the priority. Dislocation of the hip prosthesis is related to weakness of the hip muscles, improper positioning or movement of the operative extremity, and/or noncompliance with weight-bearing limitations.4. Incorrect: The client is at risk for skin breakdown if not turned and repositioned properly or ambulated as soon as prescribed. However, Airway is still the priority for this client.

he nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order?

When preparing to remove a peripheral IV line, the nurse begins by washing hands and applying non-sterile gloves. Next, the clamp is closed on the IV line or saline lock extension to prevent fluid or blood from leaking during process. Third, the nurse needs to stabilize the cannula with one hand to prevent trauma at the insertion site. Fourth, carefully begin to loosen all the tape on the site. The bottom dressing or tegaderm, is loosened last. Lastly, the nurse will place large, folded gauze square over the insertion site and gently pull the cannula out of the skin, while placing pressure on that gauze. After holding the gauze in place for a few moments, and checking for excess bleeding, the nurse will tightly tape that gauze square in place, providing pressure over the site. The client should be instructed to keep that dressing in place for at least one hour.

A nurse suspects that a client admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? Select all that apply 1. Dry mucous membranes 2. Fruity-smelling breath 3. Biot's respirations 4. Glycosuria 5. Client report of abdominal pain

1., 2., 4., & 5. Correct: The client with diabetic ketoacidosis will have signs of dehydration due to polyuria and includes dry mucous membranes. Fruity breath odor is from the acetone that occurs with breakdown of fats and formation of ketones, which are acids.. With DKA, the client would be spilling glucose into the urine. Vomiting and abdominal pain are frequently the presenting symptoms of DKA.3. Incorrect: The client will have Kussmaul respirations. Biot's respiration is a respiratory pattern characterized by periods of rapid respirations, then apnea periods. These are not the type of respirations that occur with diabetic ketoacidosis (metabolic acidosis).

Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider? You answered this question Incorrectly 1. Calf muscle irritability 2. Facial edema 3. Pressure on the bladder 4. Blurry vision 5. Hemoglobin of 11 mg/dL 6. Epigastric pain

1., 2., 4., & 6. Correct: These are danger signs/symptoms of pregnancy and need further investigation by the primary HCP. These signs could indicate preeclampsia, fluid and electrolyte disturbances, and other high risk complications during pregnancy. 3. Incorrect: As the baby gets bigger, it pushes on the bladder, causing pressure, so this is an expected symptom in pregnancy. 5. Incorrect: This is normal for the pregnant client and within the normal range for the female client.

A client who needs to have a stool specimen for an occult blood test is instructed by the nurse to avoid which substances two hours prior to testing? Select all that apply 1. Liver 2. Tomato 3. Ibuprofen 4. Sardines 5. Ascorbic acid

1., 3., 4., 5. Correct: The following foods can cause a false-positive reading: red meats, liver, turnips, broccoli, cauliflower, melons, salmon, sardines, and horseradish. Medications altering the test include aspirin, ibuprofen, ascorbic acid, indomethacin, colchicines, corticosteroids, cancer chemotherapeutic agents, and anticoagulants. Ingestion of vitamin rich foods can cause a false negative result. 2. Incorrect: A tomato is not on the food list for false-positive reading and do not have to be avoided.

Which prescription by the emergency room primary healthcare provider for a client who fell from a ladder should the nurse question? 1. Record intake and output hourly. 2. Prepare the client for lumbar puncture. 3. Perform neurologic checks every 10 minutes. 4. Schedule a brain computed tomography (CT) scan.

2. Correct: The traumatic injury to the brain from the fall may result in increased intracranial pressure. The reduction of pressure in the lumbar spine during a lumbar puncture may result in the potential for herniation of the brain. A lumbar puncture should not be performed. 1. Incorrect: Brain damage can result in metabolic and hormonal dysfunctions. Brain injuries may result in disorders of sodium regulation and endocrine function. Strict intake and output are important to monitor for any fluid changes. 3. Incorrect: The client should be assessed frequently to continue to evaluate their neurological status. The Glasgow Coma Scale (GCS), corneal and gag reflexes, vital signs should be assessed for any variations. 4 Incorrect: The client experienced a blunt trauma to the head after falling off the ladder. A computed tomography of the brain is prescribed to evaluate hemorrhage and trauma to the brain.

