Adult health

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 Incorrectly 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 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? You answered this question Incorrectly 1. Go to the client to collect data 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 collecting data related to cardiac output. Make sure to include LOC, vital signs, skin and urinary output. 2. Incorrect: Do not call before you evalute 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 evaluted first.

The nurse is caring for a client following gastric bypass surgery. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? You answered this question Incorrectly 1. Increase liquids with food. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating.

2, 3, & 4. Correct: The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. 1. Incorrect: Increasing liquids while eating will speed food processing and increase the side effects. Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. 5. Incorrect: Sitting up after a meal is counterproductive, since this will increase the speed of food through the digestive tract. Therefore, clients are encouraged to lie down on the left side following meals to slow the progress of food through the GI tract.

A client has been trying to implement a low fat diet for prevention of heart disease and enhancement of weight loss. He further reports that his wife shows her love by preparing rich foods and pastries. Which action should the nurse make? You answered this question Correctly 1. Suggest that the client prepare all meals at home. 2. Schedule a meeting with husband and wife to discuss diet and health. 3. Suggest that the client limit intake to one serving of each food at meals. 4. Ask the client to give his wife a cookbook with low fat recipes

2. Correct: The meeting with the wife and husband together may help to gain the support of the wife. She may not realize that meal preparation is actually serving as a barrier to successful change. Also, the importance of the opinions and behaviors of the wife are important to the client as he tries to engage in long-term behavioral change. 1. Incorrect: This intervention may actually increase barriers to change because the wife's feeling and support are necessary to maintain long-term change. 3. Incorrect: While this practice may reduce the intake of fat, the issue of spousal support should be addressed. 4. Incorrect: Open discussion with the wife about the need for low-fat meals is essential.

The nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include? You answered this question Incorrectly 1. Rotavirus 2. Meningococcal 3. Herpes zoster 4. Seasonal influenza 5. Human papilloma virus

2., 4., & 5. Correct: Meningococcal vaccine protects against bacterial meningitis and is recommended for students entering college. Influenza vaccine is recommended annually for protection against the viruses predicted to be most common for the season. Human papilloma virus vaccine is recommended for protection against the virus which causes cervical and anal cancers. 1. Incorrect: Rotavirus vaccine is recommended during infancy. Rotavirus is the most common cause of diarrheal disease among infants and children. 3. Incorrect: Herpes zoster vaccine is recommended for adults, over the age of 60 to reduce the risk of getting shingles.

hematemesis

blood in vomit

Cheyne-Stokes

Periods of difficult breathing (dyspnea) followed by periods of no respirations (apnea)

Biot's respirations

varying depth and rate of breathing, followed by periods of apnea; irregular

What nursing interventions should a nurse initiate for a client diagnosed with pyelonephritis? You answered this question Correctly 1. Monitor urine for dark, cloudy, foul smelling urine. 2. Place client on intake and output monitoring. 3. Decrease fluid intake to 1 liter/day. 4. Advise client that urine may change color with administration of nitrofurantoin. 5. Monitor for hypotension, tachycardia, fever.

1., 2., 4., & 5. Correct: With pyelonephritis urine will be dark, cloudy and foul smelling due to the bacteria. Anytime a client has a renal problem, that client should be placed on I&O. Nitrofurantoin, an antibiotic, will turn the urine brown. Monitor for septic shock, a complication of pyelonephritis. S/S include hypotension, tachycardia, and fever. 3. Incorrect: Fluid intake should be increased to 2-3 liters/day unless contraindicated

salpingo-oophorectomy

Surgical removal of the fallopian tubes and ovaries

Celiac disease treatment

gluten free diet

A client with chronic obstructive pulmonary disease (COPD) learns about the importance of a nutritious diet to avoid weight loss. Which food selections for a breakfast menu show understanding by the client? You answered this question Incorrectly 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast

1. Recall that clients with COPD struggle with even simple daily activities because of the difficulty in breathing. Any physical exertion, such as getting dressed or preparing a meal, increases dyspnea to the point that the client is too tired to actually eat. Obviously, weight loss is of great concern, but malnutrition can lead to additional health problems. Labored breathing requires more energy from the body, increasing caloric needs. Clients who are underweight are more susceptible to infection, and do not recover as quickly. Therefore, good nutrition provided in a manner the client can tolerate is vital. 2. The key for COPD clients is a high protein diet provided in small, frequent meals, with fluids throughout the day to help thin and remove excess secretions. The nurse needs to evaluate if the client understands this properly by presenting a list of foods and requesting choices for a good breakfast. 3. Option 1: Great choice. Eggs are a high quality protein that can be prepared in a variety of ways, or cooked into foods at several meals. 4. Option 2: Absolutely. A cheese omelet has several benefits because it incorporates eggs as well as cheese, both excellent sources of protein. The client is making good meal choices. 5. Option 3: Yes, fresh fruits and vegetables are great to incorporate into this client's diet. Fruits contain Vitamin A and antioxidants that help to fight inflammation. Additionally, fruits and vegetables provide fiber which aids in digestion. Anything that helps the body to function more efficiently decreases the effort of breathing. 6. Option 4: Another good selection. Clients with COPD struggle with excess mucus production, and are encouraged to drink fluids throughout the day, as well as with meals. Orange juice combines the nutritious properties of fruit into a liquid, making this an ideal healthy drink selection. 7. Option 5: Not quite. Whole milk contains a great deal of fat, and while clients do need a small amount of fat for digestion, this is not the best type. Low fat milk, containing both protein and vitamin D along with calcium, is a much healthier choice for this client. Whole milk tends to increase the amount of secretions, making it even more difficult for the client to breathe. 8. Option 6: Nope. Dry toast has very little nutritious value, plus the brittle nature of this selection may increase the client's coughing. That will quickly lead to exhaustion and the inability to complete the meal. A better choice would be something like a muffin or even French toast, since both also contain egg protein.

What risk factors does the nurse know for developing varicose veins? You answered this question Correctly 1. Sitting for prolonged periods 2. Obesity 3. Female 4. Leg exercises 5. Wearing high-heeled shoes

1., 2., 3, & 5. Correct: These are all risk factors for developing varicose veins: Sitting or standing for prolonged periods of time, obesity, female gender, wearing high-heeled shoes. 4. Incorrect: Exercise is good for preventing varicose veins. Get moving. Walking is a great way to encourage blood circulation to the legs.

Which signs and symptoms if noted in a male client would lead the nurse to suspect prostate cancer? You answered this question Incorrectly 1. Dysuria 2. Proteinuria 3. Nocturia 4. Polyuria 5. Lower back pain 6. Pyuria

1., 3., 4. & 5. Correct: The warning signs of prostate cancer include weak or interrupted urine flow, inability to urinate, difficulty in starting or stopping urine flow, polyuria, nocturia, hematuria, or dysuria. Continuing pain to the lower back, pelvis and upper thigh is also a sign of prostate cancer. 2. Incorrect: Proteinuria is protein in the urine. You would not expect to see protein in the urine unless the glomerulus has been damaged. 6. Incorrect: Pyuria is white blood cells in the urine and would be seen with infection.

The nurse on a neuro rehabilitation unit is caring for a client with a upper spinal cord lesion. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate? You answered this question Incorrectly 1. Place client supine with legs elevated. 2. Check bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer hydralazine if BP does not return to normal.

2., 3., 4., 5. & 6. Correct: The client is experiencing autonomic dysreflexia, which is a potentially dangerous syndrome that can develop in clients with spinal cord injuries. The cause of autonomic dysreflexia with these associated symptoms is a strong sensory or noxious stimulus. The most common stimulus is bowel, bladder distention, or irritation. Any painful, irritating or strong stimulus including environmental temperature changes, drafts, etc. can trigger autonomic dysreflexia. It is considered a medical emergency and must be promptly treated. 1. Incorrect: The client should be placed immediately in a sitting position to lower blood pressure. The supine position with the legs elevated could increase the BP to higher and more dangerous levels.

The nurse is caring for a client who receives furosemide 40 mg PO twice daily, as well as 20 meq of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.4 mEq/L this morning. How should the nurse proceed? You answered this question Correctly 1. Notify the primary healthcare provider of the potassium level immediately. 2. Administer the medications as scheduled and notify the primary healthcare provider on rounds. 3. Give the potassium, but hold the furosemide until primary healthcare provider rounds. 4. Assess the client for muscle cramps.

1. Correct: Yes, this is a very low level. Normal values are 3.5-5.0 mEq/L. This client will need more potassium and less furosemide (a potassium wasting diuretic). 2. Incorrect: No, potassium is dangerously low. Giving the furosemide will drop the potassium level further since it is potassium wasting. Do not wait for the primary healthcare providers to make rounds as they often do not make predictable rounds. 3. Incorrect: This is delaying care and confuses the issue of how much potassium needs to be administered now. 4. Incorrect: Delays care. What if there are no symptoms? Will you wait for symptoms to treat?

The nurse is caring for a client with myasthenia gravis. What teaching is essential for the nurse to reinforce with this client regarding treatment? You answered this question Incorrectly 1. Frequent low-calorie snacks. 2. Strict monitoring of intake and output. 3. Use of sweeping gaze when walking. 4. Setting the alarm clock for medication times.

4. Correct: Yes! Medication must be taken on time. Too early can cause weakness and too late can cause extreme weakness to point of paralysis. 1. Incorrect: No, the client needs frequent high calorie snacks. 2. Incorrect: No, this is not a cardiac or renal client. 3. Incorrect: No, this is done when the client has homonymous hemianopsia.

Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet? You answered this question Incorrectly 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

A clear liquid diet helps maintain adequate hydration, provides some important electrolytes, such as sodium and potassium, and gives some energy at a time when a full diet isn't possible or recommended. The following foods are allowed in a clear liquid diet: Water (plain, carbonated or flavored) Fruit juices without pulp, such as apple or white grape Fruit-flavored beverages, such as fruit punch or lemonade Carbonated drinks, including dark sodas (cola and root beer) Gelatin Tea or coffee without milk or cream Strained tomato or vegetable juice Sports drinks Clear, fat-free broth (bouillon or consomme) Honey or sugar Hard candy, such as lemon drops or peppermint rounds Ice pops or popsicles without milk, bits of fruit, seeds or nuts Any foods not on the above list should be avoided.

Which intervention would the nurse recognize as in best helping to relieve joint stiffness in a client with rheumatoid arthritis? You answered this question Incorrectly 1. Take a warm shower prior to performing activities of daily living. 2. Take an aspirin after activity to help decrease inflammation. 3. Lose 10 pounds of weight. 4. Apply cold compresses to joints for 30-45 minutes.

1. Look at each option as True or False. 2. Option 1 is true. Warm baths and/or showers can help relieve joint stiffness and allow the client to more comfortably perform ADLs. 3. Option 2 is false. Aspirin or other anti-inflammatory drugs or analgesics should be taken before activity to help decrease inflammation and reduce joint pain. 4. Option 3 is false. Weight loss may decrease stress on joints but pain and stiffness will still be a problem. 5. Option 4 is false. Cold compresses may be effective for reducing joint pain; heat is used for decreasing pain and stiffness. When a client uses a cold compress, the time should be limited to 10 to 15 minutes to decrease risk of tissue damage.

A nurse is collecting data on a client who is reporting bone pain secondary to cancer with metastasis to the bone. What does the nurse determine is the most important information to gather at this time? You answered this question Correctly 1. The physical symptoms of the client 2. The hemoglobin and hematocrit levels 3. The amount of pain medication the client is receiving 4. The client's description of the pain

4. Correct: The most important information to gather is the client's perception and description of the pain. Pain is subjective, based on the client's perception. This is also the primary complaint of the client at this time. 1. Incorrect: The question is asking about the client's pain. The physical symptoms are important but does not address the client's perception of their own pain. 2. Incorrect: RBCs are produced in the bone marrow. The H&H might be affected but will not be the cause of the pain and can be monitored later with lab and diagnostics. 3. Incorrect: The amount of pain medication is important, but is not the most important information to gather from a client who is reporting pain, particularly with cancer and metastatic bone pain

The nurse is preparing to administer scheduled medications for a client. Which medication would require clarification prior to administration? Exhibit You answered this question Correctly 1. Digoxin 2. Sacubitril/valsartan 3. Bumetanide 4. Potassium chloride

3. Correct: Bumetanide is a loop diuretic. What is worrisome about giving this medication is the fact that the client is allergic to sulfonamides. It is contraindicated because there is a cross-sensitivity with thiazides and sulfonamides. 1. Incorrect: Digoxin is a cardiac glycoside. There is nothing in the chart or other medications that prevent this medication from being administered. 2. Incorrect: Sacubitril/valsartan is a combination medication used to reduce the risk of cardiovascular death and hospitalization for heart failure. The client should not take this medication within 36 hours before or after taking any ACE inhibitor or other ARB medication. Watch for hypotension, hyperkalemia, and impaired renal function. There are no indications of adverse effects in this question. 4. Incorrect: Administering potassium chloride is acceptable since this client is on a loop diuretic which depletes potassium and digoxin. You do need to monitor for hyperkalemia as well since the client is on sacubitril/valsartan. The serum potassium level is normal in this client.

paresthesia

abnormal sensation of numbness and tingling without objective cause

Which client should the nurse recognize as being at greatest risk for the development of cancer? You answered this question Correctly 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.

Guillain-Barre Syndrome (GBS)

temporary paralysis caused by an autoimmune attack on peripheral myelin, causing weakness and usually ascending paralysis of the limbs, face and diaphragm

When caring for a client admitted with a diagnosis of pheochromocytoma, which finding would indicate the client has elevated levels epinephrine and norepinephrine? You answered this question Incorrectly 1. Headache 2. Hypotension 3. Bradycardia 4. Polycythemia

1. Correct. This disease is characterized by a headache, hypertension, tachycardia, hypermetabolism and hyperglycemia due to the increased release of epinephrine and norepinephrine. 2. Incorrect. Hypertension, rather than hypotension, would be seen in this client. 3. Incorrect. The heart rate will increase rather than decrease. 4. Incorrect. Polycythemia is elevated red blood cell count, which is not seen with this disease.

Which symptom identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider? You answered this question Incorrectly 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.

The nurse is caring for a client with a suspected urinary tract infection. Which symptoms are associated with urinary tract infections? You answered this question Incorrectly 1. Bradycardia 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia

2., 3., 4. & 5. Correct: Signs and symptoms of UTI include frequency, urgency, burning on urination, nocturia, incontinence, suprapubic, or pelvic pain, hematuria and back pain. 1. Incorrect: Bradycardia would not be a s/s of urinary tract infection.

The nurse is assigned to bathe a client diagnosed with dementia. Which nursing intervention should the nurse implement? You answered this question Correctly 1. Increase the volume of the television. 2. Finish the bath as soon as possible. 3. Clean the face and hair at the end of the bath. 4. Delegate another nurse to distract the client.

3. Correct: The client with dementia begins to be separated from reality. Gradually the client will decrease their ability to perform activities of daily living. These steps in the bathing process should be performed last because bathing the face and washing their hair may upset the client. 1. Incorrect: Because the client is having difficulty processing sensory input, the loud volume on the television will increase the anxiety of the client. The television should be turned off during the bath. 2. Incorrect: Finishing the bath as soon as possible does not address the client's inability to process the bath procedure. The client's bath should not be rushed. The nurse should proceed with the bath in a calm and controlled manner that will reduce the client's anxiety. 4. Incorrect: Options that transfer nursing responsibility to other members of the healthcare team usually are incorrect.

