Archer 9

A Choice A is correct. This client displays signs and symptoms of an ST-segment elevation myocardial infarction (STEMI). In a STEMI, myocardial necrosis is occurring, with the client exhibiting ECG changes showing ST-segment elevation not quickly reversible by nitroglycerin administration. The primary focus should be on improving myocardial oxygenation and reducing cardiac workload, as these measures will reduce further expansion of the myocardial necrosis. Choice B is incorrect. Based on Maslow's hierarchy of needs, the needs to confirm the suspected STEMI diagnosis and prevent complications are not prioritized over the need to improve myocardial oxygenation and reduce the cardiac workload. Choice C is incorrect. Based on Maslow's hierarchy of needs, pain relief and anxiety reduction are not prioritized over the need to improve myocardial oxygenation and reduce the cardiac workload. Choice D is incorrect. Providin

A client arrives at the emergency department (ED) complaining of substernal chest pain. An ECG shows ST-segment elevation, and the client's cardiac troponin level is found to be elevated. Which of the following should be the nurse's primary focus? A. Reducing cardiac workload and improving myocardial oxygenation B. Confirming the suspected diagnosis and preventing complications C. Pain relief and reduction of anxiety D. Providing a quiet, non-demanding environment and reducing anxiety

D

A client is being discharged following the insertion of a permanent pacemaker. Which of the following should be included in the client's discharge instructions? A. Air travel will not be possible due to airport screening equipment. B. You will need to discard any radios at home that have antennas. C. Computed tomography (CT) scans are not permitted with this device. D. You should use your cellular phone on the opposite side of the generator.

A Choice A is correct. Levonorgestrel (LNG) is available over the counter for emergency contraception. This medication is indicated to be used up to 72 hours following unprotected intercourse, where pregnancy could be possible. It may be used off-label up to 120 hours following the event. This medication works by postponing (or inhibiting) ovulation. Choices B, C, and D are incorrect. These medications are not indicated as emergency contraception. ➢ Tamoxifen is indicated for hormone receptor-positive breast cancer. This medication is used to prevent breast cancer recurrence. ➢ Finasteride is indicated for benign prostatic hyperplasia. This medication is highly teratogenic and should be handled with gloves by pregnant women. ➢ Methotrexate is indicated for ectopic pregnancy that has not ruptured. This may be an alternative to surgery. Several methods may be used for emergency contraception (EC). The most comm

A client presents to the clinic asking the nurse about emergency contraception. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? A. Levonorgestrel B. Tamoxifen C. Finasteride D. Methotrexate

D Choice D is correct. Respiratory distress is not caused by untreated depression during pregnancy. Choices A, B, and C are all incorrect. Teratogenicity, non-adherence to prenatal care, and tobacco use are associated issues with untreated depression in pregnancy.

A depressed pregnant patient is being seen in the clinic. Her physician has suggested that she try an anti-depressant to treat the condition. But the patient is nervous. The nurse should explain that all of the following are possible outcomes of untreated depression, except: A. Teratogenicity B. Non-adherence to prenatal care C. Tobacco use D. Respiratory distress post-birth

D Choice D is correct. A central line is a significant risk factor for a client to develop a central line-associated bloodstream infection (CLABSI). This occurs because of suboptimal sterile technique during insertion and/or inappropriate dressing changes. Additionally, TPN is a risk factor as the high glucose content makes the client more likely to develop a bacterial or fungal infection. TPN increases the risk for a CLABSI compared to solutions such as 0.9% saline. Choices A, B, and C are incorrect. A client withdrawing from alcohol has a risk for delirium tremens but not a risk for an infection. Further, being malnourished increases the risk of impaired skin integrity but not an infection. Methylprednisolone is a corticosteroid that, if used intermediate to long term, may increase the risk for infection. Asthma itself is a chronic disease but not one that raises the risk for infection. An external urinary cathete

A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client A. withdrawing from alcohol and is malnourished. B. receiving methylprednisolone for an asthma exacerbation. C. has an external urinary catheter device for urinary incontinence. D. receiving total parenteral nutrition (TPN) via a central line

A, C, D, F

A nurse is reviewing prescriptions for assigned clients. Which prescriptions require follow-up with the primary healthcare provider? A client with Select all that apply. A. congestive heart failure prescribed diltiazem. B. hypertension prescribed clonidine. C. diabetes insipidus prescribed hydrocortisone. D. pulmonary emboli prescribed clopidogrel. E. atrial fibrillation prescribed amiodarone. F. bacterial cystitis prescribed valacyclovir.

A, B, D Choices A, B, and D are correct. After splenectomy, the patient is at high risk for developing OPSI (overwhelming post-splenectomy infection) and the nurse should recognize signs of an infection early on. Administering antibiotics and antipyretics for a fever is crucial to prevent the disease from worsening. The doctor should be called immediately because further treatment may be necessary. Choices C and E are incorrect. Palpating the patient's RUQ will not tell the nurse any vital information since the spleen would be palpated on the LUQ. The patient should not be placed in the Trendelenburg position because this will have no change in the patient's status.

A nurse on the surgical floor is caring for a patient who is three days post-splenectomy. During 0700 vital signs, the CNA obtains a 100.2-degree temperature but forgets to tell the nurse about this finding. At 1500, the nurse takes the patient's temperature, and it is 101.8 degrees. After documenting the findings, the nurse should do which of the following? Select all that apply. A. Administer amoxicillin per the standing order B. Call the physician immediately C. Palpate the patient's right upper quadrant D. Administer acetaminophen E. Place the patient in the Trendelenburg position

B Choice B is correct. Nurses need to be aware of the patient's needs even if they do not pertain to the reason for hospitalization and treatment. Observation is a crucial nursing skill. The nurse should always be alert for any changes in a patient's condition, regardless of the initial diagnosis. Being aware of the patient's status will equip the nurse to be a better advocate for patients and to request referrals when concerns or issues arise during care. Choice A is incorrect. Any changes in a patient's status should be reported, even if it has nothing to do with the reason for admission. Choice C is incorrect. A referral to go to the hospital gym is not necessary. Physical Therapy can assist the client with balance and gait issues. Choice D is incorrect. The nursing care plan should include safety measures related to gait/balance impairment. However, gait training will be provided by physical therapy.

A patient being treated for hypertension is assessed by the nurse and found to have poor gait and impaired balance. What would the nurse's appropriate action be? A. Do nothing as this has nothing to do with why the patient was hospitalized. B. Speak with the attending physician about his concerns and request a referral to physical therapy. C. Speak with the attending physician about his concerns and request a referral for the patient to go to the hospital gym. D. Add this issue to the nursing care plan and have daily gait/balance training as an intervention.

C Choice C is correct. Bowel prep is necessary to make sure the x-rays are bright and bowel contents do not obstruct viewing of urinary structures. An IV pyelogram is an x-ray that is used to view the urinary structures. Choice A is incorrect. A full bladder is unnecessary for the test to be successful. Choice B is incorrect. Although the technician should be alerted if any uncomfortable sensations occur, allergies should be checked before the test is administered. Choice D is incorrect. It is not necessary to lie down after the test is performed.

A patient is scheduled for an IV pyelogram. He asks the nurse what he needs to do to prepare for the test. The correct response is: A. "You need to have a full bladder for the test to be successful." B. "You need to alert the technician if you feel any burning after the dye is injected." C. "You will receive a bowel preparation before the test can be performed." D. "You must lie on your back for four hours after the test is performed."

C Choice C is correct. Occupational therapists are excellent resources for helping patients suffering from gait and movement problems. Occupational therapists help patients transition from their hospital life to their homes. While physical therapists are mostly involved in specific gait related issues, occupational therapists also assist to help improve functional mobility so that the patients can perform their activities of daily life ( ADL). Choice A is incorrect. Case managers work with patients and their families to organize their care and to discuss resources available outside of the hospital to meet the patient's needs. They do not resolve gait issues. Choice B is incorrect. While they work with a patient to treat various disorders, nurse practitioners are best utilized to prescribe treatments and monitor a full caseload. They are not the best option to help with physical movement. Choice D is incorrect. A res

A patient recovering from a transient ischemic attack can walk but is having difficulty going upstairs. What professional should visit them to help work through this issue? A. Case manager B. Nurse practitioner C. Occupational therapist D. Respiratory therapist

A Choice A is correct. The charge nurse should consult the infection control nurse for patient placement alternatives, as the pediatric client with pulmonary tuberculosis requires airborne isolation. Choice B is incorrect. The disease is transmittable through airborne droplets. If these two pediatric clients are placed in the same room, the uninfected child could acquire the TB infection through airborne droplets. Choice C is incorrect. Despite being in an airborne isolation room with one another, the TB pediatric client and the pediatric client positive for varicella are a risk to one another. These two clients should not be placed in the same room, as both illnesses are transmitted similarly, putting both clients at risk. Choice D is incorrect. Before refusing the admission, the charge nurse should consult the infection control nurse to discuss available options. If the issue remains unresolved, the charge nurse s

A pediatric client with pulmonary tuberculosis (TB) is scheduled to be admitted to the pediatric unit when the charge nurse learns the remaining private room on the unit was filled on the prior shift. No other pediatric TB clients are currently admitted. What is the most appropriate action for the charge nurse? A. Contact the infection control nurse B. Room the client with an uninfected client 6 feet apart C. Place the client with the varicella client currently in the airborne isolation room 6 feet apart D. Refuse to admit the pediatric TB client

A

A post-adrenalectomy client is admitted to the ICU and is on IV hydrocortisone. Which nursing intervention should be included in the client's plan of care? A. Monitor blood glucose levels frequently. B. Keep the client supine for 24 hours. C. Discontinue hydrocortisone once vital signs become stable. D. Educate the client on how to properly clean his wound at home.