A client returns to the unit post scleral buckling of the right eye. Which nursing interventions should the nurse include? 1. Approach client from the right side. 2. Place personal items within easy reach. 3. Maintain eye patch over right eye. 4. Administer antiemetic for reports of nausea. 5. Assist client to turn, cough, and deep breathe every 2 hours. 6. Place client prone for 1 hour.

2., 3., & 4. Correct: Place all personal articles and the call light within easy reach. These measures prevent stretching and straining by the client. An eye patch or shield will prevent injury to the affected eye. We do not want the client to vomit, so administer an antiemetic for reports of nausea. Vomiting will increase intraocular pressure. 1. Incorrect: Approach the client on the unaffected side. This approach facilitates eye contact and communication. 5. Incorrect: The goal is to prevent anything that will increase intraocular pressure. That means coughing should be avoided. 6. Incorrect: Lying prone will increase intraocular pressure. After surgery for a detached retina, the client is positioned so that the detachment is dependent. For example, if the outer portion of the right retina is detached, the client is positioned on the right side. Positioning so that the detachment is inferior maintains pressure on that area of the retina, improving its contact with the choroid.

What should the nurse include when planning discharge teaching for a client post scleral buckling of the right eye? Select all that apply 1. Redness, tenderness and swelling should be gone within 2 days. 2. Teach to report seeing flashes of light immediately. 3. Place eye drops onto the cornea of the affected eye. 4. Wear eye shield during naps, and at night. 5. Have client demonstrate the correct technique for instilling eye drops.

2., 4., & 5. Correct: The client should be taught the signs/symptoms of retinal detachment, such as seeing flashes of light, floating spots or blurred, "sooty" vision, or a veil-like curtain obscuring parts of the visual field. The client should wear either an eye shield or glasses during the day, during naps, and at night. The client will need to instill eye drops into the affected eye appropriately to avoid injury and infection. 1. Incorrect: The pain level should decrease within a few days, but the client will continue to have redness, tenderness, and swelling for a few weeks after surgery. 3. Incorrect: The client should tilt the head backward and slightly to the side, so the solution runs away from the tear duct and other eye to prevent contamination while depressing the lower lid with the finger of one hand. Tell the client to look up when the solution is dropped on the averted lower lid. Do not the place drop directly on the cornea.

The nurse is planning care for the prevention of skin breakdown in a client diagnosed with a stroke. What intervention is important for the nurse to include? Select all that apply 1. Massage reddened skin areas located over bony prominences. 2. Place pillows under lower extremities to raise heels off the bed. 3. Position client on paralyzed side for one hour. 4. Apply emollients to dry skin. 5. Place a gel seat cushion on the wheelchair seat. 6. Shift client weight every two hours while sitting in a wheelchair.

2., 4., & 5. Correct: These interventions will decrease the risk of skin breakdown by eliminating sustained pressure to areas at greatest risk of breakdown. 1. Incorrect: Do not massage the damaged area because this may cause additional damage. 3. Incorrect: This is way too long. The client should only be on their paralyzed side for 30 minutes. 6. Incorrect: This is way too long. Skin breakdown can result within this period of time. The client's weight should be shifted within the wheelchair every 15-20 minutes.

The nurse is caring for a burn client 48 hours after the burn occurred. What would be the nurse's priority assessment? 1. Measure the abdominal girth. 2. Administer pain medication. 3. Auscultate the lungs every 2 hours. 4. Inspect the burn for infection.