The nurse on a surgical unit is collecting data on several post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? You answered this question Incorrectly 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers

4. Correct: One potential risk during a thyroidectomy is the accidental removal of some or all of the parathyroid glands. The client would develop signs and symptoms of hypocalcemia from decreased blood levels of calcium. As muscles become rigid and twitch, the resulting tetany would cause the client to experience a tingling sensation in toes and fingers. The nurse needs to notify the primary healthcare provider so that a calcium level can be drawn and the client given supplemental calcium. 1. Incorrect: Following a transurethral resection of the prostate (TURP), it is normal for urine to be cherry red in color. Continuous bladder irrigation will keep clots from developing over several days and the deep red color of urine is an expected finding following this procedure. 2. Incorrect: Mastectomy clients return from surgery with one or more drains placed under skin flaps in the breast tissue. These drains are part of a collection system that allows serous drainage to be removed from the surgical site, thus enhancing the healing process. 40 mL over 3 hours is not an excessive amount. This is an expected finding that does not need to be reported. 3. Incorrect: The sign of a healthy stoma post-op is a beefy red appearance and slightly elevated above the level of the abdomen. It is expected that the stoma will have a mucoid discharge for a day or so until normal stool begins to form again. This client displays normal post-operative findings with nothing unexpected. This is a priority question in which the nurse must determine the difference between what is expected in a particular post-op client, and what findings might indicate potential complications. That means you will need to recall each surgical procedure and what would be normal. After analyzing all four procedures, you must then decide what symptoms might require immediate intervention by the primary healthcare provider. The best approach is to eliminate any client whose post-op symptoms are normal or expected. Option 1: No problem here, right? When a client has a transurethral resection of the prostate, what would you expect the urine to look like? Bright cherry red in color because of the surgery. A three-way catheter is in place for continuous bladder irrigation, which prevents the formation of clots and keeps the urine flowing. This color will last for several days, and the nurse will monitor for the appearance of clots which would indicate a problem. Option 2: Were you unsure about this amount of drainage? Consider what happens when breast tissue is disturbed. A mastectomy is very invasive, cutting into lymph tissue, also creating large amounts of serous discharge. Several small drains are sutured into the incision and hooked to a collection system, like a Jackson Pratt drain or Hemovac. Removing this extra fluid will help the incision heal better and decrease discomfort caused by a buildup of pressure. Depending on the depth of the surgical cut, drainage varies from several hundred milliliters in the first 24 hours to less than 50 mL. The amount listed here is very small even for 3 hours. Option 3: Nothing wrong here! Recall what you learned in school about a fresh stoma. Post operatively, the stoma should be a deep beefy red. A pale stoma would indicate lack of proper circulation. Surgery always causes swelling because of tissue trauma, and so the stoma should be elevated above the level of the abdomen. Also remember that there will not be any stool initially; instead, the client should have mucoid discharge from the stoma for a day or two until the body resumes normal bowel function. Option 4: Now here is a problem! When you think about a thyroidectomy, what are some of the things that pop into your mind? Airway, of course! Positioning and checking the back of the neck for pooling of blood are also very good! But what else could go wrong? A couple of the parathyroid glands could be accidently removed, couldn't they? So now let's quickly think about the pathophysiology of that. Damage or removal of parathyroid glands causes a decrease of blood calcium levels. The resulting hypocalcemia causes tight rigid muscles that place the client at risk for everything from seizures to laryngospasms to tetany. This is definitely a serious, unexpected complication that the nurse will need to report immediately to the primary healthcare provider so that a current calcium level can be ordered, followed by administration of replacement calcium.

PTT levels are monitored for what drug

Heparin 30-40 seconds, but desired outcome of heparin therapy is PTT of 1.5-2.5 times the control without signs of hemorrhage

A client with a history of myasthenia gravis (MG) has been discharged from the hospital following a thymectomy. When reinforcing teaching with the client on how to prevent complications, the nurse emphasizes what daily actions are most important? You answered this question Incorrectly 1. Include daily weight lifting exercises. 2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals. 5. Eat three large meals daily.

The topic in this question is myasthenia gravis, an autoimmune disorder in which the client experiences progressive muscle weakness throughout all body systems. This client had a thymectomy, a surgical option for some MG clients in which removal of the thymus gland may slow the progress of the disease. The responsibility of this homecare nurse is reinforcing teaching with the client on how to manage this disease process at home. In a select all that apply question, each option must be considered as either true or false. Once the decision is made, go to the next option. Option 1: Not exactly correct. Exercise is definitely important for the MG client, but only gentle exercises completed early in the day when the client has the most energy. Weight lifting is much too strenuous and would place the client at risk for exhaustion or an exacerbation of weakness. Option 2: Good choice! Stress can quickly contribute to an exacerbation of this disease process, referred to as a myasthenic crisis. The homecare nurse reminds the client to include consistent stress reduction techniques, such as biofeedback or guided imagery, into daily activities because these techniques help MG clients improve their daily functioning ability. Option 3: Important action for the client! Remember that clients with myasthenia gravis experience increasing weakness as the day progresses. Therefore, all ADL's or chores should be scheduled early in the day while the client is strongest. When these clients do not rest frequently, they place themselves at risk for a myasthenia crisis, which could put the airway at risk! Option 4: Medication timing is important for all clients but particularly critical for the myasthenia client. Standard MG medications, including pyridostigmine bromide (Mestinon) and neostigmine (Prostigmin), are anticholinesterase drugs designed to increase acetylcholine for neuromuscular function. However, the action of these medications usually lasts just 6 hours, so taking the meds on time is crucial for this client. Additionally, meds work better when taken with food. Option 5: Not a good action for clients with MG. The biggest concern with clients experiencing neuromuscular dysfunction is airway patency, followed closely by the potential for aspiration. Any activity that overwhelms the body's finite supply of energy will place the client at risk, so frequent smaller meals are much safer than three large meals!

The charge nurse of a large medical-surgical unit is admitting several clients requiring specific infection control precautions. The LPN/VN is aware that droplet precautions are necessary for which client diagnosis? You answered this question Incorrectly 1. Mumps 2. Methicillin resistant Staphylococcus aureus (MRSA) 3. Shingles (Herpes Zoster) 4. Human immunodeficiency virus (HIV) 5. Pertussis

We are discussing infection control protocols in the hospital setting. In order for the nurse to properly assign clients to the correct rooms, it is necessary to understand how each of these illnesses is transmitted. The issue is safety of staff and other clients when determining the type of protection procedures that need instituted. The question asks you to specifically select clients needing droplet precautions. So, let's consider the transmission mode for each of these diseases. If you cannot remember the exact type of isolation required for a disease process, think about the symptoms the client may display. That will provide a great clue! Option 1: Very good. Mumps, also called parotitis, is an inflammation of the salivary glands on one or both sides of the face, and is highly contagious. The virus responsible for this illness is found in the saliva of the client and is spread by sneezing, coughing or direct contact with anything contaminated by the saliva. Remember that the saliva enters the environment in droplet form; therefore, this client definitely needs droplet precautions because secretions can be spread up to 3 feet away! Staff should wear gloves, gowns, and even masks to prevent being contaminated, or even carrying any saliva on clothing to another room. Option 2: Not this one. MRSA is a direct contact problem. These microorganisms are spread by directly touching the client or any environmental surfaces that have been contaminated by the client, such as linens or cutlery. This client will need to be placed in contact precautions. Even housekeepers entering the room to clean must be fully garbed. Option 3: Did this one confuse you a bit? Clients with shingles (Herpes zoster) need several types of precautions, but not droplet. This illness occurs in clients who have had chickenpox as a child, resulting in painful, weeping lesions that can be in one body location or disseminated to several areas of the body. Contact with those lesions can spread the disease, even to those who have never had the chickenpox. Visitors and staff will need to use gloves, gowns, and masks until those lesions are dry and crusted. The nurse would initiate contact precautions for this client. Option 4: This one is often confusing for everyone. HIV can be as intimidating for staff as for the clients. However, an HIV client needs only same the standard (universal) precautions. Because the question did not indicate any open wounds or invasive procedure, the nurse will not need any special infection control protocols other than those used for all clients. Option 5: Great choice. Pertussis is a very contagious disease only found in humans. It is spread from person to person. People with pertussis usually spread the disease to another person by coughing or sneezing or when spending a lot of time near one another where you share breathing space.

hemiplegia

paralysis of one side of the body

hypotonia

reduced muscle tone or tension

When collecting data for the development of an infection following the application of a plaster cast to the leg, the nurse should reinforcing teaching to 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 reinforcing instructions to a client with chronic obstructive pulmonary disease (COPD) about nutrition and maintaining body weight. Which information is most important for this client? You answered this question Incorrectly 1. Do postural drainage just before meals. 2. Consume fluids only at meal times. 3. Prepare meals high in carbohydrates. 4. Plan rest periods before and after meals.

1. You remember that in chronic obstructive pulmonary disease (COPD) inflammation of lung tissue causes difficulty breathing which quickly tires the client during any activity. The lungs are constantly building up excess mucus, making it even harder to breath. One important area of concern in these clients is weight loss which can lead to malnutrition. Dyspnea prevents the client from eating a complete meal. When a client is underweight, the body has to work even harder to breath or stay warm, and there is an increased susceptibility to infection. Assisting the client to understand how to improve dietary intake and breath at the same time is an important topic by the nurse. 2. Option 1: Wrong topic of discussion. While it is true that the client should perform postural drainage an hour before, or two hours after meals, postural drainage techniques are not the focus at this time. 3. Option 2: Definitely wrong. Did you notice that this answer includes the word "only"? That word is another absolute word like "always", or "never". These words are like red flags of caution because absolutes are rarely accurate. Also, you are aware that because excess mucus build up occurs continually in clients with COPD, drinking fluids throughout the day is important to help thin and expectorate the mucus. Besides, filling up with fluids would be counterproductive for this client who needs nutrients. 4. Option 3. Not the right food group. The concern is nourishment and extra calories provided in small, frequent meals that the client will easily be able to complete. The client needs high protein foods such as eggs, fish, cheese, and poultry with some fiber to improve digestion. However, there is one more important aspect of dietary intake that should be discussed first. Try again. 5. Option 4: Excellent. Even more important than what the client eats is whether the client is able to complete the meal. Dyspnea and exhaustion often prevent a COPD client from consuming enough calories or nutritious foods to maintain normal body weight. Just preparing the food can tire the client too much to eat anything. Resting just before and immediately after for at least 30 minutes will help improve the client's oral intake.

Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy? You answered this question Incorrectly 1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 4. Decreased sensitivity to sound. 5. Decrease inability to taste. 6. Numbness of affected side of face.

1., 2., 3., 5., & 6. Correct. Symptoms of Bell's Palsy include sudden weakness or paralysis on one side of the face that causes it to droop (main symptom), drooling, eye problems (such as excessive tearing or a dry eye), loss of ability to taste, pain in or behind ear, numbness in the affected side of face, increased sensitivity to sound on the affected side. 4. Incorrect. There would be increased sensitivity to sound on the affected side with Bell's Palsy.

INR lab values

2-3, critical value if off, potential for patient to bleed. Use default order for order ?'s (hold all coumadin, assess for bleeding, prepare Vit K (antidote for Coumadin), Call or notify

What is the diet of choice for a client on hemodialysis? You answered this question Incorrectly 1. Low fluid, extra protein, low sodium 2. Low protein, fluid restriction, low potassium 3. Low sodium, low potassium, low carbohydrate 4. Low fat, low sodium, complex carbohydrates

2. Correct: Yes, we need to restrict the protein to restrict the waste build up, they only get dialyzed every other day so restrict the fluid, and restrict the sodium and potassium. 1. Incorrect: Extra protein is not needed. Protein needs to be restricted. 3. Incorrect: No low carbohydrates. The client needs the carbs for energy. 4. Incorrect: This option doesn't restrict either protein or fluid. The protein and fluid needs to be restricted.

To reduce the risk of developing a hematoma post-balloon angioplasty, the nurse should implement which measure? You answered this question Correctly 1. Elevate the head of the bed 45 degrees. 2. Check the puncture site every 8 hours. 3. Assist the client to the bathroom to void. 4. Prevent flexion of the affected leg.

4. Correct: Let the clot remain stable for a while. The insertion site should stay immobile for several hours to reduce bleeding. 1. Incorrect: No, that's flexing the hip and disrupting the clot. It may take several hours before a client is allowed to sit up in bed. 2. Incorrect: Checks are needed more frequently than every 8 hours. 3. Incorrect: No! Don't get up and walk yet, although in general, clients who have angioplasty can walk around within 6 hours after the procedure.

A client has returned to the unit following an upper gastrointestinal series (Upper GI). What is the nurse's priority action? You answered this question Incorrectly 1. Keep client NPO until the gag reflex returns. 2. Perform an immediate cleansing enema. 3. Administer 30 mLs milk of magnesia orally. 4. Monitor vital signs every ten minutes until stable.

Recall that an Upper GI may also be called an esophagram or barium swallow. A client is NPO after midnight, including no chewing gum or mints! Once in the X-ray department, the client will drink barium based contrast and then x-ray images are taken under fluoroscopy to view the esophagus, stomach and small intestines for diagnostic purposes. A small amount of ionizing radiation is used to view all the structures. Occasionally the client is also asked to drink baking-soda crystals to improve images. That is rather like drinking Alka-Selter crystals! This entire procedure can detect ulcers, tumors, inflammation, scarring, hiatal hernia, blockages or abnormalities. The client must be asked about allergies to iodine prior to the test. This test may be ordered for clients suffering from reflux, difficulty swallowing, frequent or painful indigestion, or blood in stools. Following the procedure, clients are instructed to drink large amounts of water or fluids to help move barium through the gastrointestinal system. The nurse, or client, must observe for gray or whitish stools appearing within 48 to 72 hours. Clients may experience some abdominal bloating or minor discomfort temporarily. But what is the first priority action following return to the floor? Option 1: Certainly not! Following any procedure, it is very common to think about airway. However, not every procedure requires the inactivation of the gag reflex. How could the client drink the barium contrast if the gag reflex was inactivated? Try again. Option 2: No way. Eventually the barium will work its way down through the small intestine to the colon, and out of the gastrointestinal tract. However, immediately after the procedure a cleansing an enema would not be effective. Recall that the best way to clean out the upper GI tract is generally from the top down! Option 3: Great choice! Barium has a tendency to harden and block the bowel if not expelled within a couple days. The nurse and client both would observe for chalky or gray stools in 48 to 72 hours. In addition to drinking large amounts of fluid, the client is given milk of magnesia orally to help flush the barium before complications occur. Option 4: Wrong selection. The client was neither sedated nor given any medications that would impact vital signs. During an Upper GI, the client is fully awake and interactive in the entire procedure. No need to monitor vitals every ten minutes.

INR levels

0.7-1.8 on warfarin 2-3

The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? You answered this question Correctly 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine

3. Correct: We want to position for comfort with the knees flexed and on the side for airway. 1. Incorrect: Avoided to prevent pooling and edema in pelvis 2. Incorrect: Partial lying on stomach is going to be painful 4. Incorrect: Stretching out straight puts pressure on the abdomen and should be avoided

Apraxia

impaired ability to carry out motor activities despite intact motor function

Cystitis (UTI)

inflammation of the bladder

While completing the nutritional history of a client admitted with pernicious anemia, the nurse determines that the client follows a strict vegan diet. What education should the nurse reinforce to the client? You answered this question Incorrectly 1. Vitamin B12, a nutrient needed to prevent pernicious anemia, is found in some foods like meat, fish, eggs, and milk. 2. In order to increase intake of vitamin B12, your diet must contain beef or chicken liver at least once per week. 3. In addition to eating plants, you should eat dairy products and eggs in order to prevent pernicious anemia. 4. Vegetables high in protein include cabbage, carrots and squash. 5. Pernicious anemia occurs when the body produces red blood cells that are larger than normal and result in a lower than normal red blood cell count.

1. & 5. Correct: Pernicious anemia is a type of vitamin B12 anemia. The body needs vitamin B12 to make red blood cells. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. 2. Incorrect: The client does not have to eat meat or dairy products in order to obtain vitamin B12. Supplements can be taken and the client can eat vegetables that are considered to be high in protein. 3. Incorrect: A strict vegan will not eat dairy products or eggs. 4. Incorrect: For a vegetable to qualify as a low-protein source, it must contain 4g or less of protein. Green vegetables, such as lettuce, cabbage, bell pepper and asparagus provide only 1 to 2g of protein per serving. Orange vegetables, including carrots, sweet potatoes and squash also contain only 1 to 2 g. Pernicious anemia is a type of vitamin B12 anemia. The body needs vitamin B12 to make red blood cells. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Without enough vitamin B-12, the body will produce abnormally large red blood cells called macrocytes. Because of their large size, these abnormal cells may not be able to leave the bone marrow, where red blood cells are made, and enter the bloodstream. This decreases the amount of oxygen carrying red blood cells in the bloodstream and can lead to fatigue and weakness. Pernicious anemia is a type of macrocytic anemia. It's sometimes called megaloblastic anemia because of the abnormally large size of the red blood cells produced. A strict vegan will not eat dairy products or eggs. The client does not have to eat meat or dairy products in order to obtain vitamin B12. Supplements can be taken and the client can eat vegetables that are considered to be high in protein. A good source of protein provides 5 to 10g. Vegetables high in protein include soybeans, quinoa, edamame, lentils, peas, and pumpkin seeds. For a vegetable to qualify as a low protein source, it must contain 4g or less of protein. Although the protein content of vegetables varies by type, most vegetables are considered low in protein. Green vegetables, such as lettuce, cabbage, bell pepper and asparagus provide only 1 to 2g of protein per serving. Broccoli and spinach are exceptions, providing 4 and 5g per serving, respectively. Orange vegetables, including carrots, sweet potatoes and squash also contain only 1 to 2 g.

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 Incorrectly 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.

Following a thyroidectomy, a client reports shortness of breath and neck pressure. Which nursing action is the best response? You answered this question Correctly 1. Remove the dressing and elevate the head of bed. 2. Call a code, open the trach set, and position the client supine. 3. Obtain vital signs. 4. Immediately go to the nurse's station and call the primary healthcare provider.

