done : Practice Question Banks 16-30 (Not Required)

After receiving report on the following clients, which client should the nurse assess first? A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy A client who underwent a partial gastrectomy and reports feeling lightheaded A client reporting gastric distress after taking ibuprofen A client diagnosed with emphysema with questions about a new medication

A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy Dizziness with PUD may indicate hemorrhaging. This client should be assessed including a symptom assessment and vital signs. The findings in the other options are expected and not life-threatening. A client may feel lightheaded due to dehydration and pain management related to a gastrectomy. Ibuprofen is a nonsteroidal anti-inflammatory drug, which has a common side effect of gastrointestinal symptoms. While educating the client on the new medication is important, it is not a priority for assessment. Incorrect LESSON Management of Care or Coordinated Care Establishing Priorities COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS peptic ulcerPUDgastrectomyGERDgastroesophageal reflux diseaseibuprofen

The nurse is assigned to a client who is receiving treatment for a traumatic head injury. The client's blood pressure on admission was 140/70 mmHg. Four hours later, the blood pressure increased to 179/68 mmHg. The nurse is trying to determine if the client has widening pulse pressure as a result of increased intracranial pressure (ICP). What is the difference in pulse pressures? Record your answer as a whole number. (1 attempt remaining)

Correct answer: 41Pulse pressure is the difference between the systolic and diastolic blood pressures. This is calculated by subtracting the diastolic from the systolic pressure. The first pulse pressure is 140 - 70 = 70. The second pulse pressure is 179 - 68 = 111. This is an increase of 41, which is an increase in pulse pressure, termed a "widened" pulse pressure that is often seen with an increase in ICP. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM nervous KEYWORDS traumaheadinjuryintracranial pressure

The nurse is performing a surgical dressing change on a client who had a laparotomy five days ago. The nurse notices the incision edges are separated and there is a visible bulge of organ tissue protruding from the wound opening. Which is the best way for the nurse to dress the incision before leaving the room to call the surgeon? Cover the wound with sterile gauze moistened with sterile 0.9% saline. Place iodine-soaked gauze over the wound and then cover it with an abdominal pad. Apply antibiotic ointment to the wound and cover it with a non-adherent dressing. Approximate the wound edges as much as possible with wound-closure strips.

Cover the wound with sterile gauze moistened with sterile 0.9% saline. This client likely has a wound evisceration, a complication of surgery. An evisceration is when a surgical wound opens and has protrusion of internal organs. This is considered a surgical emergency. The nurse should notify the surgeon of this finding immediately. When evisceration occurs, the best way to dress the wound is to cover it with sterile gauze dampened with sterile 0.9% saline using sterile technique. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM integumentary KEYWORDS surgerycomplicationseviscerationemergency

The nurse continually avoids answering the call light of clients with alternative lifestyles. The nurse's behavior is an example of which concept? Discrimination Stereotyping Benevolence Nonmaleficence

a Nurses are responsible for caring for individuals in a manner that demonstrates benevolence and nonmaleficence. This nurse is discriminating against these clients by continually not answering the call light. Stereotyping is defined as the thought that all members of an ethnic group, culture, or race all act alike. Incorrect LESSON Management of Care or Coordinated Care Ethical Practice COURSE RN Review KEYWORDS alternate lifestylebehaviordiscrimination

The nurse is caring for a 4-year-old child who will have surgery for tetralogy of Fallot tomorrow. Which laboratory report should the nurse expect to be elevated in this client? Hemoglobin and hematocrit Arterial blood pH Erythrocyte sedimentation rate White blood cell count (1 attempt remaining)

a Tetralogy of Fallot is a congenital, cyanotic heart defect, which is caused by poorly oxygenated blood circulating. These low levels of oxygenation stimulate erythropoietin production by the kidneys and lead to a secondary polycythemia. Secondary polycythemia is characterized by higher than expected hemoglobin and hematocrit levels. The other lab values are not typically affected by this heart defect. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS tetralogy of Fallotsurgerylaboratory

The nurse is reviewing the previous assessment findings for a newborn. The nurse notes that the first APGAR score was 8 and the next score was 9. Which category of the APGAR test is most likely the reason for the improved score? Color Cry Muscle tone Heart rate

a the APGAR test is an assessment used to evaluate and monitor a newborn's physical condition at 1 minute and 5 minutes after birth. The APGAR test evaluates five categories including: A- appearance (skin color) P- pulse (heart rate) G- grimace (reflex irritability) A- activity (muscle tone) R- respiratory (respiratory effort) These categories are rated on a 0 to 2 scale. A score of 0 indicates absent or poor response and 2 indicates a normal response. A normal APGAR score ranges from 8 to 10 and no medical intervention is needed other than supporting respiratory effort and thermoregulation. It is common for the newborn to experience acrocyanosis. This occurs when the body is pink and the extremities are blue and would be scored a 1. This is the most common APGAR score deduction. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS APGARscoreskincolor