A Choice A is correct. Abruptio placentae should be considered in pregnant clients who have experienced abdominal trauma. A sign that concealed hemorrhage has occurred is the rapid increase in uterine size along with rigidity. Choice B is incorrect. Ectopic pregnancy is the implantation of a pregnancy in a site other than the endometrial lining of the uterine cavity (i.e., fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity). Ectopic pregnancies cannot be carried to term and eventually rupture or involute. Early symptoms and signs include pelvic pain and vaginal bleeding. Hemorrhagic shock can occur with rupture. The anatomic structure containing the fetus usually ruptures between 6 to 16 weeks of gestation. There is no correlation between abdominal trauma and ectopic pregnancies. Choice C is incorrect. Placenta previa is the implantation of the placenta over or near the internal os of the

A woman in her 30th week of gestation was brought in for evaluation after falling down a flight of stairs. Upon evaluation, the health care provider (HCP) notes a rigid, board-like abdomen. The fetal heart rate (FHR) is currently 167 beats per minute, with all the woman's vital signs stable. Following the potential abdominal trauma experienced by the client, which obstetric emergency must be excluded? A. Abruptio placentae B. Ectopic pregnancy C. Placenta previa D. Massive uterine rupture

A Choice A is correct. Guided imagery is a stress-reduction technique that can be done in any place at any time. In fact, this is one of the biggest advantages of this technique. Anytime the patient begins to feel anxious, they can practice guided imagery. Choice B is incorrect. Guided imagery can be done in any position that the patient is most comfortable in. They do not have to by lying down unless they choose to. Choice C is incorrect. It is not necessary for the client's mom or anyone else to be present for guided imagery unless they choose so. Any person, or no one at all, can be present depending on the client's preferences. Choice D is incorrect. Music can but does not have to be played during guided imagery, again it depends on the client's preferences.

A 12-year-old client with chronic asthma exacerbations has decided to try guided imagery as a way to manage the anxiety that is contributing to frequent asthma attacks. Which statement by the client indicates an understanding of this stress-reduction technique? A. "I can do this anytime and anywhere when I feel anxious." B. "I must be lying down to practice guided imagery." C. "My mom will have to be with me any time I try this." D. "I will play music every time I do my guided imagery to make sure it works."

A Choice A is correct. Hyperventilating can cause respiratory alkalosis. This is because there the body is blowing off too much CO2. CO2 is an acid, so when the body is loosing too much of it, the client can become alkalotic. Choice B is incorrect. These values represent typical ABG values, which would not be expected in a patient who is hyperventilation. Choice C is incorrect. These values represent respiratory acidosis, which is not caused by hyperventilation. Respiratory acidosis is more likely to occur when the patient is hypoventilating, and retaining too much CO2. Common causes of this are an overdose or respiratory depression. Choice D is incorrect. These values represent metabolic alkalosis, which would not be expected in the patient who is hyperventilating. Because it is a change in CO2 causing the pH to shift, the cause of the imbalance is respiratory, not metabolic.

A 16-year old patient injures her ankle on the soccer field. She is taken to the emergency department by ambulance. In the ambulance, she starts hyperventilating. Upon arrival to the waiting room, an arterial blood gas is drawn. What values will most likely appear on the results? A. pH: 7.55, CO2: 22, HCO3: 24 B. pH: 7.35, CO2: 39, HCO3: 26 C. pH: 7.32, CO2: 47, HCO3: 25 D. pH: 7.55, CO2: 42, HCO3: 34

D Choice D is correct. The nurse's primary responsibility is patient safety. For this deaf and blind patient, it is critical to provide secure environment. According to Maslow's hierarchy of needs, physiological needs and thereafter, safety needs should be prioritized in that order. Visual impairment has been associated with falls that often result in fractures, and dislocations. A patient with visual impairment may experience disorientation as a consequence of being in a strange hospital environment. Certain important interventions the nurse can undertake in providing a secure environment for a deaf-blind client include: escorting the patient around the new environment as and when required. This will help meet the need for safety, promote some orientation and instill a feeling of security in the patient. orienting patient to layout of room, restrooms, location and operation of call button, telephone, television, an

A 40-year-old patient who is blind and deaf has been admitted to the medical floor. What is the nurse's primary responsibility for this patient? A. Make others aware of the patient's deficits B. Communicate with the nursing supervisor any patient safety concerns C. Continuously update the patient on the social environment D. Provide a secure environment for the patient

C Choice C is correct. Yogurt is a dairy product and therefore contains lactose. Breastfeeding mothers with infants who are lactose intolerant should avoid dairy products such as cheese, milk, and yogurt. Choice A is incorrect. Leafy greens do not contain lactose and do not need to be avoided by the mother nursing a lactose intolerant infant. Choice B is incorrect. Red meat does not contain lactose and does not need to be avoided by the mother nursing a lactose intolerant infant. Choice D is incorrect. Wheat rolls generally do not contain lactose and do not need to be avoided by the mother nursing a lactose intolerant infant.

A breastfeeding mother is struggling to care for her infant with lactose intolerance. Which of the following foods should the mother avoid? A. Leafy greens B. Red meats C. Yogurt D. Wheat rolls

B Choice B is correct. Raking leaves exposes the child to allergens from the trees. The nurse should advise the parents to seek an alternative activity that will allow the child to continue to help with the work at home but minimize exposure to potentially asthma attack-inducing allergens. Choice A is incorrect. Although studies vary across the board, there is no reliable, large-scale study showing the use of brass instruments (including trumpets) is harmful to those with asthma. Choice C is incorrect. Extracurricular activities are encouraged to promote maturity, develop social skills, and foster friendship among colleagues in children. Choice D is incorrect. Swimming is a suitable exercise for the lungs. Environmental allergen exposure is one of the most common causes of asthma exacerbation. Asthma triggers range from environmental allergens and respiratory irritants to infections, aspirin, exercise, emotion, and

An emergency department nurse is caring for a pediatric client who arrived experiencing an acute asthma attack. Once controlled, the nurse interviews the client's parents to determine which of the pediatric client's activities could precipitate the client's asthma attacks. Which statement by the parents would warrant the nurse to provide additional teaching? A. "Our child loves playing the trumpet in the grade school band." B. "Our child rakes leaves every Saturday afternoon to help with the work at home." C. "Our child participates in extracurricular activities." D. "Our child swims five laps twice a week with friends."

C Choice C is correct. Ergonomically designed chairs are commonly designed with a primary focus on providing lumbar spine support. Although the chairs often provide some level of support to various levels of the spinal column, the lumbar spine is the most common region for back pain to occur and therefore is the spinal region ergonomically designed chairs routinely support. Each curve of the spine (including lumbar) is shown in the image below. Choice A is incorrect. The cervical spine is not typically supported by ergonomically designed chairs. Choice B is incorrect. Although ergonomically designed chairs do support the thoracic spine when an individual leans back, proper positioning would often have an individual sitting upright at a 90-degree angle. Choice D is incorrect. While ergonomically designed chairs do support the sacral spine, the chairs concentrate on the lumbar region of the back primarily due to socie

Ergonomically designed chairs are best designed to provide support to which region of the spine? A. The cervical spine B. The thoracic spine C. The lumbar spine D. The sacral spine

A, B, C Choices A, B, and C are correct. A pulse oximetry device should be provided to the client, and they should be encouraged to log their oxygen saturations as directed. If the client experiences dyspnea or tachypnea, the client should be instructed to seek medical attention for a level less than 95% (unless otherwise directed). Padding the tubing around pressure ears (back of the ears) is recommended to avoid injury. A sign posted on the door should be visible to alert visitors of the oxygen and extinguish and open flames. Choices D and E are incorrect. Stovetop and oven cooking is highly discouraged as the presence of oxygen may accelerate any fire that may ignite. Rather, if cooking is to be done using heat or flames, another individual should do the cooking, and the oxygen should be greater than six feet away from the flame source. Petroleum jelly should not lubricate the nares as it may be aspirated. Water-

The nurse is providing discharge instructions to a client prescribed nasal cannula oxygen. Which of the following instructions should the nurse include? Select all that apply. A. Keep a pulse oximetry device readily available. B. Pad the tubing in areas that put pressure on the skin. C. Have a sign on your door indicating the presence of oxygen. D. Use the oven and not the stovetop to cook. E. You may apply petroleum jelly to your nares to prevent drying.

B

The nurse is providing discharge instructions to a client prescribed phenazopyridine. Which of the following instructions should the nurse include? A. The amount of urine you void will increase B. Your urine will turn orange in color C. You may notice that your urine is malodorous D. Concentrated urine is an expected finding

D Choice D is correct. A shower shield should be placed over the tracheostomy when the client bathes. This would prevent water from entering the tracheostomy and potentially lead to pneumonia. Choices A, B, and C are incorrect. Lemon glycerin swabs are not recommended for mouth care because they are drying and may increase the number of bacteria in the mouth. This may lead to dental caries or pneumonia. Removing the old tracheostomy ties before applying the new ones is dangerous because this may allow decannulation if the client coughs. If the inner cannula is not disposable, it should not be washed with tap water. Rather, ½ strength hydrogen peroxide and sterile saline should be used to clean the device. Home care measures for a tracheostomy should be thoroughly taught to the client and the caregiver. These topics should include tracheostomy care, emergency procedures, and oxygen safety. A shower shield is utiliz

The nurse is providing discharge instructions to a client with a tracheostomy. Which of the following instructions should the nurse include? A. You may use lemon glycerin swabs for mouth care. B. Remove the old tracheostomy ties before applying the new ties. C. You may use warm tap water to clean the inner cannula. D. Wear a shower shield over the tracheostomy when bathing.