1. Correct: The nurse should identify that the client is in respiratory distress. So get the dressing off the neck, elevate the HOB and see if they can breathe any better. Stay with the client. 2. Incorrect: Calling a code and opening a trach set is premature. What is likely the problem? Swelling around the airway. Do something that will decrease swelling. Placing the client flat will make the swelling and breathing worse. 3. Incorrect: Don't just look and check. The nurse must do something. This is delaying treatment. Checking the vital signs will not correct the problem. 4. Incorrect: Never leave an unstable client. If the client is having trouble breathing, then that client is unstable. The nurse can call the primary healthcare provider from the room.

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? You answered this question Incorrectly 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

1. Correct: These are symptoms of pesticide exposure when combined with the details given of coming from the fields. Death can result from severe acute pesticide poisoning. 2. Incorrect: The data provided does not lead the nurse to suspect heat stroke. The stem does not tell the temperature the farmer is working in. Heat stroke signs and symptoms include increased sweating, tachypnea and temperature greater than 105.8°F (41.0°C). 3. Incorrect: The data provided does not lead the nurse to suspect anthrax poisoning. The worker has been outside in a field. This is not a risk factor for anthrax exposure. Inhalation anthrax develops when you breathe in anthrax spores. It's the most deadly way to contract the disease, and even with treatment it is often fatal. Initial signs and symptoms of inhalation anthrax include: Flu-like symptoms, such as sore throat, mild fever, fatigue and muscle aches, which may last a few hours or days. Mild chest discomfort, Shortness of breath, Nausea, Coughing up blood, Painful swallowing 4. Incorrect: The data provided does not lead the nurse to suspect gastroenteritis. These signs and symptoms do not go with gastroenteritis. Gastroenteritis signs and symptoms include diarrhea, nausea, vomiting, fever and abdominal cramping.

Which statement, if made by the client, would indicate to the nurse that teaching has been successful regarding Bell's Palsy? You answered this question Incorrectly 1. "I need to do facial exercises several times a day." 2. "I should wear an eye patch over my weak eye when I go to bed." 3. "Cold compresses can be applied to my face to relieve pain." 4. "It will be necessary for me to take steroids for the rest of my life." 5. "I should protect my eyes by wearing sunglasses."

1., 2. & 5. Correct: While paralysis lasts, nursing care involves protection of the eye from injury. Frequently the eye does not close completely and the blink reflex is decreased, so the eye is vulnerable to injury. To prevent injury, the eye should be covered with a protective shield at night. Eye drops or ointment should be placed in the eye. Sunglasses or goggles may be worn during the day to decrease chance of injury. After the sensitivity to the nerve to touch decreases, the client can massage the face several times a day to prevent muscle atrophy. 3. Incorrect: Exposure to cold and drafts should be avoided because it will cause pain. Heat may be applied to the involved side of the face to promote comfort and blood supply through the muscles. 4. Incorrect: Corticosteroid therapy may be prescribed to reduce inflammation and edema. This reduces vascular compression and permits restoration of blood circulation. It is not needed for the rest of the client's life.

The nurse is providing foot care to the client who has diabetes. The nurse reinforces teaching with the client about proper care of the feet. What should the nurse include in the discussion? You answered this question Correctly 1. Inspect the feet daily for abrasions or pressure areas. 2. Check water temperature with the hands before getting into tub. 3. Do not use heating pads on the feet or lower legs. 4. Thoroughly dry the feet, especially between the toes. 5. Cut toenails rather than file them. 6. Cut nails in a rounded fashion.

1., 2., 3. & 4. Correct: The feet should be inspected daily. Small tears or abrasions can occur without the client's awareness due to decreased sensation in the feet. The client may be burned by getting into water that is too hot due to decreased sensation in the feet. There is less chance of decreased sensation in the hands. Heating pads may burn the client's feet. It is better to apply blankets for warmth. Drying the feet and between the toes will prevent skin breakdown. 5. Incorrect: Filing is safer, as it is not likely to result in cutting or irritating the skin around the nail. A cut on the lower extremity can result in an infection. Clients should not cut their nails. Filing is safer. 6. Incorrect: The nails should be filed straight across. Filing into a round shape may result in an ingrown toenail, which may lead to infection. Skin breaks on the lower extremity can lead to infection

Which food items, if chosen by a client diagnosed with diverticulosis, would indicate to the nurse that the client understands the prescribed diet? You answered this question Incorrectly 1. Avocados 2. Acorn squash 3. Applesauce 4. Lima beans 5. Raspberries 6. Cottage cheese

1., 2., 4., & 5. Correct: High fiber foods include raw fruits, legumes, vegetables, whole breads, and cereals. Avocados have 10.5 grams of fiber per cup. Acorn squash has 9 grams of fiber per cup. Lima beans 13.2 grams of fiber per cup. Raspberries have 8 grams of fiber per cup. 3. Incorrect: Raw fruits have more fiber than cooked or processed fruits. A raw apple would provide more fiber than applesauce. 6. Incorrect: Milk and foods made from milk: such as yogurt, pudding, ice cream, cheeses, cottage cheese and sour cream are low fiber. The average adult only eats 15 grams of fiber per day. Women need 25 grams of fiber per day, and men need 38 grams per day, according to the Institute of Medicine. Total dietary fiber intake should come from food. A high fiber diet Is prescribed in the prevention or treatment of a number of gastrointestinal, cardiovascular, and metabolic diseases. Diverticulosis is one disease where a high fiber diet may help to relieve symptoms. But do not get confused. Diverticulosis is high fiber. Diverticulitis (active inflammation) needs low fiber! Increased fiber should come from a variety of sources including fruits, nuts, legumes, vegetables, whole breads, and cereals. Top sources of fiber are: beans (all kinds), peas, chickpeas, black-eyed peas, artichokes, whole wheat flour, barley, bulgur, bran, raspberries, blackberries, and prunes. Good sources of fiber include: lettuce, dark leafy greens, broccoli, okra, cauliflower, sweet potatoes, carrots, pumpkin, potatoes with the skin, corn, snap beans, asparagus, cabbage, whole wheat pasta, oats, popcorn, nuts, raisins, pears, strawberries, oranges, bananas, blueberries, mangoes, and apples. Avoiding refined grains -- such as white flour, white bread, white pasta, and white rice -- and replacing them with whole grains is a great way to boost the amount of fiber.

The nurse is contributing to a educational program for clients at the community center about influenza. Which risk factors for influenza complications should the nurse recommend? You answered this question Incorrectly 1. Age over 65 years. 2. History of grand mal seizures 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

1., 3., 4. & 5. Correct: Clients who are over the age of 65, have diabetes, have renal disease, or who reside in a nursing home are all at risk for post-influenza complications. 2. Incorrect: A client who has grand mal seizures would not put the client at risk for flu complications. If the client has the other risk factors, then flu complications are more likely.

PT levels

11-13.5 sec

What actions would the nurse expect to see in the care plan of a client admitted with Guillain-Barre syndrome? You answered this question Incorrectly 1. Monitor 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. 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 monitor for signs of respiratory distress and prepare for intubation if needed. 1. Incorrect: Ascending paralysis would be montiored 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.

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. Which information requires the most immediate action by the nurse? You answered this question Incorrectly 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature. 4. Urine description and output.

2. Correct. Septic shock involves persistent hypotension. The low blood pressure indicates that systemic tissue perfusion will not be adequate. This decreased perfusion will result in dysfunction and sometimes failure of one or more organs, such as the kidneys, heart, brain, liver and lungs. The blood pressure needs to be improved rapidly. This will be accomplished using IV fluids and sometimes vasopressors. 1. Incorrect. The Oxygen sat is 94%, so the adventitious lung sounds do not need immediate intervention. The abnormal lung sounds are the result of the diffuse infiltrates that occur as a result of the inflammatory process and increased capillary permeability which allows fluid to escape into the lung tissues and alveoli. As this progresses, gas exchange can be severely compromised. However, at this point, this client is remaining above 90% with the O2 sat levels, so the problem of poor tissue perfusion from hypotension would be the priority. 3. Incorrect. The second priority is to treat the infection that is a likely cause of the temperature elevation and hypotension. Parenteral antibiotics are administered as soon as wound or blood cultures have been obtained. When sepsis is suspected, antibiotic therapy is essential and should be instituted as soon as possible. The early initiation of antibiotics can be a lifesaving measure. 4. Incorrect. This may be the cause of the sepsis, but the priority is to improve the tissue perfusion and ultimately raise the BP. The second priority is to treat the infection. As the tissue perfusion improves, and the infection is treated, the urinary output and appearance of the urine should improve unless permanent kidney damage resulted.

The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Which foods should the nurse reinforce that are appropriate for the client? You answered this question Incorrectly 1. Cereals and breads 2. Avocados and apricots 3. Table salt and spinach 4. Blueberries and strawberries

2. Correct: Avocados, apricots, milk, fruit juices, bananas and cantaloupe are good sources of potassium. Loop diuretics deplete the electrolyte potassium. 1. Incorrect: Cereals and breads are good sources of B vitamins. Since the client is losing potassium they need foods that are high in potassium. Cereals and breads are not high in potassium. 3. Incorrect: Table salt and spinach are good sources of sodium, but the hypertensive client usually should limit intake of sodium. The client is taking a potassium depleting diuretic and needs potassium rich foods. Spinach is high in potassium but the table salt makes this option incorrect. 4. Incorrect: Blueberries and strawberries both are relatively low in potassium. Clients on loop diuretics are losing potassium and need to consume foods high in potassium.

The nurse, talking with her brother about their aging father, voices concern about hazards that their father may encounter while alone. Which statement by the nurse indicates adequate understanding of health risks common in the elderly? You answered this question Correctly 1. "Dad is not likely to fall as he has carpet on the floor". 2. "Dad may get burned in the shower if the water heater temperature is too high". 3. "We no longer have to worry about him drinking too much". 4. "His herbal supplements are safe to take because they are "all natural."

2. Correct: Elderly clients have decreased sensitivity to heat and pain, and may burn themselves before they realize it. 1. Incorrect: Elderly clients are at risk for falls due to changes in vision, balance, or impaired mental status. 3. Incorrect: Alcoholism in the elderly is a health risk. Many elderly begin drinking as a way of coping with loss of independence, loss of spouse, and physical disability. 4. Incorrect: One must be aware of herbal supplements and possible interactions with prescription medication.

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.

The nurse is providing morning care to a client who has pneumonia. The client has shortness of breath on exertion and fatigues easily. What alterations in routine may be needed to complete the hygienic needs of the client? You answered this question Correctly 1. Perform all of the hygiene needs for the client. 2. Allow periods for rest as the care is provided. 3. Leave equipment at the bedside to allow client to go at his own pace. 4. Omit the morning hygiene routine for the present time.

2. Correct: The client is likely to need to rest as the care is provided. If the client becomes short of breath or complains of extreme fatigue, the nurse should wait for a few minutes and then proceed. 1. Incorrect: The client is 40 years old and is likely to want to perform some of the personal care. 3. Incorrect: The client may overestimate abilities and need assistance from the nurse. 4. Incorrect: The bath is important, as is the bed change, to improve client's feelings of comfort.

A nurse prepares a client for a colonoscopy and presents the consent form to the client. The client states, "I don't know what a colonoscopy is." Which is the best action for the nurse to take? You answered this question Correctly 1. Explain the procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Inform the primary healthcare provider that the client requests additional information related to the procedure. 3. Give the client an information pamphlet about the procedure and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed.

2. Correct: The primary healthcare provider performing the procedure should explain the risks and benefits, recovery time, and reasonable alternatives, as well as the consequences of refusing treatment prior to the client signing a consent form. 1. Incorrect: The nurse should explain the colonoscopy procedure and expectations to the client, but the nurse is not responsible for explaining the risks, benefits, and alternatives to treatment. This responsibility rests with the primary healthcare provider performing the procedure. 3. Incorrect: Providing an information pamphlet to the client may be beneficial, but this should never be substituted for communicating with the client. 4. Incorrect: The nurse should not allow the client to sign the consent form until the primary healthcare provider has provided all necessary information to the client.

A pregnant client has been receiving daily heparin injections for a history of deep vein thrombosis (DVTs) during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider? You answered this question Incorrectly 1. PT of 13 seconds 2. PTT of 22 seconds 3. INR of 1.0 4. Hemoglobin of 11 g/dL (6.8266 mmol/L)

2. Correct: The test that monitors the efficacy of heparin is the PTT. The normal range for a PTT is 30-40 seconds, but desired outcome of heparin therapy is PTT of 1.5-2.5 times the control without signs of hemorrhage. This client's PTT is below therapeutic range so it is not preventing DVT formation. The dose of heparin will need to be increased. 1. Incorrect. PT monitors the efficacy of warfarin, which is contraindicated in pregnancy because it crosses the placenta which means the fetus would be receiving the medication. PT is measured in seconds. Most of the time, results are given as what is called INR (international normalized ratio). If a client is not taking blood thinning medicines, such as warfarin, the normal range for PT results is 11 to 13.5 seconds. Normal value ranges may vary slightly among different laboratories. Some labs use different measurements or test different samples. 3. Incorrect: INR monitors the efficacy of warfarin, which is contraindicated in pregnancy because it crosses the placenta which means the fetus would be receiving the medication. (Normal INR of 0.8 to 1.1.) If the client is taking warfarin to prevent blood clots, the primary healthcare provider will most likely choose to keep the INR between 2.0 and 3.0. 4. Incorrect: A hemoglobin of 11 g/dL (6.8266 mmol/L)​ is adequate in pregnancy. In pregnancy, there is an increase in plasma volume of the blood in order to help supply oxygen and nutrients to mother and baby. There can be a 20% increase in the total number of red blood cells, but the amount of plasma increases even more causing dilution of those red cells in the body. A hemoglobin level of pregnancy can naturally lower to 10.5 gm/dL (6.5163 mmol/L) representing a normal anemia of pregnancy.

A client with tuberculosis (TB) has been coming to the health department for directly observed therapy (DOT) for the past month. Today, the client states, "I don't think I need to come back anymore. I am feeling much better now." What should the nurse tell the client? You answered this question Correctly 1. "You have taken your medication long enough so, the primary healthcare provider should discontinue it today." 2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured." 3. "I will be required to have you arrested if you do not come back for further treatment." 4. "Just let us decide when you should stop taking the medication."

2. Correct: This is true regarding TB treatment. The Medication has to be taken for the entire course. The minimal length of time for therapy is 3 months. 1. Incorrect: Treatment usually lasts 4-7 months. If the medication regimen is not strictly and continuously followed, the disease may become drug-resistant. It is not the nurse's place to determine when enough medication has been taken. 3. Incorrect: The nurse needs to discuss the reason for continuing to take the medication. This step is premature and intimidating. Also, threatening to have the client arrested will not likely maintain a good patient-nurse relationship. 4. Incorrect: This statement is non-therapeutic and dismissive of the client. This does not address the client's statement of thinking they have had enough medicine and should stop

Which strategies should the nurse suggest for the prevention of constipation in older clients? You answered this question Incorrectly 1. Mild laxatives are appropriate if a bowel movement is not achieved daily. 2. Emphasize the importance of establishing a bowel routine. 3. Introduce abdominal toning exercises. 4. Encourage foods low in bulk. 5. Drink 6-8 glasses of water per day.

2., 3. & 5. Correct: It is important to establish a bowel routine and respond to the urge to defecate. An exercise regimen, increased ambulation, and abdominal muscle toning will increase muscle strength and help propel colon contents. Tone abdominal muscles by contracting 4 times daily and do leg to chest lifts 10-20 times per day. A diet high in fiber is also helpful. Laxatives should be used as a last resort and should not be taken regularly. Over time, laxatives can desensitize the bowel and worsen constipation. Adequate fluid intake is needed in management of constipation. 1. Incorrect: A daily bowel movement is not necessary as long as the bowels move regularly. 4. Incorrect: A diet high in bulk and fiber is needed rather than low in bulk.

A nurse is caring for a middle aged individual that is at risk for stroke. Which points should the nurse stress for decreasing the risk of stroke? You answered this question Incorrectly 1. Reduce dietary intake of unsaturated fat. 2. Swim or walk most days of the week. 3. Treat obstructive sleep apnea, if present. 4. Drink five or more 8 ounce glasses of water daily. 5. Decrease smoking to less than ½ pack a day.