3 Correct: After 48 hours, the fluid in the interstitial spaces will begin to shift back into the vascular space and can lead to fluid volume excess. Excess fluid can back up into the lungs, so auscultation of the lungs takes priority. Remember: Airway, breathing, then circulation. 1. Incorrect: No indication of need to measure abdominal girth. Fluid is now shifting out of the tissue and abdominal cavity back to the vascular space. Worry about fluid volume excess now. 2. Incorrect: Not priority over pulmonary function. Pain is a priority from the client's perspective, but remember pain never killed anyone. However, fluid in the lungs will! Lung assessment takes priority. 4. Incorrect: Not priority over pulmonary function. Again, we want to inspect for infection, but it is not the priority over assessing the lungs.

Which comment made by a client scheduled for a lumbar laminectomy and discectomy indicates to the nurse that the client needs further teaching? You answered this question Incorrectly 1. After the incision is healed, I can go for daily walks. 2. By the time I am discharged, my back and leg pain will be better. 3. I can turn by myself after surgery, but I will need help to get out of bed. 4. The staff will frequently check my feet and legs for feeling and movement.

3. Correct: The client must log roll with assistance. The spine must be kept in proper alignment to allow the area time to rest and heal. The nurse should reinforce this information with the client. 1. Incorrect: After the incision heals, it is acceptable practice to go for daily walks so this is an accurate understanding of what the client can do after the surgery. 2. Incorrect: Successful laminectomies and discectomies will relieve back and leg pain so this is accurate, also. 4. Incorrect: The nurse knows it is very important to perform neurovascular checks after ANY orthopedic surgery. Any changes from their baseline should be reported to the primary healthcare provider immediately. This indicates successful teaching.

A client has been started on intravenous gentamicin for osteomyelitis. The nurse informs the client frequent blood work will be done to monitor the amount of medication in the body. The nurse knows what labs are a priority to check every three days for the client? You answered this question Correctly 1. BUN and creatinine. 2. Liver function studies. 3. Hemoglobin and hematocrit. 4. Peak and trough levels.

4. Correct: Peak and trough levels help to determine the amount of medication in the body system at specific times. Gentamicin is a very potent antibiotic; therefore, it is crucial to keep track of blood levels of this medication. Too low a level of this drug would be ineffective against the bacteria while too high a level increases the potential for severe side effects or toxicity from this antibiotic. 1. Incorrect: Because aminoglycosides such as gentamicin can lead to nephrotoxicity, checking BUN and creatinine levels periodically is important. However, it would not be necessary to check those values every three days. 2. Incorrect: Aminoglycosides like gentamicin rarely affect the liver; therefore, liver function studies would not be needed frequently. 3. Incorrect: Hemoglobin and hematocrit levels are rarely impacted by aminoglycosides such as gentamicin. Although an initial level may be obtained prior to treatment, additional levels are not necessary.

The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? Select all that apply 1. Restricting oral fluids until the gag reflex has returned. 2. Encouraging early ambulation and deep breathing exercises. 3. Discontinuing medicines following percutaneous intervention. 4. Reporting any chest discomfort following percutaneous intervention. 5. Avoid lifting more than 10 pounds until approved by healthcare provider.

4., & 5. Correct: The number one thing you are "worried" about post PTCA is re-occlusion or re-infarction, so report chest discomfort at once. Lifting more than 10 pounds can make the client bleed and would be contraindicated until cleared by the primary healthcare provider. 1. Incorrect: Fluids need to be increased to flush the dye used during the procedure from the kidneys. Oral fluids do not have to be restricted because the client does not have to be intubated for the procedure. 2. Incorrect: To ensure a stable clot is formed at the femoral access site, the client must remain on bed rest for a minimum of 4 hours. The client is at risk for hemorrhaging at the insertion site. DO NOT ambulate until it is certain that the clot is stable. 3. Incorrect: Medications are generally continued as before the procedure. Certain medications, like anticoagulants, may be held prior to the procedure, but typically all pre-procedure medications are resumed after PTCA.