A, B Choices A and B are correct. A Calcium of 7.9 mg/dL is critically low (normal 9.0 - 10.5 mg/dL) and requires the nurse to follow up with the PHCP. A potassium level of 3.3 mEq/dl is low (normal 3.5 - 5.0 mEq/dL), and the PHCP should also be notified of this finding. Choices C, D, and E are incorrect. The laboratory values for the sodium (normal 135-145 mEq/dL), BUN (normal 10-20 mg/dL), and creatinine (0.6-1.2 mg/dL for males) are all within normal limits and do not require notification to the PHCP.

The nurse is reviewing laboratory data for a male client scheduled for surgery. Which laboratory data requires follow-up with the primary healthcare physician (PHCP)? Select all that apply. A. Calcium 7.9 mg/dL B. Potassium 3.3 mEq/L C. Sodium 143 mEq/L D. BUN 17 mg/dL E. Creatinine 0.9 mg/dL

B Choice B is correct. The client is in obvious respiratory distress. The nurse needs help with initiating life-saving procedures such as endotracheal intubation. The nurse need not call a "Code Blue" since the client is still breathing. However, a Rapid Response Team (RRT) can be called for help. The RRT is a team of healthcare professionals who respond to client emergencies even when they are still breathing and/or have a pulse. Since the client is in obvious respiratory distress, no additional assessment is needed prior to calling the RRT. Choice A is incorrect. The client is in obvious respiratory distress, even without the oxygen saturation reading. The nurse should initiate a nursing intervention to help the client. RRT needs to be contacted right away. Please note, "When in distress do not assess!" Choice C is incorrect. The Trendelenburg position is appropriate for clients in shock, but it is inappropriate f

The nurse is taking care of a client two days post lobectomy. He is complaining of difficulty breathing. He is restless, lethargic, and has bilateral crackles. What is the nurse's most appropriate initial intervention? A. Check the client's oxygen saturation. B. Notify the rapid response team (RRT). C. Place the client in Trendelenburg position. D. Check the client's surgical dressing.

A

The nurse is taking care of a patient that was recently rescued from a near-drowning experience. The patient is now having pulmonary edema. The nurse understands that pulmonary edema is the result of which process? A. Water washing out the alveolar surfactant. B. Water introducing bacteria into the lungs and causing infection. C. Decreased intrathoracic pressure in the lungs. D. A sudden change in temperature within the lungs.

A, D

The nurse is teaching a client about congestive heart failure (CHF). Which of the following information should the nurse include? Select all that apply. A. "Foods such as canned vegetables and luncheon meat should be avoided." B. "Weigh yourself daily and notify the physician when weight gain is more than ten pounds in a week." C. "You may continue to take ibuprofen for your aches and pains." D. "Annual immunizations such as the influenza vaccine are recommended." E. "If you feel sick, you will need to check your urine for ketones."

D

The nurse is teaching a group of students the causes of metabolic alkalosis. It would indicate a correct understanding of the student to state which condition causes this acid-base imbalance? A. Hyperventilation B. Urinary retention C. Opioid toxicity D. Excessive vomiting

B, E Choices B and E are correct. A nonstress test is performed in the third trimester if the client has indications such as a high-risk pregnancy that may result in a stillbirth or complications such as fetal hypoxia. Ultrasounds typically require a full bladder as the fluid moves the uterus upward and assists with visualization. Choices A, C, and D are incorrect. Oral glucose tolerance testing is completed between 24-28 weeks of gestation. This test is used to determine if the client has gestational diabetes and does not take into account fetal activity. Amniocentesis is an antepartum test that may be used to determine the gender of the fetus, lung maturity, neural tube defects, or chromosomal abnormalities. Chorionic villus sampling is a test that may be performed as early as ten gestational weeks to determine if the fetus has any chromosomal abnormalities. Amniocentesis is performed for a variety of indications

The nurse is teaching parents about antepartum testing. Which statements should the nurse include? Select all that apply. A. "Oral glucose tolerance testing will measure fetal activity at certain intervals." B. "A nonstress test may be used to measure fetal heart rate." C. "Amniocentesis may be used to assess if you have preeclampsia." D. "Chorionic villus sampling may be done to assess for neural tube defects." E. "You may need to fill up your bladder prior to an ultrasound."

C, E Choices C and E are correct. These actions by the student are incorrect and require follow-up by the nurse. When cleaning the labia with the antiseptic solution, the student should wear sterile gloves to clean the labia with their dominant hand while separating the labia with the fingers of the nondominant hand (now contaminated) to fully expose the urethral meatus. Acting correctly will greatly decrease the risk of contamination. The drainage bag of the urinary catheter should not be secured to the bed's side rails as it will move and cause tension on the tubing that may cause urinary trauma. Choices A, B, and D are incorrect. These actions by the student are correct and do not require follow-up by the nurse. Clean gloves are worn to clean the perineal area with soap and water (sterile gloves are used to apply the povidone iodine or other antiseptic solution). Asking the client to bear down gently and slowly i

The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? Select all that apply. The student A. applies clean gloves to clean the perineal area with soap and water. B. asks the client to bear down gently and slowly insert the catheter through the urethral meatus. C. separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution. D. secures the catheter tubing to the inner thigh. E. attaches the drainage bag to the side rails of bed.

A, B, D Choices A, B, and D are correct. When a child has a cleft lip and palate, the tissue and bone inside their mouth are not appropriately fused, meaning there is a space between their upper lip and palate. Ear infections will be a frequent complication for these patients due to the eustachian tube dysfunction, which connects the middle ear and the throat. Feeding issues are a common complication of cleft lip and cleft palate because it is harder for these infants to eat with the abnormality in their palate. The space in the roof of the mouth makes it very hard to suck and make a good seal around the bottle or nipple. Speech and language delays are common complications of cleft lip and palate. The roof of the mouth and lip have spaces that decrease muscle function and lead to delayed or abnormal speech. Eventually, many of these patients will require consultation with a speech-language pathologist. Choices C and

The nurse reviews cleft lip and cleft palate with a group of students. It would indicate effective teaching if the student states which are the following complications of both? Select all that apply. A. Ear infections B. Feeding difficulties C. Weight gain D. Speech delay E. Esophageal reflux

A Choice A is correct. The progressive stage occurs when compensatory mechanisms begin to fail. Signs/symptoms of the progressive stage include anasarca (generalized edema), decreased responsiveness, decreased urine output, weak pulses, hypotension, and tachycardia. Choice B is incorrect. The compensatory stage of shock is the first stage, characterized by hypotension, vasoconstriction, decreased blood flow to the lungs, and cold/clammy skin. Choice C is incorrect. The irreversible stage is the final stage of shock, characterized by decreased perfusion due to decreased cardiac output, hypotension, hypoxemia, cyanotic skin, vasoconstriction, bradycardia, and unresponsiveness. Choice D is incorrect. The nonprogressive stage is an alternative term for the compensatory stage.

The patient with septic shock presents with anasarca, weak pulses, decreased urine output, decreased responsiveness, and BP 88/52 mmHg, HR 160. The nurse would recognize these symptoms as indicators of which stage of shock? A. Progressive B. Compensatory C. Irreversible D. Nonprogressive

A Choice A is correct. Intussusception generally occurs as a result of a blockage in the intestines, which results in the telescoping of one portion of the bowel into another part of the colon. This disorder occurs more frequently in children, often males. Choice B is incorrect. Intussusception is the telescoping of the intestine and does not have to do with alveoli. Choice C is incorrect. Twisted bowel is simply a twist or loop in the gut and is not known as intussusception. Choice D is incorrect. Rectal prolapse occurs from chronic constipation and weakened anal sphincter.

The pediatric nurse is reading the chart for a newly admitted child suffering from intussusception. The nurse knows that this disorder is characterized by: A. The telescoping of one area of the intestines into another B. The absence of alveoli in one segment of the lobe C. A twisted colon D. The prolapse of the rectum

D Choice D is correct. The first specimen is discarded because it is considered "old urine" or urine in the bladder before the test began. A 24-hour urine collection helps diagnose kidney problems. It is often done to see how much creatinine clears through the kidneys. It's also done to measure protein, hormones, minerals, and other chemical compounds. Proper education on the collection of the 24-hour specimen is essential, as retaining the first specimen can cause an error in the result. Choices A, B, and C are incorrect. After the first discarded specimen, urine is collected for 24 hours.

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then: A. Placed in a separate container and later added to the collection. B. Saved as part of the 24-hour collection. C. Tested and then discarded. D. Discarded and then the collection begins.

D Choice D is correct. Making assumptions or generalizations about a patient's spiritual needs based on ethnic or religious affiliation is almost sure to be an oversimplification. The nurse should be able to identify similarities and differences among the cultural beliefs of the patients. Just because a patient belongs to a certain culture or ethnicity, it is incorrect to generalize their spiritual needs. Choices A, B, and C are incorrect. Ordering a specific diet as per the patient's specific cultural or religious preference is certainly warranted. However, generalizations cannot be made here either, and knowing the patient's specific preference will help the nurse cater to the patient's dietary or spiritual needs. Communicating with the family and performing a spiritual consult should also be done at the patient's request. While identification of cultural similarities and differences among the patients can help gu

The primary objective in identifying similarities and differences among cultural beliefs of a patient is to: A. Communicate with the family B. Make sure the proper diet is ordered C. Perform a spiritual consult D. Avoid making assumptions

B, D Choices B and D are correct. These two statements indicate that the patient needs further follow-up education to correct the misconceptions. The client does not need to weigh themselves daily (Choice B) as that would be applicable for CHF and not for atrial fibrillation. Considering daily weight checks in CHF is useful to detect excess fluid retention, which may precede symptoms such as shortness of breath. Wearing a mask in public is unnecessary as an infection is not the concern here (Choice D). Choices A, C, and E are incorrect. These options are wrong because these statements indicate correct understanding by the patient and do not require follow-up teaching. Atrial fibrillation is a common dysrhythmia that results in a decrease in an atrial kick. A client with atrial fibrillation is at risk for an ischemic stroke (Choice A) because of the formation of clots in the atrial appendage. Treatment for atrial fib

The nurse has provided education to a client with atrial fibrillation. Which of the following statements by the client would require a follow-up? Select all that apply. A. "I have an increased risk for a stroke." B. "I should weigh myself daily at the same time." C. "I may be prescribed medications such as amiodarone." D. "I should wear a mask when I am in public." E. "I should follow-up with my primary healthcare provider (PHCP) if I develop shortness of breath."