2., 3., & 4. Correct: Aerobic or cardio exercise reduces risk of stroke in many ways. Exercise can lower blood pressure, increase HDL, lower cholesterol, and improve overall health of blood vessels and heart. Exercise helps in weight loss, controlling diabetes and reduces stress. Obstructive sleep apnea can decrease oxygen to the brain and place you at increased risk of stroke. Still well hydrated if at risk for stroke, dehydration makes blood hypercoagulable. Drink water throughout the day, rather than all at once. 1. Incorrect: When choosing fats, pick unsaturated fat over saturated or trans fat. Saturated fat raises total blood cholesterol levels and low density lipoprotein. 5. Incorrect: Tobacco use is a major preventable risk factor for stroke and heart disease. Even if a person has smoked for years, the risk of stroke can be reduced by quitting all smoking.

The nurse has determined that a client is at risk for experiencing dumping syndrome after having had a partial gastrectomy. Which teachings about this condition should the nurse reinforce with this client? You answered this question Incorrectly 1. "After eating you should assume a right side lying position for 30 minutes." 2. "Drink liquids an hour after consuming meals." 3. "Eat three meals rather than six smaller meals." 4. "Carbohydrates should be decreased in the diet." 5. "The primary healthcare provider may prescribe a multivitamin with iron."

2., 4. & 5. Correct: Fluid intake with meals is discouraged: instead, fluids may be consumed up to one hour before or one hour after mealtime. Carbohydrates increase gastric motility which this client does not need. Therefore the diet should be low in carbs. Supplementary vitamins and iron may be recommended when the client has dumping syndrome. 1. Incorrect: The best position to delay stomach emptying is low Fowler's during mealtime and for at least 20-30 minutes after the meal. 3. Incorrect: The client should eat smaller, but more frequent meals.

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? You answered this question Incorrectly 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 nurse is caring for a client who was brought into the ED with a gunshot wound to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nurse take first? You answered this question Correctly 1. Elevate the head of the bed. 2. Initiate CPR. 3. Remove the occlusive dressing. 4. Notify the primary healthcare provider.

3. Correct: The client has developed a tension pneumothorax as evidenced by these signs/symptoms. This developed as a result of the placement of an occlusive dressing over the chest wound. By removing the occlusive dressing the pressure pushing to the opposite side of the chest should stop. Dressings over "sucking chest wounds" should be taped down on 3 sides only to allow air to escape but not re-enter. A needle decompression may be required as an emergency measure. 1. Incorrect: Although elevating the HOB typically helps ease the effort of respirations, in this case, it will not fix the tension pneumothorax. 2. Incorrect: It is not necessary to start CPR at this point. The client has not arrested. The client needs emergency relief measures such as removal of dressing and possible needle decompression to prevent further deterioration and possible cardiopulmonary arrest. 4. Incorrect: Call the primary healthcare provider after removing the occlusive dressing. This is an emergency situation. Attempts to resolve the issue are crucial to prevent further deterioration of the client's condition.

A nurse is caring for a client admitted to the hospital for a total hip replacement. Which goal is the highest priority in the post-operative phase of care? You answered this question Correctly 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.

A clinic nurse is collecting data from a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? You answered this question Correctly 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis

4. Correct: Histoplasmosis is a fungal infection transmitted through ingestion of soil contaminated by bird manure. 1. Incorrect: The classic symptom of Lyme disease is usually an expanding target-shaped or "bull's-eye" rash which starts at the site of the tick bite. Fever, headache, muscle aches, and joint pain may also occur. 2. Incorrect: Toxoplasmosis occurs from contact with cat feces. Symptoms may be influenza-like: swollen lymph nodes, headaches, fever, and fatigue, or muscle aches and pains. 3. Incorrect: Tuberculosis (TB) is often suspected; however, the primary difference is exposure to bird feces.

A client is brought into the emergency department (ED) with nausea, vomiting and diarrhea after eating chicken at a picnic. The nurse suspects that this client has most likely contracted which infection? You answered this question Correctly 1. Shigella 2. Escherichia coli 3. Clostridium Difficile 4. Salmonella

4. Correct: Salmonella is a gram negative bacillus found in animal sources such as chicken products, eggs, turkey, and some beef. Nausea, vomiting, and diarrhea after ingesting infected chicken would be the classic signs/symptoms. 1. Incorrect: Shigella infection is a gram negative organism that invades the lumen of the intestine and causes severe runny, bloody diarrhea which can be transmitted through the fecal/oral route. Improper hygiene is most likely cause. 2. Incorrect: Escherichia coli is the most common aerobic organism colonizing the large bowel. It is often linked to ingestion of undercooked contaminated beef and vegetables that have been contaminated by animal waste water. Signs and symptoms of E. coli include bloody diarrhea, severe cramps, nausea and vomiting, and renal failure. 3. Incorrect: Clostridium Difficile is a spore-forming bacterium usually preceded by antibiotics, which disrupt normal intestinal flora and allow the C. Difficile spores to proliferate within the intestine. C. difficile signs and symptoms can range from mild diarrhea to severe colitis.

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? You answered this question Incorrectly 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.

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 client with diabetes is hospitalized for debridement of a non-healing foot ulcer. Following the procedure, the nurse notes that the client has become confused and combative. The family expresses concern with the behavioral changes and requests that the client be restrained in bed. What is the nurse's priority action? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Apply a vest restraint as requested by family. 3. Move client to a room near the nurse's desk. 4. Obtain a finger-stick blood glucose level.

4. Correct: The client's behavior has negatively changed following the ulcer debridement procedure. The nurse's priority is to determine the cause of the client's confusion. The nurse is correct to investigate other possible causes for the behavior changes, including an abnormal glucose level in this diabetic client. 1. Incorrect: The nurse will indeed have to contact the primary healthcare provider about the client's change in behavior. However, the first priority would be to assess the client and collect data prior to placing that phone call. 2. Incorrect: The nurse understands that restraints cannot be applied by family request. Additionally, applying a restraint can often increase negative behavior while ignoring the actual cause. 3. Incorrect: Although assigning confused clients to a room near the nurses' station is an accepted practice, this does not determine the cause for the changing behavior and is not a priority at this time. The nursing priority is to assess the client for possible factors causing the behavior changes.

The family of a bedfast 80 year old is providing care in the home. Which reports by the family indicate adequate understanding of interventions that will reduce the risk for skin breakdown? You answered this question Incorrectly 1. I make sure that the sheets and the foam pad in the chair stay dry. 2. I will not encourage my parent to turn in the bed at night. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact.

Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are bedfast, 80 year old, understanding, interventions, and risk for skin breakdown. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Remember client safety is always a priority. This question is talking about interventions to prevent skin breakdown. So let's look at the options. Option 1 is true. The sheets and the foam pad should remain dry. The skin should not be exposed to a wet surface for a extended length of time. Keeping moisture from the skin is important for reducing the risk of skin breakdown. Option 2 is false. If the client is not repositioned at night, the resulting pressure on one site may lead to skin breakdown, even when the sensations of pressure are intact. A client in a state of sleep would not be as likely to respond to sensations of pressure appropriately, so the family would need to do this for her. Option 3 is true. Keeping moisture from the skin is important for reducing the risk of skin breakdown. The perineal area should cleansed and dried after each voiding and bowel movement. Option 4 is true. The nutritional status of the client should be evaluated. Appropriate levels of macronutrients (carbohydrates, proteins, and lipids) and micronutrients (vitamins and minerals) must be consumed to provide the for proper skin health. The client appears to consuming adequate food. Option 5 is true. The client who is aware of sensations of pressure on the body has less risk of skin breakdown than those that have lost sensation. If the client can tell their family, if they want to turn move.

A client who needs to have a stool specimen for an occult blood test is guided by the nurse to avoid which substances two hours prior to testing? You answered this question Incorrectly 1. Liver 2. Tomato 3. Ibuprofen 4. Sardines 5. Ascorbic acid

Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are occult blood test, avoid, and 2 hours. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. The test taker must be knowledgeable about diagnostic tests. This question is asking about what to avoid 2 hours prior to a occult blood test. So let's look at the options. Option 1 is true. Liver ingested within 2 hours of the test can cause a false-positive reading of the occult blood test. Option 2 is false. A tomato is not on the food list that will cause a false positive reading if eaten within 2 hours prior to a occult blood test Option 3 is true. Ibuprofen is on the medication list that will cause a false reading if taken within 2 hours to a occult blood test. Option 4 is true. Sardines ingested within 2 hours of the occult blood test will cause a false positive reading. Option 5 is true. Ascorbic Acid is on the medication list that will cause a false reading if taken 2 hours prior to the occult blood test.

A client has experienced a cerebrovascular accident (CVA) which resulted in left homonymous hemianopia. Based on this fact, what nursing meaasures are appropriate? You answered this question Incorrectly 1. Approach the client from his left side. 2. Place the client's meal on the right side of the over bed table. 3. Request a consult for an ophthalmologist. 4. Stand directly in front of the client when addressing. 5. Have client look at the left side of the body.

In order to get this answer correct you must know the definition of homonymous hemianopia. Homonymous hemianopia is blindness in half of the visual field. This client has lost half of the visual field in the left side of both eyes. So the client cannot see things on the left side. Remember safety and prevention of neglect of the affected side. If you cannot see one side of the body, the brain forgets about it. Option 1. Do we want to approach the client from the side the client can see you coming? No, so this is false. Option 2. Place the client's meal on the right side of the over bed table. True. You want the client to be able to see the food, right? right. Option 3. Request an ophthalmologist consult. False. Can this problem be fixed. No it is not an eye problem but rather a central nervous system problem. Option 4, stand directly in front of the client. False. You would need to stand on the unaffected side, in this case the right side, so that the client can see you. Option 5, have the client look at the left side of the body. This allows the brain to connect with the left side of the body. If the client cannot see parts of the body, then the brain will not connect with it.

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and symptoms would the nurse recognize as being indicative of RA? You answered this question Incorrectly 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of chronic hardening of connective tissure. 5. Elevated erythrocyte sedimentation rate (ESR).

Rheumatoid arthritis is an autoimmune disease in which the body's immune system mistakenly attacks the joints causing tissue lining the inside of joints to become inflamed and thickened. Rheumatoid arthritis commonly affects the joints of the hands, feet, wrists, elbows, knees and ankles. It can also affect body systems, such as the cardiovascular or respiratory systems, so it is considered a systemic disease. The inflammation results in swelling and pain in and around the joints. Left untreated, it can damage cartilage, the elastic tissue that covers the ends of bones in a joint, as well as the bones themselves. Over time, there is loss of cartilage, and the joint spacing between bones can become smaller. Joints then become loose, unstable, painful and lose their mobility. Joint deformity occurs and cannot be reversed. So signs and symptoms of RA include redness, swelling, tenderness, and pain in the joints. Morning stiffness can occur or 30 minutes or more. Along with pain, many people experience fatigue, loss of appetite and a low-grade fever. RA can also affect the eyes, mouth, skin, lungs, blood and blood vessels. Look at the options. Option 1: Joint pain, swelling, and warmth. True. These are classic features of RA. Option 2: Decrease movement in joints. True. Pain, swelling, and tenderness are worsened by movement and stressed placed on the joint. Remember, morning stiffness and limited movement is common. Option 3: Presence of Rheumatoid factor on lab analysis. True. Rheumatoid factor is an antibody found in about 80 percent of people with RA during the course of their disease. Option 4: Presence of hardened connective tissue False. Scleroderma is a collagen disorder. The connective tissue begin to harden and shrink. This is not associated with RA. Option 5: Elevated ESR. True. The ESR blood test is elevated with RA and is used to determine if an abnormal level of inflammation exists in the body.

Which actions should the nurse encourage a client diagnosed with cirrhosis to do? You answered this question Correctly 1. Use a shower chair when performing hygiene. 2. Limit alcohol intake. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.

The primary functions of the liver are: Bile production and excretion; Excretion of bilirubin, cholesterol, hormones, and drugs; Metabolism of fats, proteins, and carbohydrates; Enzyme activation; Storage of glycogen, vitamins, and minerals; Synthesis of plasma proteins, such as albumin, and clotting factors; Blood detoxification and purification. Option 1 is true. Think about it. If the liver detoxifies the body of waste products such as ammonia, then these levels increase when the liver is not functioning properly. So the client is tired. Sitting will conserve energy. Option 2 is false. Chronic alcoholism is the leading cause of cirrhosis in the United States. Drinking too much alcohol can cause the liver to swell, which over time can lead to cirrhosis. Option 3 is true. Where does ascites fluid come from? The vascular space, right? Yes. So dizziness may be an indication of decreased vascular volume. Option 4 is true. Limiting salt in the diet will help to prevent or reduce fluid buildup of ascites. Option 5 is true. Reinforce the teaching of proper hand hygiene to clients is always the best thing to do. Clients with a chronic disease are at risk for infection so proper hand hygiene is appropriate.

A client who has diabetes calls the nurse at the clinic reporting shakiness, nervousness, and palpitations. Which questions would yield information that would assist the nurse to gather data to share with the primary healthcare provider? You answered this question Incorrectly 1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? 5. Does your skin feel hot and dry?

This question wants the nurse to verify that the client on the phone is having a hypoglycemic episode. So what questions could the nurse ask to verify this diagnosis? Option 1. Is it important to know if the client has eaten and what time? Yes. If the client has not eaten, would that lead to hypoglycemia? Yes. So this is true. Option 2. True. We know that insulin does what to glucose? Decreases it. Option 3. True. Hunger is a symptom of hypoglycemia. Option 4. Is it important to know if the client can check to see what their glucose level is? Yes, true. Option 5. Does the skin get hot and dry with hypoglycemia? No. It gets cool and clammy doesn't it? Yes, so this statement is false

An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? You answered this question Incorrectly 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 4. Advanced age. 5. Response to analgesic.

Well, look at the many clues in this stem! The client is alert on admission and then that evening becomes disoriented. This is important information to answer this question. Option 1: Yes. Change of environment especially in the elderly can lead to confusion. The stem does not tell you the client's injuries from the fall but specifically says the client was elderly and alert on admission. Option 2: Good choice. Pain, especially when uncontrolled can cause disorientation and confusion. The client may be so focused on the pain that they become confused and disoriented. Option 3: Great choice! The client is now looking at the same four walls all day long. Bed rest will have effects on the brain causing confusion. Option 4: Oh no! Simply being elderly does not lead to disorientation and confusion. Do not be misled by the client being elderly. Remember in the stem, the clue is this client is an alert, elderly person. Option 5: Yes. Medications have many side effects. Analgesic pain medications can alter mental status leading to disorientation and confusion.

The nurse is caring for a client on the medical unit who has hematemesis. What data is most important for the nurse to collect? You answered this question Incorrectly 1. Vital signs 2. History of prior bleeding episodes 3. Medications the client is taking 4. Urinary output 5. Level of consciousness

What is hematemesis? It is the vomiting of blood. So what are your worried about? Hemorrhage/Shock! So what assessments will help you determine if the client is in or going into shock? Option 1? True. BP will drop, HR will increase. Option 2. False. Will this assess the current problem? No. Option 3. False. Will knowing medications fix the problem? No. Option 4? True. Are the kidneys being perfused? If not, the UOP will be low. Option 5? True. Level of consciousness will decrease as perfusion to the brain decreases.

What actions should the nurse include when providing care for a client admitted with Guillain-Barre' Syndrome? You answered this question Incorrectly 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Reinforce teaching for range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

With this disease we know that there is progressive muscle weakness, cramping and paralysis. So interventions should focus on the hazards of immobility, pain, and maintaining the airway. Option 1 is true. The client develops paralysis so contractures can occur. Contractures can be prevented by frequent ROM exercises and proper alignment. Option 2 is false. This client has decreased respiratory excursion due to muscle weakness. Placing the client prone will further inhibit adequate breathing. Option 3 is true. The main premise behind incorporating massage therapy for this disease is that massage can influence the afferent neural pathways by manually sending signals back to the brain so that the client's pain decreases. Option 4 is true. Early in the acute phase clients benefit from daily ROM exercises and proper positioning to prevent muscle shortening and joint contractures. Option 5 is false. These clients often have difficulty with dysphagia and may need more frequent, high calorie meals as well as enteral or parenteral feedings. Option 6 is true. Estimates suggest that approximately 40% of clients who are hospitalized with GBS require inpatient rehabilitation. The goals of the therapy programs are to reduce functional deficits and to target impairments and disabilities resulting from GBS.

3. Correct: The elderly client with diabetes and obesity is likely to need referrals at the time of discharge, whether to physical therapy, home health, weight loss program or other agencies. 1. Incorrect: There is no need to think that this client who is 45 years old will need assistance after nasal surgery. 2. Incorrect: This 50 year-old client postop mastectomy is mobile and does not need referral to other agencies or community outreach programs. 4. Incorrect: Delirium is an acute illness that resolves once the physical stressor is eliminated. In this case the delirium was caused by dehydration that has been corrected if the client is ready for discharge. There is no indication that the client is in need of post-hospital care.

Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. Hypothermia occurs as body temperature drops below 95ºF (35ºC). When body temperature drops, the heart, nervous system and other organs can't work normally. Left untreated, hypothermia can lead to complete failure of the heart and respiratory system resulting in death. Hypothermia is most often caused by exposure to cold weather or immersion in a cold body of water. Treatment methods include warming the body back to a normal temperature. What options provided for this question will help to warm up this client? Option 1: Remove wet or constricting clothes. Make sense to remove wet clothes, right? Yes. Water conducts heat away from the body 25 times faster than air because it has a greater density (therefore a greater heat capacity). Stay dry = stay alive! Why would we remove constricting clothes? Swelling is common so anything, such as clothing or jewelry that could cause constriction to blood flow, should be removed. Option 2: Initiate a controlled and rapid re-warming process with warm water. A controlled and rapid re-warming process is accomplished using a continuous flow of warm water until flushing is noted in the affected areas. A warmed intravenous solution may be initiated to help warm the blood. The use of humidified oxygen administered with a mask or nasal tube can warm the airways and help raise the temperature of the body. A warm saltwater solution may be used to warm the body, such as via saline lavage. Depending on the severity of hypothermia, blood may be drawn, warmed and recirculated in the body. A common method of warming blood is the use of a hemodialysis machine or heart bypass machine. Option 3: Wrap each toe individually with sterile gauze. True. Each digit is wrapped individually with sterile gauze (not constricting) to minimize the risk of infection and assist in the warming process. The core should be re-warmed first to prevent "afterdrop" which is a further drop in core temperature caused by cold peripheral blood returning to the central circulation. Option 4: Encourage the client to walk. This is false. Movement of frostbitten areas can cause ice crystals to form in the tissue and cause further damage. In addition, lack of sensation places the client at risk for falls or other injury. Option 5: Apply a heating pad to the feet. False. This is a safety issue! Don't pick that on NCLEX®! The extreme heat can damage the skin or, even worse, cause irregular heartbeats so severe that they can cause the heart to stop. Option 6: Massage the frozen digits. Initial rubbing or massage of the frostbitten digits is an absolute contraindication as it can cause further tissue damage. And did you know that excessive, vigorous or jarring movements may trigger cardiac arrest?

Which signs and symptoms does the nurse expect to see in a client admitted to the medical unit with Parkinson's disease? You answered this question Incorrectly 1. Blank affect. 2. Decreased ability to swing arms. 3. Waddling gait. 4. Walking on toes. 5. Pill-rolling tremor. 6. Stiff muscles.

Parkinson's disease is a progressive disorder of the nervous system that affects movement. It develops slowly and symptoms may be barely noticeable. For instance, the client may have a tremor of just one hand. Stiffness or slowing of movement may be noted. In the early stages, the client's face may show little or no expression, or their arms may not swing when walking. Their speech may become soft or slurred. These symptoms worsen as the condition progresses over time. So now you can look at the options and see some of the signs and symptoms, can't you? Yes. From this, did you say options 1, 2, and 6 are correct? Good. Let's look at the other options to se which others may be correct as well! Option 3. Waddling gait. False. This is a sign of Duchenne Muscular Dystrophy. The client with Parkinson's disease has a shuffling gait. Option 4. Walking on toes. This is false as well and is a sign of Duchenne Muscular Dystrophy. Option 5. Pill-rolling tremor. Well, we said that the client has a slight tremor, and that tremor looks like they are rolling a pill or something small in their hand. So, this is correct. So the correct options are 1, 2, 5, and 6. Got it? Great!

The client, who has just returned to bed following a session with the physical therapist, is reporting being short of breath. What can the nurse do to increase the client's comfort level? You answered this question Correctly 1. Raise the head of the bed to a high-Fowler's position. 2. Encourage the client to lie down and rest. 3. Raise the head of the bed 30 degrees. 4. Raise the head of the bed 15 degrees

1. Correct: High Fowler's position allows for maximum chest expansion, thus improving comfort. 2. Incorrect: If the client is feeling short of breath, lying would contribute to feelings of discomfort. 3. Incorrect: It is better to raise the head of the bed to at least 45 degrees. 4. Incorrect: The client will be more comfortable with the head of the bed elevated 45 to 90 degrees to allow for greater chest expansion and more adequate breathing patterns.

The nurse is caring for a client admitted with acute gastritis. Which client information is most significant? You answered this question Correctly 1. Takes ibuprofen for arthritis pain. 2. Had an upper respiratory infection two weeks ago. 3. Has a stressful job. 4. Enjoys spicy food.

1. Correct: Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID). NSAIDs are highly associated with GI irritation. 2. Incorrect: Upper respiratory infections have nothing to do with gastritis. 3. Incorrect: Research does not support an association between gastritis and stressful jobs. 4. Incorrect: Spicy foods may not be tolerated by clients with gastritis, but spicy foods have not been linked to causing gastritis

What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? You answered this question Correctly 1. Notify the primary healthcare provider 2. Monitor for paresthesia in the fingers and hands 3. Insert an indwelling urinary catheter 4. Assist the client with performing passive range of motion

1. Correct: Symptoms are classic for Guillain-Barre. The possibility of rapid progression and respiratory failure make this a medical emergency. The nurse's priority action is to notify the healthcare provider. 2. Incorrect: The nurse should continue to monitor for paresthesia in the upper body and arms. The first priority in this situation is to notify the primary healthcare provider of the potential life threatening situations. 3. Incorrect: Urinary retention is a possible complication with Guillain-Barre, and the client may require an indwelling urinary catheter, but the immediate priority is to notify the primary healthcare provider. 4. Incorrect: Passive range of motion is performed to prevent complications of immobility, but this is not the priority at this time. The client is presently able to move their extremities. Passive range of motion is not the priority at this time.

Which male client condition in the after-hours clinic should the nurse see first? You answered this question Correctly 1. Scrotal pain and edema. 2. Erection lasting for 2 hours. 3. Inability to void with a history of benign prostatic hyperplasia (BPH). 4. Purulent drainage from the penis.

1. Correct: This client is likely to have testicular torsion, which requires immediate intervention. Infarction of the testes can occur if not treated promptly. 2. Incorrect: This is not the most life threatening problem. Priapism, a persistent, often painful erection that lasts for more than 4 hours should be treated. 3. Incorrect: With BPH the prostate gland increases in size, leading to disruption of the outflow of urine. This can cause inability to void and needs to be checked but is not the first priority. 4. Incorrect: This client does not have the most serious condition and would not take priority.

Which client is at the greatest risk for developing pancreatic cancer? You answered this question Incorrectly 1. 70 year old obese client who smokes one pack of cigarettes a day 2. 64 year old client who had gallbladder surgery less than 5 years ago 3. 58 year old client with Chron's Disease 4. 52 year old client whose mother died from pancreatic cancer

1. Look at each option as True or False. 2. Option 1 is true. The incidence increases with age. Almost all patients are older than 45. About two-thirds are at least 65 years old. The average age at the time of diagnosis is 71. Cigarette smoking is an associated risk factor and the risk of developing pancreatic is twice as high in smokers. 3. Option 2 is false. Gallbladder disease or gallbladder surgery is not associated with pancreatic cancer. 4. Option 3 is false. Chron's Disease is not associated with pancreatic cancer. 5. Option 4 is false. Although family history is a risk factor, most people who get pancreatic cancer do not have a family history of it.

Which signs/symptoms would the nurse anticipate in the client admitted with a diagnosis of myasthenia gravis? You answered this question Incorrectly 1. Difficulty holding head erect 2. Limited facial expressions 3. Ptosis 4. Hemiparesis 5. Writhing, twisting movements of the body 6. Pill rolling

1., 2., & 3. Correct: These are three of the primary symptoms of myasthenia gravis. The muscles of the head and neck are weak and have difficulty holding the head up. Facial paralysis occurs and drooping of the eyelids develops as the client's muscles get tired. 4. Incorrect: Hemiparesis is a type of physical condition with weakness on one side of the body. 5. Incorrect: Writhing, twisting movements of the face, limbs, and body is known as chorea and is seen in Huntington's disease. 6. Incorrect: The hand tremor described as "pill rolling" is a sign of Parkinson's disease. The thumb and forefinger appear to move in a rotary fashion as if rolling a pill, coin, or other small object.

Which of the following should the nurse reinforce regarding nutrition for a client with celiac disease? You answered this question Incorrectly 1. Gluten is a protein found in wheat and oats. 2. A gluten intolerant person can eat foods that are made with barley or rye. 3. Fruits can be eaten on a gluten free diet. 4. Gluten causes inflammation of the large intestines of people with celiac disease. 5. Accidentally eating a product containing gluten may result in abdominal pain and diarrhea.

1., 3., & 5. Correct: A gluten-free diet is used in the treatment of celiac disease. Gluten is a protein found in barley, oats, rye, and wheat. All products containing these grains are to be avoided. Rice and corn may be used. Fruits, vegetables, nuts, diary products and meats not prepared with gluten containing ingredients can be eaten. Accidentally ingesting food with gluten may result in abdominal pain and diarrhea. 2. Incorrect: The main starchy foods that a person can eat are made with rice, corn, potatoes, quinoa, and Tapioca. The gluten intolerant clients cannot eat barley and rye. Gastrointestinal pain and diarrhea may occur. 4. Incorrect: Gluten causes inflammation in the small intestines of people with celiac disease. Eating a gluten-free diet helps people control their signs and symptoms and prevent complications.

A client has returned to the room following a liver biopsy. The nurse is aware what position is best for the client? You answered this question Correctly 1. Left side with right arm elevated 2. Right side for at least two hours 3. Supine with head of bed elevated 4. Left-lateral with pillow between knees

2. CORRECT: Since the liver is located in the right upper abdominal quadrant, the client would be supine or slightly left-lateral with right arm above the head during the procedure. In order to apply pressure directly to the puncture site following the biopsy, the client should be placed directly on the right side. 1. INCORRECT: This position is proper for the process of the biopsy, but not after the procedure. 3. INCORRECT: Though this position may be comfortable for the client, no pressure is being applied to the biopsy site of the liver. 4. INCORRECT: The pillow serves no purpose, and the left-lateral position does not provide any pressure on the biopsy site

The nurse collects data on a client post thyroidectomy for complications by performing which action? You answered this question Incorrectly 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 if parathyroids are accidently removed when the thyroid is removed. 1. Incorrect: Accucheck evalutes for blood glucose levels, which is not the problem post thyroidectomy. 3. Incorrect: This 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

Which assigned client should the nurse see first? You answered this question Correctly 1. Diagnosed with urinary tract infection 2 days ago who is to be discharged. 2. Admitted last night with a diagnosis of severe pneumonia. 3. 45 year old who had a hernia repair 24 hours ago. 4. Scheduled for an endoscopy in two hours

2. Correct: The client with severe pneumonia is at greatest risk for respiratory difficulty and should be seen first. Clients with severe pneumonia may develop the following complications: bacteremia, septic shock, lung abscesses, pleural effusion, empyema, pleurisy, renal failure, and respiratory failure. 1. Incorrect: The client who is being discharged is considered to be stable. A client who was diagnosed with a urinary tract infection is considered to be stable. This client is not exhibiting signs of potential airway complications. 3. Incorrect: This postoperative client of 24 hours is considered stable. The client's age of 45 also does not suggest that the client was a surgical risk. 4. Incorrect: The client admitted for an endoscopy is considered to be stable at this point. There is no data listed to support the client needing to be assessed first.

A nurse is observing an unlicensed nursing personnel (UAP) feed a client who is on aspiration precautions. Which action by the UAP would require the nurse to intervene? You answered this question Correctly 1. Elevating the head of the bed to a 90 degree angle 2. Instructing the client to lean the head back slightly when swallowing. 3. Adding a thickening agent to liquids. 4. Feeding the client small amounts of food per bite.

2. Correct: This is an incorrect action, and needs intervention by the nurse. The chin should be flexed to prevent the risk of aspiration. A chin down or chin tuck maneuver is widely used in dysphagia treatment to prevent aspiration. 1. Incorrect: This is a correct action. The head of the bed should be elevated which assists in esophageal peristalsis. Swallowing is then aided by gravity. 3. Incorrect: This is a correct action. Thickened liquids are easier to swallow without aspirating. Drinking liquids thickened will help to prevent choking and stops fluid from entering the lungs. 4. Incorrect: This is a correct action by the UAP, so the nurse does not need to intervene. Smaller amounts of food can be chewed more thoroughly and swallowed with less risk for aspiration.

What dietary information should the nurse provide to a client diagnosed with Celiac disease? You answered this question Correctly 1. "The most cost effective way to follow the lactose free diet is to eat more fruits and vegetables." 2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta."

2., 3., 4., & 5. Correct: Soups and sauces are one of the biggest sources of hidden gluten, as many companies use wheat as a thickener. It is always a good idea to read the label of any pre-prepared or canned soups and sauces, paying special attention to those that are cream based. Grains that are naturally gluten free include rice, corn, potato, quinoa, kasha, flax, and nut flours. Malt flavoring or extract, which contains gluten may be found in cornflakes and puffed rice cereal. It is also found in beers, ales, and malt vinegars. As a rule, traditional wheat products such as pastas, breads, crackers, and other baked goods are not gluten-free. However, there are many gluten-free options available that use alternative flours and grains. 1. Incorrect: The client who has Celiac disease is prescribed a gluten free diet rather than a lactose free diet.

Which client is at the greatest risk for ineffective oral hygiene? You answered this question Correctly 1. A client who has just had knee surgery after a skiing accident. 2. A right-handed client who has had a stroke causing mild weakness on the left side of the body. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An independent, elderly client having elective surgery.

3. Correct: A client with severe nausea and vomiting after chemotherapy is at an increased risk for ineffective oral hygiene problems due to vomiting, decreased oral intake, and the effects of the chemotherapy on the normal bacterial flora of the mouth. 1. Incorrect: This client can perform oral hygiene with minimal assistance. 2. Incorrect: This client can perform oral hygiene with minimal assistance. 4. Incorrect: This client can perform oral hygiene with minimal assistance.

The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority? You answered this question Incorrectly 1. Continue to monitor urine output 2. Check pulse 3. Check blood pressure 4. Check level of consciousness

3. Correct: This is the best answer because we are "worried" this client is going into SHOCK. So.. you better be checking BP. This is a time where checking the BP is appropriate. (If we "assume the worst" I better check blood pressure. It could have dropped out the bottom.) 1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are already shocky. 2. Incorrect: Checking the pulse is a good thing, but not as important as checking the BP. 4. Incorrect: If my client is going into shock, the highest priority is to assess the BP.

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? You answered this question Correctly 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: Checking 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.

In what position should the nurse place a client diagnosed with gastric reflux? You answered this question Correctly 1. Orthopneic 2. Semi-Fowler's 3. Sims' 4. Reverse Trendelenburg

4. Correct: The entire bed is tilted with the foot of the bed lower than the head of the bed. This position promotes gastric emptying and prevents esophageal reflux. 1. Incorrect: Orthopneic position has the client sit in the bed or at the bedside. A pillow is placed on the over-bed table, which is placed across the client's lap. The client rests arms on the over-bed table. This position allows for chest expansion and is especially beneficial to clients with COPD. 2. Incorrect: The head of the bed is elevated 30 degrees. This position is useful for clients who have cardiac, respiratory, and neurological problems and is often optimal for clients who have a nasogastric tube in place. 3. Incorrect: Sims' or semi-prone position has the client on the side halfway between lateral and prone positions. Weight is on the anterior ileum, humerus, and clavicle. The lower arm is behind the client while the upper arm is in front. Both legs are flexed but the upper leg is flexed at a greater angle than the lower leg at the hip as well as at the knee. This is a comfortable sleeping position for many clients, and it promotes oral drainage.

The nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O2 saturation while sleeping drops to 82% on 3 liters of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse's best action at this time? You answered this question Correctly 1. Keep the O2 sat machine at the bedside and set the alarm to beep loudly when O2 sat drops below 93%. 2. Give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for next dose. 3. Let the client sleep until he has rested, then discuss abuse potential of narcotics. 4. Call the primary healthcare provider and report client findings.

4. Correct: Yes, this client has unstable respirations and is in respiratory distress. The client needs naloxone,the antidote for narcotic overdose. Since that is not an option, you need to call the primary healthcare provider to get a prescription for the antidote. 1. Incorrect: That will work the first time, but the client is too sedated to remain awake and take deep breaths. The client will continue to have respiratory distress until naloxone can be given. 2. Incorrect: No, that won't fix the problem of too much medication. We need to fix the problem now. 3. Incorrect: No, client is too sedated. Naloxone is needed, so the nurse needs to notify the primary healthcare provider.

Idiopathic Thrombocytopenic Purpura (ITP)

disorder marked by platelet destruction by macrophages resulting in bruising and bleeding from mucous membranes

Pheochromocytoma

hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor)

What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis? You answered this question Correctly 1. Effusion to knees. 2. Weight loss of 1 kg in 2 weeks. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.