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? You answered this question Correctly 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space

1. Correct: A chest tube placed in the upper chest is to remove air from the pleural space. Remember air rises and fluid settles down low. 2. Incorrect: Chest tubes are placed in the pleural space to get rid of air, blood, fluid, or exudate so that the lung can re-expand. The purpose is not to create an access for irrigating the chest cavity. 3. Incorrect: The chest tube is inserted into the pleural space because the lung has collapsed due to air, blood, fluid, or exudate. The chest tube does not go into the lung so secretions can not be removed from the bronchioles and alveoli by way of the chest tube. 4. Incorrect: You have to know the purpose of the upper chest tube. Fluid drains down, so the lower one is for fluid.

A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement? You answered this question Incorrectly 1. Put a pillow under the costal margin. 2. Place in the right side lying position. 3. Perform passive range of motion exercises to right shoulder. 4. Take vital signs every 10 - 15 minutes for first hour. 5. Instruct the client to avoid strenuous exercise for 1 month.

1.,2., & 4 Correct: The client is placed on the right side and a pillow placed under the costal margin. The pillow will place additional pressure on the rib cage which will assist with applying pressure to the liver capsule. By positioning the client on the right side, the liver capsule at the site of the biopsy is compressed against the chest wall. If the puncture site is not compressed, there is the possibility that blood or bile will leak from the puncture site. The vital signs are measured at 10 - 15 minute intervals for the first hour. Variations of the vital signs will indicate complications such as bleeding, severe hemorrhage, and bile leakage. 3. Incorrect: Passive range of motion exercises is not correct. The shoulder is not placed in a position during and after the biopsy to warrant passive exercises to the shoulder. 5. Incorrect: The client should be instructed to avoid strenuous exercise for 1 week not 1 month. The strenuous exercise is restricted to 1 week to prevent the possibility of liver bleeding.

What interventions should the nurse include in the care plan of a client admitted with Guillain-Barre syndrome? Select all that apply 1. Assess for descending paralysis. 2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min. 4. Maintain in side-lying, supine position. 5. Have client perform active range of motion (ROM) every 2 hours while awake.

2. & 3. Correct: This client is at risk for respiratory paralysis as the disease progresses. An emergency tracheostomy may need to be performed so the nurse should watch out for imminent signs of respiratory failure. Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm. The nurse should assess for signs of respiratory distress and prepare for intubation if needed. 1. Incorrect: Ascending paralysis should be assessed for with this disease. Paralysis begins in the lower extremities and moves upward. 4. Incorrect: The client should be assisted to a position with head of bed elevated for full chest excursion. 5. Incorrect: The nurse should perform passive range of motion exercises. Active exercise should be avoided during the acute phase as the client is easily fatigued and muscles are weak. Passive ROM stimulates circulation, improves muscle tone and increases joint mobilization.

What preferred lab value would the nurse expect to see the primary healthcare provider prescribe for a client admitted with generalized malnutrition? You answered this question Correctly 1. Albumin 2. Prealbumin 3. Iron 4. Calcium

2. Correct: The preferred lab value to screen for generalized malnutrition is prealbumin. This assessment is preferred because it decreases more quickly when nutrition is not adequate. 1. Incorrect: Albumin is a major serum protein that is below normal in clients who have inadequate nutrition. However, it can take weeks to drop. 3. Incorrect: Low serum iron and anemia indicate an iron deficiency. Again, the prealbumin will decrease sooner than other lab values that assess nutrition level. 4. Incorrect: Older women may have low calcium levels which place them at risk for bone demineralization. But, prealbumin provides more data on generalized nutrition.

After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority? 1. Position the client on her left side 2. Increase the IV fluid rate 3. Place the client in the knee-chest position 4. Administer oxygen per tight face mask

3. Correct: The fetal heart pattern is that of repetitive deep variable decelerations. This pattern is likely due to a prolapsed umbilical cord after AROM. The priority intervention is to relieve the pressure on the cord from being trapped between the presenting part and the pelvis. This can be accomplished by manual pressure on the presenting part, placing the client in Trendelenburg position, or placing her in the knee-chest position. 1. Incorrect: This intervention will improve placental perfusion, but will not relieve compression of a prolapsed cord. If the cord is compressed, it doesn't matter how well perfused the placenta is because the oxygen cannot reach the baby. Late decels and low BP would be an indicator that we need to increase uterine perfusion by positioning on left side. 2. Incorrect: This intervention will not improve placental perfusion. IV fluids will not relieve compression of a prolapsed cord. 4. Incorrect: This intervention will improve placental perfusion, but will not relieve compression of a prolapsed cord. If the cord is compressed, it doesn't matter how well perfused the placenta is because the oxygen cannot reach the baby.