A

The nurse has provided medication instruction to a client who has been prescribed metformin. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? A. "This medication may cause me to have bloating or loose stools." B. "I will need to take my blood glucose prior to taking this medication." C. "If I eat fewer carbohydrates in a day, I should skip a dose." D. "The goal of this medication is to increase my hemoglobin A1C."

C Choice C is correct. Phosphorous and calcium have an inverse relationship, meaning that as one level rises, the other decreases. Since this patient has hypocalcemia or low calcium, decreasing serum phosphorus through phosphate secreting medications will inversely increase serum calcium. Choices A, B, and D are not correct. These would not occur.

The nurse is administering phosphate excreting medications to her patient with hypocalcemia because she understands what core information about calcium and phosphorous? A. As phosphorous exits the body so does calcium. B. Calcium is managed by the excretion of phosphorous. C. When serum phosphorous decreases, serum calcium increases. D. Phosphorous must be above 4.5 mg/dL before calcium can increase.

A Choice A is correct. The nurse should assess the client for the presence of orthostatic hypotension. Orthostatic hypotension is often seen in association with hyponatremia secondary to dehydration. Orthostatic or postural hypotension refers to a significant decrease in systolic blood pressure of greater than 20 mmHg or a reduction of at least 10 mmHg in diastolic pressure upon 3 to 5 minutes of standing. Choices B, C, and D are incorrect. Peaked T-waves are associated with hyperkalemia, not hyponatremia. Bounding peripheral pulses would be a clinical finding associated with fluid volume overload. Polyuria would be a finding associated with hyperglycemia and diabetes inspidus. This is not a finding found with hyponatremia and dehydration.

The nurse is assessing a client admitted with hyponatremia secondary to dehydration. Which of the following physical assessment findings would be expected? A. Orthostatic hypotension B. Peaked T-waves on electrocardiogram (ECG) C. Bounding peripheral pulses D. Polyuria

C Choice C is correct. Phantom limb pain (PLP) is a form of neuropathic pain that can be treated with medications such as pregabalin, gabapentin, amitriptyline, or propranolol. Propranolol is a beta-adrenergic blocker, and while its action related to PLP is not fully understood, it has demonstrated efficacy for this type of pain. Choices A, B, and D are incorrect. Aripiprazole is an atypical antipsychotic and is not indicated in the management of PLP. Oxycodone is an opioid, and while opioids are effective for nociceptive pain, they have limited benefits for neuropathic pain. Hydroxyzine is a histamine antagonist commonly used in the treatment of allergies and anxiety. Phantom limb pain (PLP) may occur after an above-the-knee amputation. This type of neuropathic pain is often described as a burning, crushing, or cramping sensation. It is essential for the nurse to acknowledge the pain and refrain from being dismiss

The nurse is assessing a client with phantom limb pain following an above-the-knee amputation. The nurse anticipates a prescription for A. Aripiprazole B. Oxycodone C. Propranolol D. Hydroxyzine

A, C, D, F Choices A, C, D, and F are correct. Low socioeconomic status, a history of being a sex worker, illicit drug use, and a previous history of sexually transmitted infections are all risk factors for contracting STIs. Other factors include numerous sexual partners and being unmarried. Choices B and E are incorrect. A history of cancer and exclusive/monogamous relationships are not examples of risk factors for acquiring an STI.

The nurse is assessing her prenatal client for sexually transmitted infections (STIs) by looking for risk factors. Which of the following are risks of acquiring an STI? Select all that apply. A. Low socioeconomic status B. A monogamous relationship C. A past history of working in the sex industry D. Illicit drug use E. History of cancer F. Previous history of STIs

A Choice A is correct. Administering the IV antibiotic is the top priority in a client with cystic fibrosis (CF) that develops a fever. Due to the excessively thick mucus that builds up in their bronchi and bronchioles, children with CF are incredibly susceptible to respiratory infections. A fever is an indication of infection and aggressive management is the top priority. Choice B is incorrect. Pancreatic enzymes are administered to children with CF within 30 minutes of any meal and snack. These are given to aid in digestion since the excessive, sticky mucus clogs up the pancreatic duct in these clients. This is a standard medication given every day, but is not the top priority when a child with CF develops a fever. Choice C is incorrect. Fat soluble vitamins are a daily medication for children with CF. Due to the buildup of excessive, sticky mucus in their bile duct, children with CF do not absorb fat normally. Th

The nurse is caring for a 16-year-old client with cystic fibrosis. The client develops a temperature of 101.2 degrees F (38.4C). Which medication does the nurse administer with top priority? A. IV antibiotic B. Pancreatic enzyme C. Fat soluble vitamin D. Albuterol

A

The nurse is caring for a 3-year-old client diagnosed with bronchitis. The mother asks the nurse what this diagnosis means. Which response most correctly explains the diagnosis of bronchitis? A. "Bronchitis occurs when an infection causes inflammation in the large airways. These include the trachea and bronchi, which are in the lower part of the respiratory tract." B. "Bronchitis occurs when an infection causes inflammation in the small airways. These include the trachea and bronchi, which are in the upper part of the respiratory tract." C. "Bronchitis occurs when an infection causes inflammation in the large airways. These include the trachea and bronchi, which are in the upper part of the respiratory tract." D. "Bronchitis occurs when an infection causes inflammation in the small airways. These include the trachea and bronchi, which are in the lower part of the respiratory tract."

A, C Choices A and C are correct. Hemarthrosis is defined as bleeding into a joint cavity. Most commonly affected joints include knees, ankles, and elbows. Hemarthrosis is a frequent complication of hemophilia because of the deficiency of clotting factors and prolonged clotting times. When the nurse has a patient with hemarthrosis, she can expect joint pain and swelling, and external bruising in the hemarthrosis area due to the accumulation of blood in that joint cavity. Choice B is incorrect. A decreased level of consciousness (LOC) is not a finding expected with hemarthrosis. Hemarthrosis is defined as bleeding into a joint cavity, which would not cause a decreased LOC. Decreased LOC may be seen in patients with hemophilia if they develop a brain bleed. Other symptoms to look out for if a brain bleed is expected include slurred speech, vision changes, and headaches. Choice D is incorrect. Melena is not a finding e

The nurse is caring for a 5-year-old girl diagnosed with hemophilia with a recurrent episode of hemarthrosis. Which of the following would the nurse expect on their assessment? Select all that apply. A. Joint pain and swelling B. Decreased level of consciousness C. Bruising D. Melena

D Choice D is correct. A client with severe pre-eclampsia should be monitored closely for seizures which are the hallmark manifestation of eclampsia. The nurse should plan care involving seizure precautions at the bedside, including suction equipment, padded side rails, and oxygen. Choices A, B, and C are incorrect. Sterile gloves, portable ultrasound, and a liter of 0.9% saline would not be necessary to manage a client having a seizure directly related to pre-eclampsia. These tools would be helpful for other obstetric procedures but not for a severely pre-eclamptic client at risk of having a seizure. Severe pre-eclampsia may require intensive care monitoring, depending on other factors. Nursing care for a client with severe pre-eclampsia includes: ➢ Appropriate safety equipment at the bedside, which includes seizure precautions. ➢ Frequent vital signs and blood pressure must be closely monitored as a hypertens

The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside? A. One liter of 0.9% saline B. Sterile gloves C. Portable ultrasound D. Suction equipment

B

The nurse is caring for a client experiencing an adrenal crisis (Addisonian crisis). The nurse should be prepared to administer which intravenous fluid? A. Lactated Ringers (LR) B. 0.9% saline C. Dextrose 5% in water (D5W) D. Dextrose 5% in water and Lactated Ringers (D5LR)

A, B, C, E

The nurse is caring for a client immediately following an ultrasound-guided thoracentesis. Which client finding requires follow-up? Select all that apply. A. Nagging cough B. Trachea slanted more to the unaffected side C. Rapid heart rate D. Localized discomfort at the needle site E. Crackling sound made at the insertion site when palpated

B Choice B is correct. Tenofovir-emtricitabine is a medication used as pre-exposure prophylaxis (PrEP) for clients at high risk for HIV infection. This medication is taken daily and may provide up to 96% efficacy against HIV infections. Choices A, C, and D are incorrect. The other options are not utilized in PrEP. Voriconazole is an antifungal agent. Raloxifene is an estrogen modulator utilized in the management of breast cancer. Lurasidone is an atypical antipsychotic indicated for psychotic and mood disorders. ADDITIONAL INFO ✓ Pre-exposure prophylaxis (PrEP) is an effective medication in reducing HIV infections for those at risk. ✓ PrEP can be administered via a daily pill or an injection every two months. ✓ The efficacy of PrEP is up to 99% when taken as prescribed. ✓ Indications for a client to start PrEP include unprotected intercourse, multiple sexual partners, and intravenous drug use.

The nurse is caring for a client interested in pre-exposure prophylaxis for human immunodeficiency virus (HIV). Which prescription would the nurse anticipate? A. Voriconazole B. Tenofovir-emtricitabine C. Raloxifene D. Lurasidone

D Choice D is correct. The physical needs of the client with a mental health disorder prioritize over psychosocial needs. The client experiencing dizziness is highly concerning because this could be suggestive of severe dehydration or other electrolyte imbalances. Choices A, B, and C are incorrect. Dental caries, sores in the oral mucosa, electrolyte disturbances, dehydration, irregular menses, and calluses on the fingers are all manifestations associated with bulimia nervosa. A client expressing self-negating statements requires follow-up but does not prioritize over the client endorsing dizziness. ADDITIONAL INFO Maslow's Hierarchy of Needs signifies that physical needs must be assessed and cared for first before psychological needs can be satisfied. Thus, the priority is to take care of the client's physical need of dizziness as this is a manifestation associated with significant dehydration.