Rheumatoid arthritis is a painful, chronic inflammatory autoimmune disorder that affects primarily the small joints within the body. The body's immune system attacks the body's own healthy tissues by mistake, causing painful swelling and possible permanent damage to joints. Early signs/symptoms include joint inflammation, low-grade fever, fatigue, weakness, anorexia, and paresthesia. This question is asking about late signs and symptoms. Option 1 is true. As the disease worsens, the joints become progressively inflamed and very painful. On palpation the joints feel soft and look puffy because of synovitis and effusions, especially in the knees. Option 2 is false. A 1 kg weight loss over 2 weeks would more likely occur in the early stages of the disease. As the disease progresses, there is moderate to severe weight loss and accompanying anemia. Option 3 is true. The most common cause of swan-neck deformity is rheumatoid arthritis. Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. Option 4 is true. Peripheral neuropathy occurs in later stages of the disease due to vasculitis. Vasculitis is inflammation of blood vessels. It causes changes in the blood vessel walls, including thickening, weakening, narrowing or scarring. These changes can restrict blood flow, resulting in organ and tissue damage. Option 5 is true. Subcutaneous nodules or Rheumatoid nodules are firm bumps of tissue thatmost commonly form around pressure points, such as the elbows. They are round, movable, and nontender and they can disappear and reappear at any time. These nodules are associated with severe, destructive disease. They occasionally open and become infected and may interfere with activities of daily living.

A client has been transferred to the orthopedic floor following application of a long leg cast for a fractured femur. What nursing action takes priority? You answered this question Correctly 1. Perform neurovascular checks of the extremities. 2. Cover the edge of the cast near the groin area. 3. Tell client not to insert anything into cast. 4. Use palms of hands to lift and position the cast.

1. Correct: The most vital aspect of care for clients with a fracture and/or cast is frequent neurovascular checks. Circulation can quickly become compromised secondary to edema from the injury or application of the cast, leading to permanent nerve and tissue damage. Neurovascular checks are performed every two hours for the first 24 hours, or more often per hospital protocols, and both extremities must be compared when looking for problems. 2. Incorrect: While this is a vital action by the nurse, it is not the initial priority. Because this client has a long leg cast for a fractured femur, there is the potential for urine to contaminate the cast close to the groin. That would impair the integrity of the cast, or potentially cause an infection. The nurse definitely needs to cover the upper edges of the cast near the groin with water proof material, but there is another action to complete first. 3. Incorrect: Proper cast care is essential and, in particular, the importance of not placing anything down inside the cast. Clients tend to complain of itching skin beneath a cast and may put baby powder, corn starch or other objects inside the cast to scratch. All these can cause serious complications. This option is not the most immediate priority for the nurse at this time. 4. Incorrect: Casting material can take up to 24 hours to dry hard enough to protect the client's injury. In the meantime, careful handling of the cast when positioning the client is crucial. The nurse is aware that the cast must be lifted using only the palms of the hands to prevent indentations which could injure the client's skin beneath the casting material.

A client diagnosed with heart failure has been prescribed a 2 gm sodium diet. Which food choices selected by the client would indicate to the nurse that the client understands this diet? You answered this question Incorrectly 1. Pork loin 2. Frozen cheese ravioli dinner 3. Instant vanilla pudding 4. Thin crust pepperoni and ham pizza 5. Fresh salad with fresh citrus juice dressing 6. Bottled tomato juice

1., & 5. Correct: A 3 ounce serving of pork loin contains approximately 54 mg of sodium. Slices of lemon, lime, or even oranges squeezed over a salad is low sodium (0-85 mg). 2. Incorrect: Canned entrees, and frozen dinners are high in sodium (Up to 1000 mg). 3. Incorrect: Instant puddings and cakes are high in sodium (1400 mg). 4. Incorrect: Pizza is high in sodium, particularly with meats such as pepperoni and ham (690 mg). 6. Incorrect: Bottled or canned tomato juice (980 mg), vegetable juice, mineral water, and softened water is high in sodium. Select coffee, tea, fruit juices, soft drinks, and low sodium tomato and vegetable juices.

The nurse is contributing to an educational seminar on ophthalmic health. Which risk factors for cataract formation should the nurse recommend? You answered this question Incorrectly 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.

1., 2. & 4. Correct: All these factors put a client at greater risk for development of cataracts. 3. Incorrect: A family history of glaucoma places a client at risk for the development of glaucoma, not cataracts. 5. Incorrect: Thin cornea is a risk factor for glaucoma, not cataracts.

An Orthodox Jewish client receives the following lunch tray. What is the nurse's priority action? Exhibit You answered this question Correctly 1. Nothing, since this is a healthy and acceptable lunch. 2. Ask the client to eat the lunch so food is not wasted. 3. Remove the tossed salad so the client can eat the rest. 4. Call dietary to immediately make a new tray for the client.

4. CORRECT. One Jewish religious belief contends that dairy and meat cannot be served, or eaten, at the same meal. The tray includes meatballs in the spaghetti and milk served with the meal. Nothing on this tray could be consumed by the client, and an entirely new tray must be prepared immediately. 1. INCORRECT. The "healthiness" of the lunch is not the issue. The Jewish faith contends that milk and meat can neither be eaten nor served at the same meal. Because both items are on the same tray, this meal would not be acceptable for this client. 2. INCORRECT. Because milk and meat has been placed on the same tray, the client cannot eat anything from this "contaminated' meal. Expecting the client to eat anything from this tray is not acceptable. 3. INCORRECT. The issue is not the tossed salad. The problem is that dairy (milk) has been served along with a meat product at the same meal. This is not acceptable for those of the Jewish faith, and the entire tray must be removed from the client's room.

The nurse is monitoring a client in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? You answered this question Correctly 1. pH 7.32 2. PaCO2 47 3. HCO3 25 4. PaO2 78

1. Correct: In DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. 2. Incorrect: Normal PaCO2 is 35-45. Remember CO2 is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO2 will either be normal or low. This value of 47 is high and not an expected finding. 3. Incorrect: Normal HCO3 is 22-26. For a client in DKA, the expected HCO3 would be less than 22. HCO3 is a base. In acidosis, the expected finding is low HCO3​. 4. Incorrect: Normal PaO2 is 80-100. An expected finding in DKA will be normal or increased PaO2, not decreased

Which vaccines would a clinic nurse encourage a 65 year-old adult to receive? You answered this question Correctly 1. Influenza 2. Herpes Zoster 3. Diphtheria 4. Pertussis 5. Pneumococcal vaccine 6. Measles, mumps, and rubella (MMR)

1., 2., 3., 4., & 5. Correct: Influenza is often quite serious for people 65 and older due to weaker immune defenses. CDC recommends a single dose of herpes zoster vaccine for people 60 years of age or older to prevent shingles.Tetanus, diptheria and pertussis (Tdap) vaccine is given to older adults to protect against whooping cough (pertussis), tetanus and diptheria. Adults should get one dose of the tetanus and diptheria (Td) vaccine every 10 years. For adults who did not get Tdap as a preteen or teen, they should get one dose of Tdap in place of a Td dose to boost protection against whooping cough. However, adults who need protection against whooping cough can get Tdap at anytime, regardless of when they last got Td. Pneumococcal vaccines protect against infections in the lungs and blood stream and are recommended for all adults over 65 years old and for adults younger than 65 who have certain chronic health conditions. 6. Incorrect. A booster for measles, mumps, and rubella is not indicated for this age group.

Which interventions should the nurse initiate for a client who has been admitted with a head injury? You answered this question Incorrectly 1. Pad side rails. 2. Elevate head of bed 35 degrees. 3. Maintain neck in neutral position. 4. Cluster nursing activities. 5. Maintain a quiet environment.

1., 2., 3., and 5. Correct: The client with a head injury is at risk for seizures. Padding the side rails is a safety precaution. Elevate the HOB 30-45 degrees to facilitate venous drainage and reduce ICP. Maintain the client's head midline to facilitate blood flow. A quiet environment is necessary to keep the client calm. An increase in environmental stimuli can increase ICP. 4. Incorrect: Clustering nursing activities will increase ICP. Activities should be spaced out. Remember, the client needs a quiet environment.

Which are modifiable risk factors for developing a stroke? You answered this question Correctly 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

1., 2., 4., 5., & 6. Correct: These are all modifiable risk factors that can be managed through lifestyle changes or medical treatment. 3. Incorrect: Hispanics, African Americans, Native Americans, and Asian Americans have a higher incidence of strokes than whites. You cannot change your race or ethnicity so this is a non-modifiable risk factor for stroke.

A nurse is reinforcing teaching with a client who has frequent urinary tract infections on how to prevent future infections. What statement by the client would indicate to the nurse that this has been successful? You answered this question Correctly 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1., 3., & 5. Correct: Holding urine can lead to stasis of urine and increasing the risk for infection. Foods such as eggs, cheese, meat and poultry, whole grains, cranberries, plums and prunes, and tomatoes tend to increase the acidity of urine. Acidic urine is less likely to allow for bacterial growth. Discarding toilet paper after each swipe will decrease exposure and accidental introduction of bacteria into the urinary meatus. 2. Incorrect: Emphasize the importance of drinking eight to ten 8 ounce glasses per day. Water helps flush bacteria from the urinary tract. 4. Incorrect: Cotton underwear is recommended. The natural fibers work to wick moisture away from the skin which discourages yeast growth.

Which nonpharmacologic interventions may help a client's backache? You answered this question Incorrectly 1. Providing the client information regarding pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing warm moist compress. 5. Using distraction techniques.

2, 3, 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy (not a heating pad), and using distraction techniques could help the client's backache. 1. Incorrect: Education regarding pain control does not directly help the client's complaint of pain.

Which nursing action represents secondary prevention level? You answered this question Incorrectly 1. Reinforcing teaching about the effects of alcohol to elementary school children. 2. Providing care for abused women in a shelter. 3. Leading a group of adolescents in drug rehabilitation. 4. Ensuring medication compliance in a client with schizophrenia.

2. Correct: Providing care for clients in a shelter for abused women indicates that a problem has been identified and is being monitored to prevent the problem from getting worse. The focus of secondary prevention is early detection, use of referral services, and rapid initiation of treatment to stop the progress of the disease. 1. Incorrect: This is primary prevention which is aimed at reducing the incidence of mental or physical disorders within the population. 3. Incorrect: This is tertiary prevention which is designed to restore self-suffering and to limit complications and disabilities associated with a disease state, such as substance abuse or mental illness. 4. Incorrect: This is tertiary prevention which is designed to restore self-suffering and to limit complications and disabilities associated with a disease state, such as substance abuse or mental illness.

The client complains of crushing substernal chest pain radiating down the left arm. Which measure should the nurse initiate first? You answered this question Correctly 1. Monitor for abnormalities on a cardiac monitor 2. Administer oxygen at 2 L/nasal cannula 3. Start an intravenous (IV) line of D5W to keep open 4. Draw blood for troponin level

2. Correct: So what should the nurse be worried about? That the client is having an MI? Yes. A crushing substernal chest pain radiating down the left arm is classic for an MI. So what option can help the client? Oxygen administration to get more oxygen to the heart muscle. 1. Incorrect: Looking and watching is what you are doing if you select this option. Will monitoring the client on the cardiac monitor first help the client? No. Give the client oxygen first. 3. Incorrect: Getting an IV line is good so that cardiac medications can be given, but help the client first by starting the O2. If you wait to provide oxygen until after starting the IV, the client may be waiting while heart muscle is dying. 4. Incorrect: Yes, the lab will be there shortly, but get started with O2 while you wait.

The nurse is caring for a client on the skilled nursing unit. The client has lost 8 pounds (3.6 kg) since admission 3 months ago. Which strategy may help to improve the client's caloric intake? You answered this question Correctly 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the nursing tech to feed the client at each meal.

2. Correct: The client may be lonely and miss the interaction with others. Eating with others may help to improve appetite and intake of food. 1. Incorrect: Eating alone may actually reduce food intake. Eating is also a social activity. 3. Incorrect: A high protein supplement may increase caloric intake; however, to give that to the client 30 minutes before a meal will interfere with food intake at mealtime. 4. Incorrect: Assisting the client is important if the client cannot feed self; however, there are no data to suggest that the client cannot feed self independently.

A nurse is assigned a client in the unit following application of a long leg cast to the left leg due to a fractured tibia and fibula. Which actions should the nurse implement? You answered this question Incorrectly 1. Elevate foot of bed 30 degrees. 2. Palpate bilateral pedal pulses. 3. Apply ice packs to fracture site. 4. Mark break through bleeding. 5. Monitor client's ability to move

2., 3., 4., & 5. Correct: The priority focus of care is any action that maintains good circulation to the extremity and prevents complications that can impair mobility. This must include checking distal pulses in both legs to compare the strength of the pulse on both the affected and unaffected side. The nurse should also decrease swelling and risk of compartment syndrome by applying ice to fracture site, monitor for bleeding, and check for tingling, coldness, numbness, and ability to move toes; in other words - neurovascular/sensation checks. 1. Incorrect: The affected leg should be elevated, but not both. The nurse should place the affected leg on a pillow and not raise the foot of the bed since this would raise both extremities.

Which signs/symptoms would indicate to the nurse that a client with cancer needs follow up care? You answered this question Correctly 1. Unexplained weight gain of 10 pounds 2. Leukoplakia 3. Prolonged hoarseness 4. Hematuria 5. Persistent abdominal bloating

2., 3., 4., & 5. Correct: White patches inside the mouth or white spots on the tongue may be leukoplakia, which is a pre-cancerous area that is caused by frequent irritation. It is often caused by smoking or other tobacco use. People who smoke pipes or use oral or spit tobacco are at high risk for leukoplakia. If untreated, it can become mouth cancer. A cough that does not go away and prolonged hoarseness may be a sign of cancer. Hematuria may be a sign of bladder or kidney cancer and needs further investigation. Although women may experience bloating with changes in the menstrual cycle, constant bloating should be investigated to rule out ovarian cancer. 1. Incorrect: Unexplained loss of weight or loss of appetite may indicate some types of cancer. Weight gain is not typically associated with cancer.

The nurse is caring for a burn client 48 hours after the burn occurred. What would be the nurse's priority action? You answered this question Incorrectly 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! The lung takes priority. 4. Incorrect: Not priority over pulmonary function. Again, we want to inspect for infection, but it is not the priority over aucultating the lungs

A client being prepared for surgery is to be given a pre-operative medication. What is the nurse's priority action when administering the medication? You answered this question Correctly 1. Verify client has signed all consent forms. 2. Escort the client to the bathroom to void. 3. Check that identification band is in place. 4. Raise side rails and put call bell in place.

3. CORRECT. All the actions mentioned are important, but the priority is client identification. Regardless of whether the nurse is administering medication, preparing the client to leave for surgery or for testing, the I.D. band must be in place during the entire hospitalization. If the band falls off or is removed for any reason, the client must be re-identified and banded before proceeding with any orders. 1. INCORRECT. While it is important for a client to sign pre-operative forms, this is not the nurse's responsibility. The primary healthcare provider or surgeon must witness and verify the client has signed all consent forms prior to surgery. 2. INCORRECT. Having the client void prior to transport to the O.R. can easily be accomplished by any staff member, including a UAP or LPN. This action would be extremely important if the nurse was going to administer a narcotic or sedative. But the scenario does not indicate the type of pre-op med to be administered. 4. INCORRECT. Again, raising side rails is generally completed after administration of a pre-operative medication, especially narcotics or sedatives. The call bell should always be within the client's reach, and although side rails are an important safety factor, it is not the first priority.

The LPN is administering morning medications on a surgical unit. What client report provided to the nurse during medication rounds should be immediately reported to the RN? You answered this question Incorrectly 1. Severe headache post lumbar puncture. 2. Abdominal cramping post colonoscopy. 3. Shortness of breath post liver biopsy. 4. Pink-tinged mucus post bronchoscopy

3. CORRECT. The LPN must be aware of any abnormal symptoms following a procedure, and report that situation immediately to the RN. A liver biopsy involves removing a tiny tissue sample from the liver for diagnostic purposes. One of several potential complications following this procedure is a pneumothorax. The client's report of shortness of breath indicates this has most likely occurred. This is a medical emergency which should be immediately reported to the RN. 1. INCORRECT. Although an intervention will be required to relieve this client's pain, a severe headache is not unexpected following a lumbar puncture. This can result from depletion of fluid in the spinal canal and can be treated either with I.V. fluids or a blood patch. 2. INCORRECT. The client has had a colonoscopy, which involves instilling a small amount of carbon dioxide gas to inflate the bowel for visualization. Sometimes this can lead to uncomfortable gas cramping and is alleviated with positioning or ambulation. 4. INCORRECT. Bloody or pink tinged mucus is not unexpected after a bronchoscopy. A large scope has been passed down the client's airway, and although a numbing spray is used, a sore throat with small amounts of blood-tinged mucus is expected. Only bright red mucus would be of concern

A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the LPN/VN that the RN's discharge teaching has been effective? You answered this question Correctly 1. I will need to eat a low fat diet since I no longer have a gallbladder. 2. I can expect drainage from the incisions for a few days. 3. I may have some mild pain from the procedure. 4. I should plan to limit my activities and not return to work for several weeks.