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? You answered this question Incorrectly 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms

3. Correct: The irrigation is regulated so that the urine is free of clots and slightly pink tinged. When it becomes clear after surgery, the fluid is going too fast and not clearing any blood clots effectively. 1. Incorrect: The irrigation should be increased if you see clots in order to keep the catheter patent. 2. Incorrect: Bladder pressure may mean that the indwelling urinary catheter is obstructed. Either increase flow or manually irrigate catheter to ensure patency and no retention of fluid in the bladder. 4. Incorrect: Bladder spasms occur with clots so you do not want to slow the irrigation if this happens. This would indicate the need for increasing the irrigation fluid rate.

One hour after administering pyridostigmine, the nurse notes increased salivation, lacrimation, and urination in the client. What initial action should the nurse take? You answered this question Incorrectly 1. Administer a second dose of pyridostigmine. 2. Place client in side lying position. 3. Notify the primary healthcare provider. 4. Prepare for intubation and mechanical ventilation.

3. Correct: These are signs and symptoms of cholinergic crisis. The client can get increasingly worse. The primary healthcare provider can prescribe atropine as treatment of overdose. 1. Incorrect: Giving an additional dose of pyridostigmine will make the client worse. 2. Incorrect: For better respiratory effort the client should be placed in a semi fowler's position. 4. Incorrect: This can be done after notifying the primary healthcare provider.

The pediatric nurse is assessing a child following an appendectomy. What is the nurse's main priority following surgery? You answered this question Incorrectly 1. Obtain vital signs every four hours. 2. Assess the need for pain medication. 3. Tally intake and output every eight hours. 4. Auscultate lung sounds every four hours.

4. CORRECT: No matter what type of surgery, recall that the effects of anesthesia and intubation, if performed, can lead to complications, particularly in children. The potential for atelectasis and pneumonia follows surgery; therefore the client is encouraged to cough and deep breathe to minimize these risks. Auscultating lung sounds frequently post-op is crucial. 1. INCORRECT: Although vital signs are important, initially the nurse should check vitals every half hour to one hour. Despite the frequency, another assessment is even more important. 2. INCORRECT: It is crucial to medicate a post-operative client; however, pain medications should never be administered until after the initial assessment as pain medication will alter important symptoms the nurse needs to determine any complications. 3. INCORRECT: Standard intake and output is tallied once a shift, or every eight hours. Though this information is vital to determine hydration and function of the kidneys, it is not the nurse's main priority.

The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention? 1. Apply warm compresses to the throat. 2. Encourage gargling to reduce discomfort. 3. Position the child supine. 4. Monitor for frequent clearing of the throat.

4. Correct: Continuous swallowing and frequent clearing of the throat are signs of bleeding. 1. Incorrect: This would increase blood flow, causing edema and bleeding, so this should not be done. 2. Incorrect: Gargling increases motion of throat and may cause bleeding. This is also something that could be a developmental challenge for a 5 year old. 3. Incorrect: The blood can drip down into the stomach and the client will wake up and vomit the old blood while lying flat. This puts the client at risk for aspiration so the nurse should place the client in a side lying position.

The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time? You answered this question Incorrectly 1. Warm the room. 2. Submerge the hand in warm water. 3. Order a K pad and apply to hand. 4. Have the client exercise the fingers to increase blood flow.