The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow-up? A. "These sores in my mouth hurt." B. "When can I weigh myself?" C. "I hate my life and wish it was over." D. "I feel really dizzy right now."

A, B, D, E

The nurse is caring for a client who presents with hyperglycemia. Which of the following findings are expected? Select all that apply. A. Blurred vision B. Increased urinary output C. Cool and clammy skin D. Tachycardia E. Orthostatic hypotension

45%

The nurse is caring for a client who sustained a full-thickness burn to his anterior torso, back, and bilateral anterior arms. Using the rule of nine's, calculate the total body surface area (TBSA) burned. Fill in the blank

A, B, E

The nurse is caring for a client whose most recent serum sodium level was 152 mEq/L. Which of the following signs and symptoms can be attributed to the client's sodium level? Select all that apply. A. Lethargy B. Dry mucous membranes C. Tachypnea D. Cyanosis E. Excessive thirst

D Choice D is correct. Amoxicillin is an antibiotic that is commonly used to treat Helicobacter pylori infections. When treating this infection, this medication is often coupled with a proton pump inhibitor such as esomeprazole. Choices A, B, and C are incorrect. Dicyclomine is an antispasmodic medication used to treat gastrointestinal spasms, which are common in individuals with irritable bowel syndrome. Metoclopramide is a medication that causes gastric emptying and is used for nausea and vomiting. Valacyclovir is an antiviral indicated for herpes infections. H. pylori is a gram-negative bacterium spread via the oral-oral route or oral-fecal. This bacterium may cause an individual to develop a gastrointestinal ulcer. Antibiotic therapy consisting of one or two antibiotics is often the treatment.

The nurse is caring for a client with Helicobacter pylori. The nurse should anticipate a prescription for which of the following medications? A. Dicyclomine B. Metoclopramide C. Valacyclovir D. Amoxicillin

B

The nurse is caring for a client with heart failure. Which medication should the nurse clarify with the primary healthcare provider (PHCP)? A. Lisinopril B. Prednisone C. Hydralazine D. Carvedilol

Perform hand hygiene, identify the patient, explain the procedure to the patient, and prepare the insertion kit using sterile gloves. Spread the labia and hold them open. Cleanse the meatus from front to back on the right side, then left side, and down the center. Insert the catheter and inflate the balloon. Secure the catheter to the patient, then initial the securement device with the date and time.

The nurse is caring for a female client who is incontinent of urine. The MD orders an indwelling Foley catheter to be placed. Place the following actions in the correct order for the nurse to appropriately insert the Foley catheter: Perform hand hygiene, identify the patient, explain the procedure to the patient, and prepare the insertion kit using sterile gloves. Cleanse the meatus from front to back on the right side, then left side, and down the center. Spread the labia and hold them open. Insert the catheter and inflate the balloon. Secure the catheter to the patient, then initial the securement device with the date and time.

D Choice D is correct. The collection of vital signs may be delegated to a UAP. This includes pulse, blood pressure, temperature, and oxygen saturation. Choices A, B, and C are incorrect. Oxygen is regarded as medication, and any adjustment or application of oxygen is not within the scope of a UAP. Venipuncture is not within the scope of a UAP, and it would be inappropriate for this task to be delegated. Removing a vascular access device may be delegated to an LPN - not a UAP.

The nurse is caring for a newly admitted client. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Apply nasal cannula oxygen B. Remove a vascular access device that is not patent C. Perform venipuncture for laboratory work D. Obtain vital signs every four hours

Stop the transfusion Administer oxygen Take vital signs Obtain a urine specimen

The nurse is caring for a patient receiving a blood transfusion. On assessment, the nurse notes that the patient's respirations are rapid, the face is flushed, and the patient is complaining of itching. The nurse suspects the patient is having a transfusion reaction. The nurse should accomplish the following actions: Take vital signs Stop the transfusion Administer oxygen Obtain a urine specimen. The nurse should complete the tasks in the following order:

D Choice D is correct. When evacuating from an internal disaster, the nurse should first evacuate the most ambulatory client. The client with acute glomerulonephritis only has one device, and the nurse can quickly change the system to a leg bag or instruct the client to keep the bag below their bladder. Choices A, B, and C are incorrect. The client with a below-the-knee amputation will require significant resources to mobilize. Further, the client's PCA device must be secured before evacuation. The client receiving mechanical ventilation will require manual ventilation and oxygen. Thus, requiring a significant number of resources. Finally, the client with dementia receiving enteral feedings and IV fluids must have their devices clamped and locked before evacuation. This client also is unlikely to effectively comprehend evacuation instructions and should be supervised. For a fire, the nurse should first evacuate the

The nurse is caring for assigned clients. Which client should be evacuated first during a fire? A client with A. below-the-knee amputation receiving patient-controlled analgesia. B. acute respiratory distress syndrome receiving mechanical ventilation. C. advanced dementia receiving enteral feedings and intravenous fluids. D. acute glomerulonephritis with an indwelling urinary catheter.

B Choice B is correct. This is an optimal hemoglobin A1C as it is less than 5.7%. A hemoglobin A1C of 5.7% to 6.4% is prediabetes. This is a concerning finding as the client is on a negative trajectory toward diabetes mellitus. A hemoglobin A1C of 6.5% is the diagnosis of diabetes mellitus. Choices A, C, and D are incorrect. Total cholesterol of 215 mg/dL is a concerning finding. The goal is to have total cholesterol of less than 200 mg/dL. Elevated total cholesterol contributes to metabolic syndrome, which is the driver of diabetes mellitus. Fasting blood glucose of 128 mg/dL is elevated (this is impaired fasting glucose), and a level greater than 126 mg/dL requires further testing for diabetes mellitus. Random blood glucose of 210 mg/dL is concerning as this is a provisional diagnosis for diabetes mellitus. ADDITIONAL INFO The following are diagnostic criteria for diabetes mellitus A1C >6.5%. The test should be

The nurse is counseling a client who has prediabetes. The nurse understands that the client is meeting the treatment goal as evidenced by A. total cholesterol of 215 mg/dL. B. hemoglobin A1C of 5.4%. C. fasting blood glucose 128 mg/dL. D. random blood glucose of 210 mg/dL.

B, C, E

The nurse is developing a plan of care for a client diagnosed with Addison's disease. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Diet high in potassium B. Continuous telemetry monitoring C. Intravenous hydrocortisone D. Fluid restriction E. Fall precautions F. Indwelling urinary catheter

A, B, E

The nurse is evaluating a client taking levothyroxine for hypothyroidism. Which findings indicate that the client is experiencing an adverse effect? Select all that apply. A. Heat intolerance B. Palpitations C. Bradycardia D. Constipation E. Insomnia F. Weight gain

D

The nurse is going over the list of assigned clients for the shift. The nurse knows which client is most at risk for experiencing a fluid volume deficit? A. A client with cirrhosis B. A client with an ileostomy and normal amount of output C. A client with a BUN of 32 and creatinine of 2.7 D. A client with diabetes insipidus and an NG tube set to low intermittent wall suction

A Choice A is correct. Signs and symptoms of cervical cancer include back and leg pain, spotting between menstrual periods and after intercourse, vaginal discharge, and lengthening of a menstrual period. A pap smear is needed to assess cellular changes (i.e. check for cancerous and precancerous conditions). Choice B is incorrect. Endometrial cancer manifests as menorrhagia (excessive menstrual bleeding), low abdominal pain, backache, and constipation due to pressure from an enlarging mass. A biopsy is needed to confirm the diagnosis. Choice C is incorrect. Initial signs and symptoms of ovarian cancer include the following: an increasing abdominal girth due to ovarian enlargement, constipation due to rectal pressure from the enlarging mass, anemia, vomiting, and cachexia. Choice D is incorrect. A bacterial infection causes vaginitis. Signs and symptoms include pruritus, burning urination, dysuria, dyspareunia, and a

The nurse is in the screening room of a women's health clinic. The nurse notices a particular woman complaining of back and leg pain, spotting after intercourse with her husband, and vaginal discharge for the past few months. The nurse suspects: A. Cervical cancer B. Endometrial cancer C. Ovarian cancer D. Vaginitis

A Choice A is correct. DKA treatment aims to lower the blood glucose by 50 to 75 mg/dL/hr. This is accomplished by the prescribed regular insulin, which is given intravenously. Choices B, C, and D are incorrect. Dextrose 50% should be available in the event of severe hypoglycemia. Dextrose 5% is not sufficient to treat hypoglycemia. The treatment goal for the hypovolemia caused by DKA is isotonic saline, not hypertonic saline. Urine output would decrease with the infusion of regular insulin as correcting the hyperglycemia would treat the polyuria, which is a symptom of hyperglycemia. DKA is a common complication associated with type one diabetes mellitus. DKA may cause both hyperglycemia and hypovolemia. Treatment for hyperglycemia includes the initiation of a prescribed regular insulin bolus at 0.1 unit/kg followed by a continuous infusion at 0.1 unit/kg/hr. This treatment will also target the acidosis found with

The nurse is planning a staff development conference about diabetic ketoacidosis (DKA). Which of the following information should the nurse include? A. The goal is to lower blood glucose by 50 to 75 mg/dL/hr. B. Dextrose 5% should be available for hypoglycemia symptoms. C. Hypovolemia caused by DKA may be treated with 3% saline. D. The urine output would increase once regular insulin is initiated.