3. Correct: After a laparoscopic procedure the client can expect to have some mild pain. Severe pain, however, would indicate a problem. 1. Incorrect: The client can resume their usual diet. The liver will produce enough bile to digest fats. The gallbladder stores bile. Without the gallbladder, the bile just drains from the liver. 2. Incorrect: The client should not have drainage from the incisions. There are 2-3 small incisions on the abdomen that do not normally have drainage. 4. Incorrect: The client can return to normal activities in 2 to 3 days. This is not considered a major surgical procedure with a large abdominal incision. Recover time is much shorter, allowing the client to return to normal activities sooner.

The nurse observes that the client's respirations have a rhythmic increase and decrease of rate and depth and include brief periods of apnea. How would the nurse document this respiratory pattern? You answered this question Incorrectly 1. Biot's respirations 2. Ataxic 3. Cheyne-Stokes 4. Cluster

3. Correct: The respiratory pattern described is Cheyne-Stokes, an abnormal pattern of breathing. The respirations pattern is characterized by rhythmic increase and decrease in respirations and brief period of apnea. 1. Incorrect: Biot's respirations is characterized by a pattern of bradypnea and shallow respirations which change to tachypnea and deep respirations, followed by apnea. 2. Incorrect: Ataxic respirations have an irregular, random pattern of deep and shallow respirations with irregular apneic periods. The irregularity of it differentiates ataxic respirations from Cheyne-Stokes respirations. 4. Incorrect: Cluster breathing is characterized by a closely grouped series of gasps followed by a period of apnea. There is no rhythmic increase and decrease as in Cheyne-Stokes respirations.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? You answered this question Correctly 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

4. Correct: This is a correct statement. The goal of palliative care is to help the client living with a chronic, life threatening illness. It focuses on the client's symptoms and the relief of these symptoms. Palliative care helps the client obtain their best quality of life throughout the course of their illness. 1. Incorrect: Palliative care is not aimed at cure. It is provided to clients who have chronic, life threatening illnesses. 2. Incorrect: Palliative care can begin at diagnosis. Hospice care is usually offered when the person has 6-12 months or less to live. 3. Incorrect: The client does not need to give up his or her primary healthcare provider. This is not a requirement of palliative care

Which clients can the nurse assign to the same room? You answered this question Correctly 1. A 48 year old female one day postoperative appendectomy and a 30 year old female with nephrolithiasis 2. A 41 year old male with nausea, vomiting, and diarrhea and a 62 year old male with neutropenia 3. A 41 year old male with Methicillin-resistant Staphylococcus aureus (MRSA) infection and a 42 year old male with Clostridium difficile 4. A 14 year old two days postoperative splenectomy and an 80 year old female with Parkinson's disease 5. A 57 year old female with chronic obstructive pulmonary disease (COPD) and an 68 year old female with asthma

Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are clients, assign, and same room. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Option 1 is true. Ask yourself which groups of clients have something in common. The client post-operative appendectomy and the client with nephrolithiasis will both need to be frequently assessed for pain and interventions aimed at pain management. Also neither client has an infection that could be transmitted to the other client. Option 2 is false. The client with neutropenia has a low number of neutrophils which are a common type of white blood cell important to fighting off infections. The client should assigned to a private room. In addition the other client could be contagious depending on the causative factor of the nausea,vomiting and diarrhea. The client with neutropenia should not be assign with this client since their diagnosis has not been identified.. Option 3 is false. Contact isolation is required for both MRSA and C. difficile but the causative organisms for the diseases are not the same. Option 4 is false. The age difference between teenager and the elderly adult are so vast that the developmental needs of the clients vary too much for them to be placed in a room together. Option 5 is true. Neither client has an infectious disease. The clients with bronchitis and COPD have similar respiratory conditions that are not infectious.

Following a motor vehicle accident, a client is brought to the emergency room with shallow, labored respirations. The client is intubated and placed on a ventilator. What is the nurse's priority action immediately after the intubation? You answered this question Correctly 1. Suction to clear all secretions 2. Listen for bilateral breath sounds 3. Secure the endotracheal tube 4. Obtain x-ray to verify tube placement

Looking at these four options, did you say "They are all really important"? You would indeed be correct! When it is difficult to narrow down options, recall the nursing process. That is your best action! Maybe you were thinking that you do not remember much about intubation because it is not a nursing responsibility. Rather, it is a task that is completed by doctors, anesthesiologists, paramedics, or even respiratory personnel. However, the nurse has two definite responsibilities during this procedure: to assist and assess the client following the intubation. Let's think about the actual procedure. You know intubation is necessary when a client is not breathing properly or is in danger of losing airway ventilation. Quite simply, an endotracheal tube is passed between the vocal cords, down the trachea to just above the bifurcation of the carina in the lungs. If the tube is pushed too far, or not far enough, the client is at risk of poor or inadequate ventilation which can result in serious complications or even death. So, what should the nurse do immediately after the endo tube is inserted? Option 1: Sounds really important but it is not the first priority. In order to intubate, most clients are given some type of sedation or paralytic, meaning they are not able to cough to remove secretions. The point of the endotracheal tube is to provide a clear, intact airway, and you would definitely want to clear any secretions to improve ventilation. As important as this may be, it is not an immediate priority for the nurse. Option 2: Now you have it! The nursing process states that the first action is to assess the situation. This client is having respiratory problems; therefore, the issue you must worry about is the client's breathing. If this client has been properly intubated, there should be clear and even bilateral breath sounds with equal chest wall movement. If the endo tube has been advanced too far, say into the right mainstem bronchus, there will be diminished breath sounds on the client's left chest. Assessment of bilateral lung sounds is the most immediate priority action to be taken by the nurse. Option 3: Were you thinking that this seems like a priority? This is incorrect for several reasons. Remember that proper ventilation of the client is dependent on correct placement of the endotracheal tube. Although a lighted laryngoscope is used to insert the tube, the exact location cannot be determined without assessing lung sounds. Secondly, if for any reason the tube would have to be moved or reinserted, for example if the tube was placed in the esophagus by mistake, taking time to remove the mouth tape would traumatize the client's skin and further delay proper ventilation. Option 4: Good idea, but not the initial priority. Many things can go wrong during intubation. The endotracheal tube could be placed into the esophagus instead of the trachea, there could be bleeding around the vocal cords, teeth could be damaged, or the tube could be in the wrong location in the lungs. A post procedure x-ray is necessary to locate the position of the tip of the endotracheal tube, which should be just above the bifurcation in the lungs. Most often, a portable chest x-ray is ordered after intubation, but the nurse needs to complete an important assessment prior to this.

Hemoglobin levels

males: 14-18 females: 12-16

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

Cholinergic crisis is an episode of excessive stimulation to one of the body's neuromuscular junction points. Such an event results from a buildup of acetylcholine stemming from acetylcholinesterase inactivity or insufficiency. A common cause of cholinergic crisis episodes is the unintended overdose of treatment drugs in myasthenia gravis clients. Remember DUMBELLS - Diarrhea and abdominal cramping, Urination increased, Miosis (pinpoint pupils), Bradycardia, Emesis (nausea and vomiting), Lacrimation, Lethargy, Salivation to help you remember these signs and symptoms.

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 nurse is preparing to discharge four clients from the unit. Which client is most likely to receive a referral to other agencies or community outreach programs? You answered this question Correctly 1. 45 year-old client who had nasal surgery. 2. 50 year-old client postop mastectomy. 3. 72 year-old client with diabetes and obesity. 4. 80 year-old client with a diagnosis of delirium caused by dehydration.

3. Correct: The elderly client with diabetes and obesity is likely to need referrals at the time of discharge, whether to physical therapy, home health, weight loss program or other agencies. 1. Incorrect: There is no need to think that this client who is 45 years old will need assistance after nasal surgery. 2. Incorrect: This 50 year-old client postop mastectomy is mobile and does not need referral to other agencies or community outreach programs. 4. Incorrect: Delirium is an acute illness that resolves once the physical stressor is eliminated. In this case the delirium was caused by dehydration that has been corrected if the client is ready for discharge. There is no indication that the client is in need of post-hospital care.

A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? You answered this question Correctly 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

4. Correct: If a client is receiving a radiation implant, a lead container and long-handled forceps should be placed in the client's room and kept for the duration of the therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. 1. Incorrect: The placement of the implant into the lead container should be done initially. The primary healthcare provider may be notified but this is not the initial nursing action needed. 2. The implant should be picked up with long forceps for distance and reduction of contact. In addition, a biohazard bag is not sufficient for proper disposal of the radiation implant. 3. The initial action is to use long-handled forceps and dispose of the implant in a lead container. Calling the radiology department is delaying care and exposing individuals to the implant.

A 35 year old client asks a clinic nurse how to find out if they are considered overweight or obese. The client weighs 135 pounds and is 5 feet 2 inches tall. How can the nurse determine if this client is overweight or obese? You answered this question Correctly 1. Calculating body mass index 2. Measuring abdominal circumference 3. Determining lean body mass 4. Finding the nearest hydrostatic testing location

1. Correct: Calculating body mass index (BMI) would determine if the client is considered overweight or obese. 2. Incorrect: BMI is the most efficient way to determine if a client is overweight or obese. Measuring the abdominal circumference is one assessment for determining if a client is at risk for metabolic syndrome. 3. Incorrect: BMI calculates whether the client is overweight or obese. Once you have the BMI, you can calculate the lean body mass. 4. Incorrect: Although this is the "gold standard" for measuring body fat percentage by weighing the body in water, it is often performed in hospitals and university labs. It is not the most practical means of determining overweight or obesity.

A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What information would the nurse reinforce with the client? You answered this question Incorrectly 1. Monitor blood sugar around 0200 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.

1. Correct: Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect. 2. Incorrect: The nurse must determine the cause of morning hyperglycemia in order to care for the client. Information concerning bedtime snacking will be determined by the cause. 3. Incorrect: The nurse must determine the cause of hyperglycemia in order to care for the client. An appropriate intervention for a client with Somogyi effect would be to decrease the evening dose of intermediate acting insulin, however, the nurse must first determine that the client is in fact experiencing the Somogyi effect. 4. Incorrect: Increasing the intermediate acting insulin would not be appropriate action for a client experiencing Somogyi effect.

Which client should the nurse see first after receiving report on assigned clients? You answered this question Correctly 1. Having dyspnea after surgery. 2. Needing vitals signs taken before the administration of blood. 3. Crying with pain after back surgery. 4. Vomiting dark brown, granular material.

1. Correct: The client may be having a pulmonary embolism after surgery. This client with oxygenation needs takes priority over the other three clients. 2. Incorrect: Needing vitals signs taken before blood administration does not take priority over oxygenation. If blood is needed, tissue perfusion could be altered, so this would need to be addressed in a timely manner after airway issues and other potentially deteriorating situations have been addressed. 3. Incorrect: Pain is expected after back surgery and is not a priority over oxygenation. When possible, the pain should be assessed and medications administered. Remember, pain never killed anyone. 4. Incorrect: This client with dark brown emesis may have an upper GI bleed that has slowed or stopped. This is the second client to see but is not a priority over oxygenation. This could potentially return to active GI bleeding and the client's condition could deteriorate rapidly, so the client would need to be seen following the client with dypnea.

Which statement about acquiring the Ebola virus by a client would indicate to the nurse that follow up is necessary? You answered this question Incorrectly 1. "I can get a vaccine to prevent getting the Ebola virus." 2. "Ebola is not spread through casual contact, so my risk of getting the virus is low." 3. "The Ebola virus is passed from person to person through blood and body fluid." 4. "Ebola viruses are mainly found in primates in Africa."

1. Correct: This is an incorrect statement. At present, there is no vaccine to prevent Ebola. 2. Incorrect: This is a correct statement about the Ebola virus. Ebola is not spread through casual contact. 3. Incorrect: This is a correct statement about the Ebola virus. Ebola virus is passed from person to person through blood and body fluid. 4. Incorrect: This is a correct statement about the Ebola virus. Ebola viruses are mainly found in primates in Africa.

Which actions are appropriate for the nurse to reinforce in the nutritional teaching plan to accomplish the goal of a diet lower in fat? You answered this question Correctly 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

1., 2. & 4. Correct: Two percent milk can reduce the amount of fat consumed daily, not only in milk that the client drinks, but also in foods that contain milk as an ingredient. Air-popped corn contains no fat unless butter is added after popping. The client still is able to have a crunchy snack without the fat. Plant proteins such as kidney, black, or lima beans are good sources of protein without the fat from a meat source. 3. Incorrect: Red meats are high in fat. Chicken, fish, and seafood are better meat choices. 5. Incorrect: Olive oil is low in saturated fat but still a source of fat. While olive oil may be a healthier choice, all fats have essentially the same number of calories per serving. The goal is to reduce the amount of fat in the diet.

What signs and symptoms would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? You answered this question Incorrectly 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 19 year old client preparing to enter college asks the clinic nurse about immunizations. What immunizations should the nurse suggest the client discuss with the primary health care provider? You answered this question Incorrectly 1. Meningococcal conjugate vaccine 2. Tdap vaccine 3. HPV vaccine 4. Seasonal flu vaccine 5. Hepatitis B 6. Polio

1., 2., 3., 4, & 5. Correct: These vaccine are specifically recommended for young adults ages 19-24. Meningococcal conjugate vaccine is recommended as it protects against bacterial meningitis. It is required for students living in a dorm. Tdap vaccine protects against tetanus, diphtheria, and pertussis. HPV vaccine protects against the human papillomavirus, which causes most cases of cervical and anal cancers, as well as genital warts. Seasonal flu vaccine is recommended. Hepatitis B is a blood-born infection, which can also be transmitted through sexual activity. 6. Incorrect: The inactivated polio (IPV) vaccine is a 4-dose series given during early childhood. IPV is not routinely recommended for children aged 18 years or older.

The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? You answered this question Incorrectly 1. Oily skin 2. Weight gain of 4 pounds in one week 3. Loss of muscle mass in extremities 4. Blood glucose of 58 mg/dL 5. Serum potassium of 3.2 mEq

2., & 5. Correct: Remember that aldosterone is a mineralocorticoid, which causes the client to retain sodium and water. Retaining sodium and water will cause the client's weight to increase. Also remember, any sudden gain in weight is due to water retention. Too much aldosterone makes you retain too much sodium and water and lose potassium. Normal potassium is 3.5-5.0 mEq/L, so a lowering of potassium could indicate high levels of aldosterone. 1. Incorrect: Oily skin would be seen with an increase in sex hormones such as testosterone and estrogen. Oily skin is not common with mineralocorticoids like aldosterone. 3. Incorrect: Too many glucocorticoids will cause the breakdown of protein and fat but muscular weakness and increased fatigue is seen with too little mineralocorticoids. 4. Incorrect: Too many glucocorticoids will inhibit insulin, causing the serum blood glucose level to go up. Normal blood glucose is 70-110.

Which nursing actions are correct for a client in a Halo Traction? You answered this question Incorrectly 1. Observe for signs of serous drainage. 2. Inspect skin under the halo vest. 3. Use sterile technique to clean pin sites. 4. Tape a torque screwdriver to the headboard. 5. Tighten a loose pin with a torque screwdriver.

2., 3. & 4. Correct: Inspecting the skin under the halo vest is necessary to look for excessive perspiration, redness, skin blistering, especially over bony prominences. When cleaning halo pins, sterile technique should be used in an effort to prevent infection which could enter the bone. A torque screwdriver should be readily available in case the screws on the frame need to be tightened by the neurosurgeon. 1. Incorrect: Serous drainage does not indicate infection: purulent drainage, redness, and pain would indicate the likelihood of infection. 5. Incorrect: This is out of the scope of the nurse's practice. This should be done by the surgeon. The nurse should maintain the head in a neutral position while having someone else notify the neurosurgeon.

A client admitted to the hospital following a fall has a history of Alzheimer's disease with apraxia. The nurse knows the client will need priority assistance with what activity? You answered this question Correctly 1. Ambulating to the bathroom. 2. Understanding instructions. 3. Using utensils at mealtime. 4. Identifying objects in room.