1. Correct: When caring for clients with skin grafts, we want good circulation, so warm that room up.2. Incorrect: This will not improve circulation and can lead to infection. 3. Incorrect: This will not improve circulation. Someone who has a skin graft doesn't have good sensation so there is risk of another burn to the graft with this. 4. Incorrect: Working those stiff, cold fingers will further imbalance the oxygen supply. This will not help, particularly if the environment remains cool.

Which nursing interventions will help to prevent a contracture post-operatively in a client with a below the knee amputation? Select all that apply 1. Keep the residual limb elevated on a pillow at all times 2. Ensure the residual limb is positioned flat on the bed 3. Position the client prone several times a day 4. Keep head of bed elevated with knees up. 5. Apply anti-embolism stockings to the unaffected leg

2. & 3. Correct: We want the limb flat on the bed to prevent a contracture, the prone position will also stretch out any flexion that has occurred as a defensive withdrawal to muscle spasms. 1. Incorrect: This will promote a contracture. Flexion contractures are avoided by preventing hip flexion and elevation of the limb on pillows. 4. Incorrect: This will promote rather than prevent a contracture. The client must avoid positions that promote hips being flexed. 5. Incorrect: Looks good, doesn't it? But what does the stem say? What will help prevent contractures? Anti-embolism hose have nothing to do with contractures do they? No, so again, remember to read the stem carefully and look at each option as a True/False

What should the nurse teach the client following a right knee arthroscopy? Select all that apply 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

2., 3., 4. & 5. Correct: Elevating the joint for several days will reduce swelling and pain. Tingling to the extremity could mean nerves have been damaged. Exercise is gradually started to strengthen muscles surrounding the joint and prevent scarring of surrounding soft tissues. The client needs to keep the site as clean and dry as possible. 1. Incorrect: Continuous ice can cause tissue damage.

A client with a history of angina has returned to the unit following a cardiac catherization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

4. CORRECT: The greatest risk following a cardiac catherization is the potential for hemorrhage, most often from the insertion site. Therefore, the affected extremity must remain straight and immobilized for 4-6 hours after the procedure. 1. INCORRECT: The frequency of vital signs is determined by facility protocol, but generally vital signs are obtained every ten minutes for the first half hour, then every fifteen minutes for another half hour. While vital signs provide valuable information to compare to baseline, another action is more important. 2. INCORRECT: It is vital to assess pedal pulses in order to verify circulation following a catherization. The frequency is based on facility protocol. However, this action is not the highest priority. 3. INCORRECT: Because the client is on bed rest, it is crucial for the client to be able to summon staff when needed. Despite the importance of this action, there is an even more important action.

A client with an automated internal cardiac defibrillator (AICD) was successfully defibrillated. The telemetry technician shouts out that the client was in ventricular fibrillation (VF). What should the nurse do first? 1. Go to the client to assess for signs and symptoms of decreased cardiac output. 2. Call the primary healthcare provider to report that the client had an episode of VF so medication adjustments can be made. 3. Notify the "on call" person in the cath lab to re-charge the ICD in the event that the client has a recurrence. 4. Document the incident on the code report form and follow up regularly.

1. Correct: The client comes first. Check to see how they are doing by completing a head to toe cardiac output assessment. make sure to include LOC, vital signs, skin and urinary output assessment. 2. Incorrect: Do not call before you assess the client who may be unconscious if the arrhythmia has decreased their cardiac output. 3. Incorrect: This is not needed because there is a battery that keeps it charged, so that they don't have to re-charge after each shock. 4. Incorrect: Documentation is not appropriate until the client has been assessed first.

A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? You answered this question Correctly 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate.

1. Correct: The safest response is to STOP the feedings and re-assess in 1 hour. Nausea may be a sign of intolerance. Continuing the feeding may also result in vomiting with possible aspiration. 2. Incorrect: Reducing the rate requires a primary healthcare provider's prescription and does not fix the problem. In this answer, the NCLEX people are giving you a scope of practice question. If you select this answer, you are telling the people who write the test that you are going to write prescriptions for your clients. 3. Incorrect: Changing the feeding schedule requires a primary healthcare provider's prescription and does not fix the problem. Again, with this answer, the NCLEX people are giving you a scope of practice answer. If you choose this answer, you are telling the people at NCLEX that you are going to write prescriptions for your clients. 4. Incorrect: Do not discard residual volumes. Discarding residual volumes can disrupt a client's fluid and electrolyte balance. Standard practice is to give it back. Discarding the residual requires a prescription. Continuing at the same rate is not safe when you have high residuals. The feedings should be stopped.