B Choice B is correct. Homonymous hemianopia (HH) is vision loss on the same side of the visual field in both eyes. It is appropriate for the nurse to teach the client to scan the room. Scanning the room will expand the visual field because the same half of each eye is affected. Choices A, C, and D are incorrect. An eye patch is an appropriate intervention for a client with double vision (diplopia). HH is not a problem with hearing and changing the approach to speaking to a client and providing ear plugs is irrelevant to this disorder. Homonymous Hemianopia is characterized by vision loss on the same side of the visual field in both eyes. This is usually caused by a stroke, tumors, or epilepsy. Visual field loss is indicative of a lesion involving the visual pathway posterior to the chiasm.

The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan? A. Place an eye patch over the affected eye B. Instruct the client to turn their head from side to side C. Speak slowly, clearly, and in a deeper voice D. Provide the client with ear plugs to promote rest

C Choice C is correct. The nurse should make sure that the patient receives a prescribed bronchodilator about 15 minutes before their chest physiotherapy procedure. Chest physiotherapy is used to loosen secretions trapped in the lungs. When administered before this procedure, a bronchodilator helps to dilate the bronchioles and liquify secretions. Choice A is incorrect. A gown or piece of fabric should be placed between the hands or percussion device right before the procedure. However, this should be done just before the process. Another option (administering bronchodilator 15 minutes prior) exists in the choices and is the initial action. Choice B is incorrect. Walking with the patient before the procedure is not necessary before chest physiotherapy. Choice D is incorrect. Calling the physician to confirm the x-ray results is not necessary at this time and does not alter the plan for chest physiotherapy.

The nurse is planning to assist a respiratory therapist in performing a chest physiotherapy procedure. Which of the following is the initial action by the nurse before the process? A. Place a gown or fabric between the hands or percussion device and the client's skin B. Walk with the patient for a few laps around the unit to aid in percussion C. Administer a prescribed bronchodilator D. Call the physician to confirm x-ray results

A Choice A is correct. The nurse is a mandatory reporter of any suspected violence and is required by law to report her suspicions. Parents may become upset and confront the nurse when these allegations come to light, but that should not stop the nurse from saying what she has seen. The nurse should remain calm when the parent confronts her and she should state that she is required to report any suspected violence. Choice B is incorrect. This statement is an accusation and could further aggravate the mother. The nurse does not know that she abused her son and should not make statements such as this one. The nurse needs to remain calm and stick to the fact that she is required to report any suspected violence. Choice C is incorrect. This statement is based on emotion, not fact. The nurse should not apologize to the mother. Instead, she should remain calm and inform her that she is required to report any suspected vio

The school nurse is assessing a 12-year old boy who came into her office for a nose bleed. She notices several bruises on his back and forearms that are in various stages of healing. When she asks the boy about them, he is very deceptive. The nurse notifies child protective services of her suspicion. The next day, the boy's mother comes to the nurse's office and yells at her for calling child protective services. Which of the following responses is most appropriate? A. "I am required by law to report any suspected violence." B. "You should have thought about this before you abused your son." C. "I'm so sorry. Please don't take this out on me." D. "Don't talk to me about this. I don't want to see you."

C Choice C is correct. Family members can become frustrated when clients with Alzheimer's disease lose short-term memory. The nurse should explain to the family member that it's the "short-term memory" that is declining and encourage the client to talk about things that he/she can remember. Choice A is incorrect. During the early stages of Alzheimer's, family members are still trying to learn about and cope with the changes that their loved ones are experiencing. Patience with the family will be more beneficial than the scolding tone that this answer choice portrays. Choice B is incorrect. Early Alzheimer's symptoms are not usually reflective of anxiety. Also, the client is not reliving past experiences because it makes him calm again. Instead, his behavior is expected as Alzheimer's first affects short-term memory. Choice D is incorrect. Reminding an Alzheimer's patient that he is repeating himself will not improve

The son of a client with early Alzheimer's disease states, "I'm so tired of hearing Dad talk about the past all the time." What is the nurse's best response? A. "You should be more patient with your father and accepting of his disease." B. "He is quite anxious at this stage. Reliving the past helps him become calm again." C. "He has lost his short-term memory but can still remember events from long ago." D. "Just remind him when he repeats himself and that will reinforce better behavior."

D Choice D is correct. When there is an excessive loss of fluid within the body, dehydration can occur. Dehydration may be caused by acute illness or a chronic disease process. Common symptoms include dry mucous membranes, dark urine, decreased urinary output, confusion, low blood pressure, muscle cramps, and constipation. Choice A is incorrect. Urinary output is decreased with dehydration. Choice B is incorrect. Weight gain and edema are not signs of dehydration. However, weight loss and poor skin turgor are signs of dehydration. Choice C is incorrect. Patients experiencing dehydration will exhibit hypotension, not hypertension.

When assessing for dehydration, the nurse should observe for which of the following? A. Headache and increased urinary output B. Weight gain and edema C. Hypertension and decreased urinary output D. Hypotension, headache, and dry mucous membranes

B

When instructing a post-surgical patient with an abdominal incision on deep breathing and coughing, the nurse explains that the patient should be sitting up for these activities because: A. It is physically more comfortable for the patient B. Helps the patient to support their incision with a pillow C. Loosens respiratory secretions D. Allows the patient to observe their area and relax

A Choice A is correct. This ABG shows metabolic acidosis. The pH is less than 7.35, which is acidosis. The PCO2 is between 35 and 45, which is normal. Lastly, the HCO3 is less than 22, which is acidotic. The HCO3 shows acidosis like the pH, so we know this is metabolic acidosis. Choices B, C, and D are incorrect. These are not the correct acid-base disorder for the patient.

Which of the following is the correct interpretation for the following arterial blood gas? pH: 7.31 PCO2: 40 HCO3: 18 A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

B Choice B is correct. Although all of these findings are abnormal, elevated potassium is a life-threatening finding and must be reported immediately. Acute renal failure can cause a significant imbalance in lab values. Although all of the lab results listed are abnormal, the elevated potassium level is a life-threatening finding. Choices A, C, and D are incorrect. Each of these lab values is abnormal. However, they don't pose a life-threatening finding like answer choice B. A: The average BUN level should be 7 to 20 mg/dL. C: Venous blood pH should be 7.31 to 7.41. D: Normal hemoglobin levels differ based on age, sex, and general health. The normal range for hemoglobin is 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 grams per deciliter for women.

Which of the following labs for a client with acute renal failure should be reported immediately? A. Blood urea nitrogen 50 mg/dL B. Serum potassium 6mEq/L C. Venous blood pH 7.30 D. Hemoglobin of 10.3 mg/dL

A Choice A is correct. LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound cultures. Choices B, C, and D are incorrect. Teaching, assessment, and planning of care are complex actions that should be carried out by a registered nurse.

Which of the following nursing actions can an LPN/LVN perform on a patient who has a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA)? A. Obtain wound cultures during dressing changes. B. Plan ways to improve the client's oral protein intake. C. Assess the risk for further skin breakdown. D. Educate the client about home care of the leg ulcer.

C Choice C is correct. The parenting style described is authoritarian. This parent is often described as the 'rigid disciplinarian'. They are highly controlling; they expect always to be obeyed and are still inflexible with the rules. Though these parents may have their child's best interests at heart, they do not support their growing autonomy. Instead, they expect to be obeyed without reason. Choice A is incorrect. Authentic not the parenting style described. An authentic parent sets reasonable limits on behavior, encourages the growing autonomy of their children, and promotes open communication about the rules. These parents would not be inflexible with the regulations; rather, they would explain why the rules work the way they do with their children to promote autonomy and open communication. Choice B is incorrect. Permissive is not the parenting style described. A permissive parent sets few or no restraints, gi

Which of the following parenting styles is described as highly controlling, expecting to always be obeyed, and inflexible with the rules? A. Authentic B. Permissive C. Authoritarian D. Indifferent

A, B Choices A and B are correct. The vasodilation properties of a beta-blocker mean that they decrease blood pressure. This is because the beta-blockers are blocking the receptor sites for your catecholamine, so they cannot do their job and cause vasoconstriction (Choice A). Beta-blockers decrease the workload of the heart. This is because of the vasodilation, subsequent decrease in blood pressure, and then fall in afterload. Remember, afterload is the pressure against which the left ventricle must pump. With decreased blood pressure, we reduce afterload. With reduced afterload, the left ventricle does not have to work as hard to pump blood to the body. Therefore, beta-blockers decrease the workload of the heart (Choice B). Beta-blockers block the beta cells of the body. Beta cells are receptor sites for catecholamines, such as epinephrine and norepinephrine. When we block the receptor sites for the catecholamines,

Which of the following statements are true regarding beta blockers' mechanism of action? Select all that apply. A. Decrease blood pressure B. Decrease workload of the heart C. Increase contractility D. Increase cardiac output

A, C Choices A and C are correct. Stage II pressure ulcers occur when the epidermis is lost as well as part of the dermis (Choice A). Stage III pressure ulcers expose subcutaneous fat but do not extend deep enough to expose the bone and muscle. That would be considered a Stage IV pressure injury (Choice C). Choice B is incorrect. Stage I pressure ulcers do not involve any loss of tissue. The epidermis remains intact, but it is reddened and does not blanch. Choice D is incorrect. Stage IV pressure ulcers expose bone and muscle. If the base of the wound is covered by slough or eschar, the nurse can't assess how deep the pressure injury goes. Therefore the pressure ulcer is considered unstageable.

Which of the following statements regarding pressure ulcers are true? Select all that apply. A. In a stage II pressure ulcer, part of the dermis and epidermis are lost. B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only. C. In a stage III pressure ulcer, there is a deep tissue injury that can expose fat. D. In a stage IV pressure ulcer, the base of the wound is covered by eschar.