3. Correct: Apraxia is a motor disorder of voluntary movements in which the individual can no longer execute purposeful activity, even though there is adequate mobility, strength, and coordination. This loss of ability to carry out previously learned movements could occur secondary to brain injury or a disease process such as Alzheimer's disease. The client has the ability to pick up utensils but is unable to use them correctly, which may affect the client's nutritional status. 1. Incorrect: Apraxia does not affect the ability to ambulate to the bathroom, although the client may not be able to follow cleanliness procedures once in the bathroom. However, there is another activity is of more concern. 2. Incorrect: The ability to understand is not affected by apraxia, which is a disorder in which the client loses the ability to perform purposeful movement. The client is still able to comprehend instructions at this point. There is another situation in which the client will need assistance. 4. Incorrect: The client is still able to identify objects in the environment; however, the diagnosis of apraxia indicates the client cannot use previously known objects correctly. Because of this situation, there is another area in which assisting the client is of more importance.

A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the intensive care unit. Which nursing intervention should the nurse initially implement? You answered this question Correctly 1. Administer an osmotic diuretic. 2. Complete a neurological assessment. 3. Maintain the head of the bed at 30 degrees. 4. Instruct the client to take a stool softener daily.

3. Correct: Hemorrhagic strokes are the result of ruptured vessel bleeding in the cranial cavity. This action will result in increased intracranial pressure (ICP). ICP can cause a decrease in the brain's metabolism and hypoxia of the brain tissue. The head of the bed should be elevated to decrease the increased intracranial pressure which can reduce damage to the brain. The intervention of raising the head of the bed to 25 -30 degrees is directly related to a decrease in ICP. 1. Incorrect: An osmotic diuretic is administered to increase the osmotic effect on the kidneys which will decrease ICP. An osmotic diuretic is initiated during the acute care protocol for a stroke. 2. Incorrect: A neurological assessment would be done upon admission to the medical unit. But maintaining the head of the bed at 30 degrees is the initial action. 4. Incorrect: The readiness of the client to learn should be evaluated prior to initiating teaching. Due the client's immediate transfer from ICU, this is not the apparent time to begin to the initiate client teaching. Ways to avoid straining during a bowel movement instruction is not the priority nursing intervention.

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

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

What is the only acceptable use of restraints by the nurse? You answered this question Correctly 1. An elderly male client had a chest restraint applied after crawling over the bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV. 4. A dementia client is in a Geri-chair with lap belt at nurse's station at night.

3. Correct: Restraints are considered a last resort when caring for a client, whether soft cloth or chemical restraints. The most acceptable use is to prevent a client from harming self or others. In this instance, a confused client has previously pulled out an ordered IV. Therefore, the use of hand mitts is the most appropriate, least restrictive method to prevent the client from further self harm. 1. Incorrect: There are several problems here. The client had side rails up, which are considered a form of restraint and in many facilities are no longer permitted. By applying a chest restraint, the client has been restrained twice. Just because a client is elderly does not mean restraints are needed. This restraint is not acceptable. The nurse should provide regular toileting periods and determine why this client is climbing out of bed. 2. Incorrect: Closing a client into a room is overly restrictive and unsafe. This Alzheimer's client needs to be observed and closing the room door prevents visual access. Additionally, closing the door may violate fire safety codes in certain facilities. At shift change, when staff is occupied with report, special arrangements should be made so that the client can be observed and not restrained. 4. Incorrect: Depending on the facility, placing a client upright at night, using a Geri-chair and a lap belt is overly restrictive. A client with dementia is challenging, particularly at night. However, keeping a client upright all night, belted into a chair for the purpose of observation, is neither safe nor healthy for the client.

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.

Which signs and symptoms indicates a tension pneumothorax? You answered this question Correctly 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

3. Correct: Yes, as pleural pressure on the affected side increases mediastinal displacement occurs with resultant respiratory and cardiovascular compromise. Symptoms of tension pneumothorax include dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention and cyanosis. 1. Incorrect: Hypoxia causes tachycardia rather than bradycardia. The client would more likely to be hypotensive due to decreased cardiac output. 2. Incorrect: Yellow mucus indicates infection, such as from pneumonia. This does not indicate a tension pneumothorax. 4. Incorrect: Profuse hemoptysis and weakness may indicate a serious condition such as a ruptured vessel, but it is not an indication of a mediastinum shift.

What signs/symptoms would the nurse expect to be manifested in a client diagnosed with Guillain-Barre' Syndrome? You answered this question Incorrectly 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches

3., 5., & 6. Correct: Guillain-Barre' Syndrome is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It is characterized by ascending, symmetric paralysis affecting the cranial and peripheral nerves. Signs and symptoms include paresthesia, hypotonia, areflexia, muscle aches, cramps, orthostatic hypotension, hypertension, bradycardia, facial flushing, facial weakness, dysphagia, and respiratory distress. 1. Incorrect: Opisthotonos is extreme arching of the back and retraction of the neck. This is seen with tetanus, not with Guillain-Barre' Syndrome. 2. Incorrect: Seizures can be associated with many neuromuscular problems but are not typical with Guillain-Barre' syndrome. Look for seizures with such problems as increasing ICP, infections of the brain, high fever, epilepsy. 4. Incorrect: Hemiplegia, paralysis on one side of the body, is not seen. There is a symmetric paralysis starting in the lower extremities and ascending through the body. In other words, weakness begins in the feet and progresses upward. The client gets better in reverse order

The nurse is participating in providing a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? You answered this question Correctly 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies

4. Correct: Biologically-based therapies use substances found in nature such as herbs, foods, and vitamins. 1. Incorrect: Energy therapies use energy fields. Substances found in nature are biologically-based therapies. 2. Incorrect: Mind-body interventions use the mind to help affect the function of the body. Substances found in nature are biologically-based therapies. 3. Incorrect: Body-based methods use movement of the body. Substances found in nature are biologically-based therapies.

The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find? You answered this question Correctly 1. Increased white blood cells 2. Presence of protein 3. Presence of ketones 4. Increased specific gravity

4. Correct: Specific gravity is an indicator of hydration status and urine osmolality. In a dehydrated client, specific gravity is increased, indicating highly concentrated urine. 1. Incorrect: White blood cells should not be found in the urine unless an infection is present. Dehydration does not cause white blood cells in the urine. 2. Incorrect: Protein should not be found. Presence of protein indicates renal disease. In order to have proteinuria there must be damage to the glomeruli 3. Incorrect: Ketones should not be present. They are found in clients with poorly controlled diabetes or hyperglycemia, because ketones are a by-product of fat breakdown. Fats are broken down and used for energy when glucose cannot be transported into the cells because of lack of insulin.

While preparing an information sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? You answered this question Incorrectly 1. Wash hands with hot water and soap when hands are soiled. 2. Gloves are not needed in the home since contamination with VRE has already occurred. 3. Wash hands before using the bathroom and after preparing food. 4. Clean the bathroom and kitchen with warm water and bleach.

4. Correct: The bathroom and kitchen should be cleaned with warm water and bleach to decrease contamination. The client should wash hands after using the bathroom and before preparing food. 1. Incorrect: Instructing the client and family to wash with hot water can cause drying and cracking of the skin. Hands should be washed with all contacts. Washing hands is the single most important thing to do to prevent infection. 2. Incorrect: Gloves are needed with VRE to prevent spread of infection. Gloves are especially needed if contact with blood or other infectious materials is anticipated. 3. Incorrect: Hands should be washed after using the bathroom and prior to handling or preparing food

A client is received from surgery to the post-anesthesia care unit (PACU) post left upper lobectomy. What action should the nurse take when bubbling is noted in the water-seal chamber of the chest tube drainage unit? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Milk the chest tubing. 3. Replace the drainage system unit. 4. Document the finding.

4. Correct: With a lobectomy, the nurse would expect to see bubbling in the water-seal chamber because there is air in the thoracic cavity that needs to escape. The finding should be documented. 1. Incorrect: With a lobectomy, the nurse would expect to see bubbling in the water-seal chamber because there is air in the thoracic cavity that needs to escape. 2. Incorrect: Milking the chest tubing is not indicated and could lead to increased intrathoracic pressure which could cause damage to thoracic and lung tissue. 3. Incorrect: An air leak due to bubbling does not indicate that the unit is malfunctioning, but that there is air in the chest.

A nurse is planning to discuss steps that senior citizens can take to keep the brain healthy. What should the nurse include? You answered this question Incorrectly 1. Memorize poetry. 2. Eat foods low in Omega 3, fatty acids. 3. Brush teeth with nondominant hand. 4. Do crossword puzzles. 5. Learn a new language. 6. Volunteer.

Although there is no known definitive way to prevent Alzheimer's disease, steps can be taken to keep the brain healthy. Growing evidence indicates that people can reduce their risk of cognitive decline by adopting key lifestyle habits. When possible, combine these habits to achieve maximum benefit for the brain and body. To keep the brain active, learn something new. Take up a language, an instrument, memorize poetry. A good, healthy diet will improve all areas of our health, but there are many studies and an increasing amount of evidence suggesting that certain foods slow mental decline. Brain-boosting food is any food high in Omega 3 fatty acids, which has been linked to a lower risk of dementia and improved focus and memory. Brain games, puzzles and brainteasers help create new associations between different parts of the brain, which keeps it sharp. Challenge the brain by doing normal activities with the non-dominant hand like brushing your teeth or combing your hair. Research shows that volunteering can lower stress levels and increase mental functioning. It also adds to a person's wellbeing and overall health. Social activity keeps our minds sharp. This is especially true later in life, when aging takes its toll on memory and other complex neurological processes.

The LPN/VN is reinforcing teaching in a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer? You answered this question Correctly 1. Diagnosed with irritable bowel syndrome 2. Has a family history of colon polyps 3. Diagnosed with cirrhosis of the liver 4. Has a history of colon surgery

Most colon cancers originate from small, benign tumors called adenomatous polyps that form on the inner walls of the large intestine.Some of these polyps may grow into malignant colon cancers over time if they are not removed during colonoscopy. Cancer can be the result of a genetic predisposition that is inherited from family members. It is possible to be born with certain genetic mutations or a fault in a gene that makes one statistically more likely to develop cancer later in life. Age is an important risk factor for colon cancer. Colon cancers are more likely to occur in people with sedentary lifestyles, obese people, and those who smoke tobacco. Diet is an important factor associated with colon cancer. Diets that are low in fiber and high in fat, calories, and red meat and processed meats increase the risk of developing colon cancer. There are several diseases and conditions that have been associated with an increased risk of colon cancer. Diabetes, acromegaly (a growth hormone disorder), radiation treatment for other cancers, ulcerative colitis, and Crohn's disease all increase the risk of colon cancer.

The nurse, caring for a client who has terminal cancer, finds that the client is extremely restless. In response to this data, what would be the appropriate nursing action? You answered this question Incorrectly 1. Play soothing music. 2. Use chamomile aromatherapy. 3. Place soft restraints on arms. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.

When an individual is nearing their final days, terminal restlessness is a common symptom. Terminal restlessness (sometimes called terminal agitation) includes anxiety, agitation and confusion. Other symptoms include hallucinations, paranoia, and disorientation. These signs are more intense than simple mood changes and can be very troubling for family members. A calm, quiet and stress-reduced environment, with reassurance from those who are close to the person, can often help to relieve this symptom. Option 1 is true. It's believed that music has been used since practically the beginning of time to help people deal with difficult feelings and better connect to one another. Music has a strong and immediate influence over our emotions, and naturally increases our neurochemicals or "feel good" endorphins. Option 2 is true. Chamomile has been found to be very effective in eliminating feelings of sadness, depression, disappointment, and sluggishness while inducing a sort of happy or charged feeling. Chamomile is effective in calming down annoyance, anger, and irritation. It has analgesic properties, which effectively reduces pain in the muscles and joints. Chamomile essential oil has also been used as a mild sedative to calm nerves and reduce anxiety by promoting relaxation. Inhaling it is one of the best ways to utilize essential oils for anxiety. The fragrance is carried directly to the brain and serves as an emotional trigger. Option 3 is false. Don't do this. Restraints will only agitate the client more. Remember, use restraints as a last resort. Option 4 is true. One of the hormones produced by dimming the lights is melatonin. Also known as the "hormone of darkness", melatonin promotes relaxation and sleep. Option 5 is true. The goal is to decrease stimuli. So, we want to create a quiet environment. Turn off the TV. Talk softly, calmly, and quietly. Option 6 is true. People use massage for a variety of health-related purposes, including to relieve pain, rehabilitate sports injuries, reduce stress, increase relaxation, address anxiety and depression, and aid general wellness.

Opisthotonos

hyperextension of neck BAD, put on side

A client has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease? You answered this question Correctly 1. "I can be treated and then no one else is at risk." 2. "Using condoms will keep my sex partner from acquiring the disease." 3. "If I have no sores, I am not contagious to anyone." 4. "My sex partner should be tested because we have not always used condoms."

4. Correct: The sex partner may become infected even if using a condom. The condom does not always cover all lesions. Condoms do, however, reduce the likelihood of getting/transmitting the disease. 1. Incorrect: Sex partners can acquire the disease even if no open sores are present. Treatment manages outbreaks but does not cure the disease. 2. Incorrect: Condoms decrease the risk. Abstinence is the only guaranteed way to not expose your partner. 3. Incorrect: Sex partners may get the disease even if no open sores are present; therefore, they should be tested for the disease.

After completing several rounds of chemotherapy, a client's laboratory results indicate severe neutropenia. After admission, what is the nurse's priority action for this client? You answered this question Incorrectly 1. Notify dietary no fresh, unpeeled fruits or vegetables. 2. Avoid all venipunctures or IM injections. 3. Have client wear mask when leaving room. 4. Instruct client to use a soft toothbrush.

1. Correct: Neutropenia is an abnormally low white blood cell count caused, in this case, by the recent chemotherapy. The greatest concern is the client's inability to fight off infection. Fresh fruits and vegetables have a high bacterial count and present an increased risk for infection. Asking dietary to remove fresh fruits and vegetables from meal trays is an important priority action by the nurse. 2. Incorrect: Avoiding venipunctures of any type, including IM injections, is an important precaution for neutropenia, in which infection is the main concern. However, the word "ALL" makes this statement to definite. The client may need an IV. Remember, nothing is that definite in the world. 3. Incorrect: This immunocompromised client is at risk for infection, as indicated by a low neutrophil count. While airborne bacteria may be a concern at some point, there is another action by the nurse which takes priority. 4. Incorrect: A soft toothbrush is used as part of the precautions for clients at risk for bleeding, which would not apply to this client. The nurse here is concerned about infection control secondary to a low neutrophil count.

A 3 day post-operative client with a left knee replacement is reporting chills and nausea. Temperature: 100.8ºF/38.2ºC, pulse: 94, respiration: 28 and blood pressure is 146/90. What is the nurse's best action? You answered this question Correctly 1. Call the surgeon immediately. 2. Administer extra strength acetaminophen per prescription. 3. Monitor the surgical site. 4. Offer extra blankets and increase fluids.

1. Correct: The client's symptoms are indicative of infection, and the primary healthcare provider needs to be notified and may want diagnostic tests performed. The other actions are appropriate to treat the symptoms and provide comfort, but they are not the best action to fix the problem. 2. Incorrect: While this may be appropriate, it may also delay treatment of the problem, which is infection. Remember, you can only pick one answer to fix the problem and this action will only treat the symptoms. 3. Incorrect: The primary healthcare provider may want the site monitored, but this also delays treatment. Since you can only pick one option, this is not the best. 4. Incorrect: Comfort measures are always appropriate, but this is not the best action available.

Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? You answered this question Incorrectly 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia 6. Flank pain

Cystitis is a fairly common lower urinary tract infection, it refers to an inflammation of the bladder, specifically, the wall of the bladder. All this question is asking is "Hey new nurse, do you know the signs/symptoms of cystitis? Well do you? Remember to look at each option individually and decide if it is a sign or symptom of cystitis. Option 1. Incontinence - loss of bladder control? True or False? True. Option 2. Urgency - A strong desire to urinate, accompanied by a fear of leakage.? True Option 3 Frequency - the need to urinate many times during the day, at night (nocturia), or both but in normal or less-than-normal volumes. ? True Option 4 Hematuria - the presence of blood in urine.? True Option 5. Nocturia - Frequency at night? True Option 6. Flank pain? False. Flank pain occurs with a kidney infection, pyelonephritis.

The nurse will monitor for which sign of increased intracranial pressure (ICP) in a client with a brain injury? You answered this question Correctly 1. Increased pulse 2. Lowered systolic pressure 3. Narrowed pulse pressure 4. change in pupil size

4. Correct: Signs of increased intracranial pressure include change in pupil size, elevated systolic pressure, wide pulse pressure, decreased pulse, and slow respirations. 1. Incorrect: Decreased pulse, not increased pulse. 2. Incorrect: Elevated systolic pressure, not lowered pressure. 3. Incorrect: Wide pulse pressure, not narrowed pulse pressure.