The nurse is assessing a client with advanced cirrhosis and notes an abdominal girth increase of 5 inches (12.7 cm) since yesterday. What is the best position for the nurse to place this client? You answered this question Correctly 1. Supine 2. Semi Fowler 3. Trendelenburg 4. Lateral, left side

2. Correct: If I've got an increasing abdominal girth, I've got lots of pressure on my abdomen, so sit me up! The head of the bed may be elevated 30 degrees or highr if the client needs help to breathe easier. 1. Incorrect: Now, look at this position. What will this position do? That's right, make it harder to breathe! 3. Incorrect: Please don't put me in Trendelenburg and stand me on my head when I am not perfusing well! 4. Incorrect: What will putting them on their left side do? Nothing, that's right!

he nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (PEEP). The high-pressure alarm begins sounding. What actions should the nurse initiate? Select all that apply 1. Check to see if client is biting ET tube. 2. Examine tubing for presence of water. 3. Inspect for any loose connections. 4. Reduce the amount of PEEP used. 5. Assess client's need for suctioning.

1, 2 and 5. CORRECT: The high-pressure alarm on a ventilator indicates the machine is pushing against excessive resistance while trying to deliver oxygen to the client. There are multiple potential causes for a high pressure alarm. The client could be fighting against the ventilator and thus biting down on the endotracheal tube. Another possible issue may be the water that accumulates in the vent tubing from condensation. Or the client may have excessive mucus in the airways that requires the nurse to suction lungs frequently. Any of these problems could initiate the high pressure alarm. 3. INCORRECT: Loose or disconnected tubing results in a low pressure alarm, indicating the ventilator is unable to exert the expected amount of pressure needed to oxygenate client. 4. INCORRECT: The amount of PEEP provided to a ventilator-dependent client is determined by respiratory diagnosis or ABGs and is ordered by the primary healthcare provider. The high pressure alarm does not generally indicate a problem with the PEEP setting.

Which finding in fetal heart rate during a non-stress test would indicate to the nurse that a potential problem for the fetus may exist? You answered this question Incorrectly 1. Increases 30 beats per minute for 20 seconds with fetal movement. 2. Increases 8 beats per minute for 10 seconds with fetal movement. 3. Remains unchanged with maternal movement. 4. Increases 5 beats per minute for 30 seconds with maternal movement.

2. Correct. A non-reactive test is when the FHR accelerates less than 15 beats per minute above baseline. This may indicate fetal compromise. 1. Incorrect. This would be a reactive test. This is characterized by acceleration of fetal heart rate of more than 15 beats per minute above baseline, lasting for 15 seconds or more. 3. Incorrect. This test does not look at fetal heart rate with maternal movement. 4. Incorrect. This test does not look at fetal heart rate with maternal movement.

A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority? 1. Psychoses 2. Renal calculi 3. Positive Trousseau's sign 4. Laryngospasm

4. Correct: Yes, airway is most important here. But don't pick it just because it sounds scary all by itself. Think about the why. When the parathyroids are removed, calcium is affected because these glands help control calcium levels in the blood. 1. Incorrect: This is disturbing, and important, but AIRWAY is priority. 2. Incorrect: Renal calculi can cause problems and lead to pain and possibly renal failure but are not as important as airway obstruction. 3. Incorrect: A positive Trousseau's sign is seen with hypocalcemia but is not the highest priority. Airway is the most important in this question.

The nurse is demonstrating ostomy care to a client with a new stoma in the sigmoid area of the colon. The nurse knows teaching is successful when the client completes care in what order?