A, B Choices A and B are correct. Osmosis is an essential principle upon which peritoneal dialysis functions. Osmosis is the passive movement of solvents, such as water, across a permeable membrane. The peritoneum is a permeable membrane. (Choice A). Diffusion is an essential principle upon which peritoneal dialysis functions. Distribution is the passive movement of solutes across a membrane. Solutes diffuse from an area of higher concentration to an area of lower concentration, across the peritoneum, until there is an equal amount of each on both sides of the membrane (Choice B). Choice C is incorrect. The oncotic pressure is a form of osmotic stress induced by proteins in a blood vessel's plasma that displaces water molecules. This is not an essential principle upon which peritoneal dialysis is based. Choice D is incorrect. Osmotic pressure is the pressure that would have to be applied to a pure solvent to prevent

While orienting a new graduate nurse in the ICU, you take care of a patient scheduled for peritoneal dialysis. Which of the following principles do you explain to the new graduate about peritoneal dialysis functions? Select all that apply. A. Osmosis B. Diffusion C. Oncotic pressure D. Osmotic pressure

A Choice A is correct. Aplastic anemia leads to pancytopenia, a severe decrease in all hematological cell types: red blood cells, white blood cells, and platelets. Aplastic anemia may be caused by primary bone marrow failure or from secondary causes such as medications. Some medications that cause aplastic anemia include chloramphenicol, phenylbutazone, sulfonamides, anticonvulsants, cimetidine, and NSAIDs. Drug-induced aplastic anemia is the result of an idiosyncratic hypersensitivity reaction and is often reversible. In such drug-related aplastic anemias, the nurse must notify the physician and withdraw the offending agent. Choice B is incorrect. Leucocytosis refers to increased white blood cells. Leucocytosis can be induced by some medications (for example, Lithium); however, it is not serious bone marrow toxicity. Instead, Leukopenia (a reduced number of white blood cells) is more serious and makes the patient s

While reviewing medication-related hematological side effects, the nurse recognizes which of the following as the most severe form of bone marrow toxicity: A. Aplastic anemia B. Leukocytosis C. Thrombocytosis D. Granulocytosis

B Choice B is correct. You would respond to the client's statement of "I do not want to become a druggie" with "The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse" when your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. Responding in this manner allows you to educate the client about a misconception related to pain management in terms of fears of addiction because only a small number, approximately 5% of people, without a prior history of substance abuse that take narcotic analgesics for pain become addicted to them. This response also educates the client about some of the possible complications of unrelieved pain, such as immobility, atelectasis, and infections. Choice A is incorrect. This is an inappropriate response because it is NOT therapeutic, and it is also false. Approxim

Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, "I do not want to become a druggie." How would you respond to this client's comment? A. "That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse." B. "The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse." C. "A lot of people prefer to be brave and stick it out so you are not alone." D. "You have a right to refuse any and all treatments, so just do without it."

A Choice A is correct. This client with chronic pancreatitis and gastroparesis is complaining of a migraine headache. Butorphanol is available in the oral form, transnasal form, transdermal, and parenteral form. The doctor has ordered butorphanol orally as needed for pain, but you would call the doctor and suggest transnasal butorphanol because the client has gastroparesis. Choice B is incorrect. Butorphanol is not available for rectal administration. Choice C is incorrect. You would not administer butorphanol orally for pain because this route is contraindicated among clients with gastroparesis. Choice D is incorrect. You cannot administer transdermal butorphanol without a doctor's order. The doctor needs to be called to obtain such an order.

Your client, who has chronic pancreatitis and gastroparesis, is complaining of a migraine headache. The doctor has ordered butorphanol orally as needed for pain. What would you do? A. Call the doctor and suggest transnasal butorphanol because the client has gastroparesis. B. Call the doctor and suggest rectal butorphanol because the client has pancreatitis. C. Administer the butorphanol orally as ordered. D. Administer the butorphanol transdermally for pain.

D

A nurse is caring for a client receiving nitroglycerin. It is essential to monitor the client's A. Temperature B. Respirations C. Urinary output D. Blood pressure

D Choice D is correct. Sexual pleasure is heightened during the second trimester of pregnancy. In the second trimester, most women experience significant relief from the discomforts of early pregnancy (nausea and vomiting, breast tenderness). The uterus is not too large to interfere with comfort and rest. The second trimester is also the time when pelvic organs are congested with blood, increasing pleasure in sexual activities. Choices A and B are incorrect. As long as risk factors such as preterm labor or incompetent cervix are not present, intercourse should not harm the pregnancy. Sexual intercourse should not be a cause of concern even in the third trimester unless risk factors such as preterm labor or placenta previa are present. Choice C is incorrect. Many women experience changes in sexual desire at different stages in pregnancy, depending on their general sense of well-being and the presence of certain disco

A nurse at an obstetric clinic has conducted a teaching class on sexuality during pregnancy. Which of the following comments from a participant would indicate that the teaching has been effective? A. "At around the time I would normally have my period, I should abstain from intercourse." B. "I should no longer have sex during the last trimester of pregnancy." C. "My sexual desire will remain the same for the entire pregnancy." D. "The best time to enjoy sex is in the second trimester."

B Choice B is correct. The injection should be given within 72 hours after birth. RhoGAM is administered intramuscularly within 72 hours after birth to prevent sensitization to the Rh factor in an Rh-negative woman with an infant who is Rh-positive. This injection will prevent hemolytic disease in subsequent pregnancies. Each vial of RhoGAM is cross-matched to a specific woman. The nurse must do all appropriate checks for patient identification to avoid an error in administration. Choices A, C, and D are incorrect. Any history of a systemic allergic reaction to human immunoglobulins is a contraindication for the RhoGAM injection. RhoGAM is administered to an Rh-negative female. The injection should be withheld in a patient who has an elevated temperature.

A nurse has received orders to administer a RhoGAM injection IM to a postpartum patient. Which situation is NOT a contraindication for administration of this injection? A. Administration to a patient who has a history of a systemic allergic reaction to preparations containing human immunoglobulins. B. Administration of the injection within 72 hours after delivery. C. Administration to an Rh-positive female patient. D. Administration to a patient with an elevated temperature.

D

A nurse is assigned to care for a client who recently underwent a thyroidectomy. The nurse notes that the client has developed peripheral numbness and tingling, muscle twitching, and spasms. Based on this information, the nurse should anticipate administering: A. Thyroid supplements B. Barbiturates C. Antispasmodics D. Intravenous calcium gluconate

A, E

A nurse is caring for a client receiving digoxin. The client's most recent digitalis level was 2.5 ng/mL. The nurse should take which action? Select all that apply. A. Withhold the client's scheduled dose B. Administer the dose, as prescribed C. Assess the client's 24-hour urinary output D. Assess the client's most recent sodium level E. Assess the client's heart rate and rhythm F. Obtain a prescription for an echocardiogram

A Choice A is correct. Mineral oil is contraindicated in pregnancy as it decreases nutrient absorption in the mother. Choice B is incorrect. Sleeping in a side-lying position removes the weight of the fetus on the superior and inferior vena cava, promoting venous return and decreasing venous pressure. Choice C is incorrect. Increasing fiber and water intake promote the formation of bulkier stools. Preventing constipation and relieving rectal pain. Choice D is incorrect. Cold compresses relieve pain by vasoconstriction of the hemorrhoids.

An 11-week pregnant client is complaining to the nurse about her hemorrhoids. The nurse understands that hemorrhoids occur because of pressure on the rectal veins from the bulk of the growing fetus. All of the following are measures to alleviate hemorrhoid pain, except: A. Instruct the client to use mineral oil to soften her stools. B. Rest in a side-lying position daily. C. Increase the client's fiber and water intake. D. Apply a cold compress to the area

D Choice D is correct. It is the responsibility of the nurse to evaluate and check if the delegated tasks to the LPN have been performed. Choice A is incorrect. The LPN cannot assess a client. This is a task for the RN. Choice B is incorrect. The child has just undergone a cleft palate repair. There is a risk for the child to damage his incision site and aspirate if he/she is fed by untrained personnel. This task is for the RN. Choice C is incorrect. Demonstrating a procedure to the mother is similar to educating or teaching the client. The LPN is not allowed to perform teaching/education.

An RN is in charge of the unit with an LPN. Which situation indicates proper delegation of tasks by the RN? A. The RN delegates to the LPN to check the circulation of the child with a forearm cast. B. The LPN is tasked to feed a one-year old that just had a cleft palate repair. C. The LPN demonstrates urinary catheterization to the mother of a child with neurogenic bladder. D. The RN checks if the LPN completed all delegated tasks.

A Choice A is correct. At 1-year-old, children should be beginning to walk. Hospitalization during this age could delay this stage of development. Choice B is incorrect. The patient should just be learning to walk at this age, not running. Choice C is incorrect. The child should be sitting up by six months of age. Choice D is incorrect. The child should already be crawling before age 1.

Hospitalization may affect or delay the progression of which physical development of a 1-yr-old patient? A. Walking B. Running C. Sitting D. Crawling

B Choice B is correct. If the ICD administers shock, others in physical contact with the patient may feel it but will not be harmed. A shock from the ICD indicates that it's effectively treating the rhythm disorder. Choice A is incorrect. If the ICD administers shock, others in physical contact with the patient may feel it but will not be harmed. Choice C is incorrect. The ICD does not produce any magnetic field. Choice D is incorrect. The shock felt by the patient's friend is an expected outcome of a functional ICD that's treating the patient's rhythm. The question does not mention any clinical symptoms such as chest pain following the shock. This does not necessitate an immediate checkup by a physician. If the patient had just one shock in 24 hours and feels fine after the shock; no immediate intervention is necessary. However, if the patient reports chest pain/ chest pressure/ shortness of breath following an ICD

The client with an implantable cardioverter defibrillator (ICD) is at the outpatient department. He is concerned about a shock that his friend felt when they were shaking hands. The nurse can discuss which of the following in response to the patient's concern? A. His friend should have an ECG taken to check if his heart rhythm was affected in anyway. B. He shook hands with his friend at the exact same time the ICD delivered a shock to restore his rhythm, and that he need not worry. C. The shock was due to the magnetic field the device emits. D. He should get urgently checked by the physician.