Changing an ostomy appliance can be challenging for an individual without assistance from another individual. Successful completion of the procedure involves not only a willingness to learn, but also the client's physical capabilities to reach, view, and accomplish the task based on the type or location of stoma. The basic principles of stoma care are similar to any dressing change. The client must remove and dispose of the old, inspect and clean the area, then prepare and apply the new appliance. Though there are multiple steps, many clients can perform self-ostomy care with practice and minimal assistance. The ostomy flange is designed to remain in place for 3 to 5 days, while the bag can be changed, or cleaned, daily. There are many types of appliances, including some which are sealed and are simply thrown away at the end of each day. The steps have been simplified here, but are basic: First, remove both the ostomy bag and old flange. Second, thoroughly wash the entire abdomen with warm soapy water, being sure to wash stoma gently. (The client must be instructed to carefully inspect the skin for any signs of excoriation which should be reported to the primary healthcare provider). Third, a skin protectant is applied and allowed to dry. Fourth, the new flange is sized/cut to fit the stoma. Fifth, a thin "bead" of stoma paste is placed around the new flange opening. Lastly, Press flange into place and attach the bag. The bag is snapped over the center rim of the flange, and "burped" to allow any excess air to escape. This will create a strong seal. It is also vital to apply the clamp onto the bottom of the new bag to prevent leakage of stool.

Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? You answered this question Incorrectly 1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 3. Use cotton balls to clean the suture site. 4. Use sterile gauze squares to dry the wound 5. Use sterile forceps when cleaning the wound.

1., 2. & 5. Correct: Using cleansing solutions at body temperature enhances the healing process by not lowering the temperature of the wound and enhancing circulation to the wound bed. Drainage should be removed so that it does not become infected because drainage and exudate can create an environment where bacteria can thrive. Sterile forceps should be used so that contaminated hands/gloves do not increase the risk of infection at the wound site.3. Incorrect: Cotton balls may leave small cotton filaments behind that may serve as a site for infection.4. Incorrect: Moisture is important for the healing process, so drying the wound could delay the healing process and cause undue harm to the client. Cells that are kept moist and hydrated promote epidermal growth. This will promote the healing of the cell base of the wound.

A concerned mother is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer

3. Correct: Baseball is an activity that is considered "asthma friendly". It requires short, intermittent periods of exertion and is therefore tolerated better by children with asthma. 1. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 2. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 4. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma.

The nurse is reviewing morning laboratory results on four clients. Which lab finding should the nurse report to the primary healthcare provider immediately? Exhibit Client diagnosed with deep vein thrombus who is receiving a heparin infusion. aPTT- 85 sec Client diagnosed with possible appendicitis. WBC -18,000 per mm3 Client diagnosed with rheumatoid arthritis. Sed rate- 100 mm/hr Client diagnosed with congestive heart failure receiving furosemide. K +- 2.9 mEq/L 1. aPTT 2. WBC 3. Sed rate 4. K+

4. CORRECT: Notice that all laboratory results are abnormal, based on the disease process of each client. However, the potassium level for the cardiac client is way below normal, most likely secondary to the furosemide. Levels that low can result in premature ventricular contractions (PVCs) or other arrhythmias, placing the client at risk for sudden onset of CHF. 1. INCORRECT: The client is on the heparin infusion for a diagnosed deep vein thrombus (DVT). While normal aPTT levels should be between 20 - 36 seconds, the therapeutic levels of heparin are usually 2 ½ to 3 times normal to keep the blood thin. This result is expected and not alarming at this point. 2. INCORRECT: Appendicitis is a serious infection that is treated with either antibiotics or surgery to remove the organ. While normal WBC values are 5,000 to 10,000, this elevated result is not unexpected for an infection. 3. INCORRECT: A Sed rate or sedimentation rate, reveals inflammatory activity in the body and can be used to diagnose or monitor the status of an inflammatory disease process. The blood cells affected (erythrocytes) will settle to the bottom of a blood tube and that speed indicates the severity of the inflammatory process in the body. This is not an unexpected result in clients with rheumatoid arthritis.