A Choice A is correct. Here, the nurse should hold the medication and contact the HCP to clarify the medication order, as multiple red flags have been presented in the scenario. First, subcutaneous heparin is typically used as prophylaxis against deep vein thrombosis (DVT) and pulmonary embolism (PE), with intravenous heparin used in the event of a PE developing. Here, the client has a PE, raising questions about the route of administration ordered. Second, an order for 50,000 units of heparin should raise questions, as this dose is significantly higher than any dose appropriate for a PE client. The prescribed dosage of 50,000 units is unsafe and would put the client at an increased risk for bleeding. Therefore, the nurse should hold the medication and contact the HCP to clarify the medication order. [As a footnote, following order clarification (i.e., when the medication is ultimately administered), the client shou

The health care provider (HCP) has prescribed 50,000 units of heparin via subcutaneous injection for a client with a pulmonary embolism (PE). The vial on hand contains 20,000 units per mL. The nurse calculates that the drug volume to be administered will be 2.5 mL. The nurse verifies that the client understands the action of the medication when the client states: "This medication will help prevent blood clots." After double-checking the dosage to be administered, the nurse decides to do which of the following? A. Hold administration and contact the health care provider (HCP) to clarify the medication order B. Administer 0.2 mL of the medication instead of the calculated volume of 2.5 mL C. Administer the prescribed dose while monitoring the client for signs of bleeding D. Administer the medication as prescribed, initiate bleeding precautions, and instruct the client to remain in bed to prevent injury

A Choice A is correct. Elderly clients do not show "typical" symptoms of pneumonia, such as fever. The nurse should watch for altered levels of consciousness or behavioral changes as these may indicate decreased oxygenation to the brain from sepsis. Therefore, the nurse should see this client first. Choice B is incorrect. The client is showing the expected signs and symptoms of influenza. This patient does not require the nurse's immediate attention. Choice C is incorrect. Tidaling in a water-seal system is expected; therefore, the nurse would not need to see this client first. Choice D is incorrect. Drainage from the nose in a patient with a sinus infection is expected.

The nurse has just finished receiving the shift report from the night nurse. Which patient should the nurse see first? A. A 90-year-old patient with pneumonitis who is getting restless but is currently afebrile. B. A 20-year-old patient with influenza who is febrile and complaining of a headache. C. A 40-year-old patient with hemothorax in the right lung who is attached to a chest drainage system that is tidaling. D. A 27-year-old with sinusitis having green drainage from his nose.

B Choice B is correct. When securing an indwelling urinary catheter for a male, it is appropriate to anchor it to the lower abdomen (with the penis pointed upward) or upper thigh. The catheter tubing should be secured to the lower abdomen or the upper thigh to prevent urethral injury. Choices A, C, and D are incorrect. These are anatomical locations are inappropriate for securing an indwelling catheter. When securing an indwelling catheter for a female, it should be anchored to the inner thigh. When securing an indwelling catheter, the following should occur - ✓ The catheter should be attached to a male's upper thigh (with the penis pointed upward) or lower abdomen. ✓ For a female, the catheter should be connected to the inner thigh. The catheter should be secured with an adhesive device. The device is typically gently removed with an alcohol swab to avoid a shearing injury to the skin.

The nurse has just inserted an indwelling urinary catheter for a male client. The nurse plans on securing the catheter to the client's A. inner thigh. B. lower abdomen. C. outer thigh. D. medial thigh.

D

The patient is diagnosed with atrial fibrillation. What assessment data would require immediate intervention by the RN? A. Irregular QRS complexes on telemetry reading B. Rapid, irregular pulse C. The patient reports palpitations D. The patient reports lightheadedness

B

The patient that has just undergone cardiac surgery is recovering in the post-anesthetic care unit. The nurse notices that the patient's blood pressure is 88/52 mmHg and that his jugular veins are very prominent. The nurse auscultates his heart rate and cannot hear any heart sounds. The nurse immediately informs the physician on duty and prepares for which procedure: A. Thoracentesis B. Pericardiocentesis C. Arthrocentesis D. Paracentesis

B, C, D, E Choices B, C, D, and E are correct. This device is an external fixator and has pins directly into the skull. Any signs or symptoms of infection should be reported immediately, as these manifestations may suggest osteomyelitis. The wrench of the device should always be kept affixed to the front of the vest in the case of the need to perform CPR. It would be correct for the client to get out of bed by pushing against the mattress. Cotton clothing should be worn under the vest to absorb any excess moisture and prevent skin breakdown. Choice A is incorrect. These statements are incorrect. Driving a vehicle and riding a bicycle are prohibited while in this device because of the client's inability to turn from side to side to view traffic. The halo fixator device may be connected to traction or a vest. This device is used for cervical spinal cord fractures. The client will need to meet with occupational and sp

The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make? Select all that apply. A. "You should ride a bicycle instead of driving a car." B. "Report any fever or drainage at the pin sites." C. "Always keep the wrench taped to the front of the vest." D. "When you are getting out of bed, roll to the side and push on the mattress." E. "Wear a cotton t-shirt under the vest to absorb any moisture."

B

The patient is diagnosed with acute kidney failure. Which of the following is an appropriate psychosocial problem for the RN to include in the care plan? A. Imbalanced nutrition: less than body requirements related to altered metabolic state and dietary restrictions. B. Anxiety related to the disease process and uncertainty of prognosis. C. Excess fluid volume related to compromised regulatory mechanisms secondary to acute renal failure. D. Risk for infection related to invasive procedures and an altered immune response secondary to renal failure.

C Choice C is correct. It is widely accepted that a finding of a single transverse palmar crease on the palm - often referred to as a simian line or simian crease - is often observed in a wide range of chromosomal defects, including, but not limited to, Down syndrome, congenital limb deficiency, trisomy 13/18/21, 4p, 18q, etc. Although this finding does not in and of itself render a diagnosis of a chromosomal disorder, this finding by the nurse would necessitate the need to alert the newborn's primary health care provider (HCP), as genetic and chromosomal testing will likely need to be performed. Choice A is incorrect. Fontanels are one of a newborn's skull's most prominent anatomical features, helping to facilitate the movement and molding of the newborn's cranium through the birth canal during labor. The diamond-shaped soft area present at the top of the newborn's head is the anterior fontanel (also commonly refer

While working in the nursery, a nurse assesses a newborn born less than two hours ago. Which of the following findings by the nurse would necessitate further investigation? A. A diamond-shaped soft area present at the top of the newborn's head B. Greasy, white substance that resembles cheese on the newborn's neck, back, and thighs C. A single crease on the palm D. Acrocyanosis

C Choice C is correct. Topical nitroglycerin is used to help prevent/ treat anginal symptoms in coronary artery disease. To apply nitroglycerin correctly, be sure to rotate the application sites with each application to avoid irritation from the medication. The medication comes with a supply of paper applicators with a small ruler on the paper for proper measurement of the drug. Apply the appropriate amount of ointment on the paper and apply the cream to an area of the skin. Choices A, B, and D are incorrect. Do not rub the cream on the skin until it disappears. Tape the paper into place, and do not cover it with gauze. The cream is usually applied to the chest, back, upper arms, or other torso parts.

You are caring for a patient with a new order for nitroglycerin ointment one inch applied to the skin twice a day to prevent angina. To use nitroglycerin correctly, you know to: A. Apply it only to the upper chest B. Rub the ointment into the skin until it disappears C. Rotate the application sites D. Cover the application site with a gauze dressing

B, C Choices B and C are correct. It is important to teach parents that electrical outlets should have plug covers in place by the time their child is 7-months-old. At this age, the infant will be able to crawl and will be reaching out to touch unfamiliar things. This is when electrical outlets start to pose a risk and should therefore be covered (Choice B). It is important to teach parents that toilet lids should have locks on them by the time their child is 7 months old. At this age, the infant will be able to crawl and will be reaching out and pulling themselves up on things. This is when toilets start to pose a risk and should have locks placed on their lids so that they cannot fall into them (Choice C). Choice A is incorrect. It is not necessary to use stair gates until the child is in kindergarten, as they should be able to safely navigate stairs on their own by 3 to 4 years of age. Advise parents to use stair

You are providing education on home safety to a group of new parents. Which of the following educational points are important to include? Select all that apply. A. Use stair gates to keep children off the stairs until they are in kindergarten. B. Cover the electrical outlets by the time your infant is 7 months old. C. Place locks on toilet lids by the time your infant is 7 months old. D. Move items on coffee tables to areas that cannot be reached before your child is a year old.

C Choice C is correct. The first thing that you should do is establish the client's trust. Trust is the early stage of the therapeutic nurse-client relationship. After the trust is established, the nurse should encourage, facilitate, and allow the client to ventilate their feelings. This ventilation of feelings is used for and enfolded into the assessment of the client as well as their current psychosocial functioning; this is often used to generate a nursing diagnosis that is specific to the client's needs. Choice A is incorrect. Although the nurse will assess the client and their current psychosocial functioning, this cannot be done until other phases of the nursing process, and the therapeutic nurse-client relationship is established. Choice B is incorrect. A nursing diagnosis is not established until other phases of the nursing process have been started, including the therapeutic nurse-client relationship. Choi

Your adolescent client has been admitted to the adolescent psychiatric mental health unit. What is the first thing that you should do for this client? A. Assess their current psychosocial functioning. B. Generate a nursing diagnosis. C. Establish trust with the client. D. Allow the client to ventilate their feelings.

B

Your client has been diagnosed with acute renal failure. Which one of the following lab results should be reported immediately? A. Blood urea nitrogen 50 mg/dL B. Serum potassium 6 mEq/L C. Venous blood pH 7.30 D. Hemoglobin of 10.3 mg/dL