The nurse in the emergency department is assessing a client diagnosed with an acute asthma attack. Which assessment finding would support this diagnosis? Diffuse expiratory wheezes Loose, productive cough Fever and chills Sharp pain during inspiration (1 attempt remaining)

a; Asthma is characterized as a hyper-responsive inflammatory disorder of the terminal bronchioles. The inflammation causes constriction of the smooth muscle around the bronchioles (bronchoconstriction). These changes make it difficult for air to enter the lungs, resulting in wheezes. The other findings are not typically seen with an acute asthma attack. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmaassesswheezing

An emergency room nurse is assigned to the triage area of a nearby mass casualty event. Which of these clients should the nurse tag as "Black" or "to be seen last"? A 45-year-old client with second and third degree burns over 90% of their body A 7-month-old infant with closed fractures to both lower legs who is crying loudly An 83-year-old client with an open fracture of the left arm A 14-year-old client with a small amount of bright red blood dripping from their nose

a; Clients that are deemed least likely to survive are tagged "black" or "to be seen last." This increases the ability to provide treatment to victims who have a greater chance of survival. Fractures are treatable with splinting and immobilization. It is a positive sign that the infant is alert and crying. The client with minor bleeding from the nose should be evaluated for head trauma, but appears stable at this time. A client with burns over 90% of their body will experience massive fluid loss and the burn injuries will most likely be fatal. Therefore, this client should receive a black tag or be seen last. Incorrect LESSON Safety and Infection Control Security Plan COURSE RN Review KEYWORDS disastertriageprioritization

A nurse is educating a client about digoxin toxicity. Which statement made by the client indicates that more teaching is needed? "I must report a strong pulse of 62 beats per minute to the health care provider." "I will let the health care provider know if my pulse feels uneven or misses beats." "High levels of digoxin can cause vision changes." "I should report nausea and vomiting lasting more than a few days."

a; Digoxin is used to increase the strength of heart contraction. The expected effect of digoxin use is a slower, strong pulse. The client should be instructed to check their pulse prior to taking this medication and to note the rate and if the rhythm is irregular. If the heart rate is less than 60 or greater than 100 the client should not take the medication. Therefore, a strong pulse of 62 is a therapeutic effect of this medication and would not warrant a call to health care provider. This needs to be clarified with the client. The other statements indicate understanding of the medication. Digoxin toxicity would cause irregular pulse, loss of appetite, nausea, vomiting and vision changes. The client should be alert to these clinical manifestations and call the health care provider if they experience any of these changes. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS digoxintoxicpulseheart

The nurse is planning care for a client following a stroke. Which approach would be most effective in the prevention of skin breakdown? Reposition every two hours when in bed Massage reddened bony prominence Pad the bony prominences Place client in the wheelchair for four hours daily

a; Following a stroke, clients often experience some degree of immobility, leading to an increased risk for impaired skin integrity. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained. Repositioning the client every two hours while in bed would be most effective in preventing skin breakdown such as a pressure ulcer. If the client is in a wheelchair, a shift of the weight should be done every hour. Massage of reddened bony prominences is no longer recommended to prevent pressure ulcers or injuries. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM integumentary KEYWORDS skinbreakdownCVA

The home health aide calls the nurse to report information about a client. Which information should be the highest priority for the nurse? "The urine in the urinary catheter bag is of a deeper amber, almost brown color." "The client reports not sleeping well for the past week." "The family wants to discontinue the home meal service called Meals on Wheels." "The partner says the client has gotten slower when doing things every other day." (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

a; Home health aides often report diverse client information to nurses through phone calls and electronic documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs that require immediate action and follow-up. The information of highest priority is the abnormal color of the urine from the client's urinary catheter which can be indicative of a urinary tract infection or other renal-urinary problem. The other options may need further assessment but are not the priority. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS aideUAPsupervision

The nurse is performing the initial assessment of a client in the emergency department. Which statement by the client most strongly suggests domestic or partner violence? "I have tried leaving home but have always gone back." "I have only been married for two months." "I am determined to make things work out." "No one else in the family is as accident prone as I am."

a; Intimate partner violence may occur as a pattern or frequently. The violence is part of a cycle of abuse. After the incident, the honeymoon phase occurs, and the abuser demonstrates love and vows to change. The victim may feel responsible for the violent attack and may consider reconciliation. The victim may leave the abuser and return frequently before a decision to leave permanently may occur. Incorrect LESSON Psychosocial Integrity Abuse, Neglect COURSE RN Review KEYWORDS domestic violencepartner violence

The nurse is admitting a client diagnosed with uncontrolled hypertension. Which of the following questions is a priority for the nurse to ask? "What over-the-counter medications do you take?" "Describe your usual exercise and activity patterns." "Tell me about your usual diet for one day." "Describe your family's cardiovascular history."

a; Over-the-counter (OTC) medications, especially those that treat cold symptoms, can increase blood pressure. Clients diagnosed with hypertension should be educated to avoid OTC medications that contain phenylephrine and look for OTC cold medication specifically design for people with hypertension. The other options are essential parts of this client's medical history. However, they do not pose the greatest risk to the client. Incorrect LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS assesshypertensionOTC

The nurse is caring for a client who is prescribed lithium for bipolar disorder. Which clinical manifestations would indicate the client may be experiencing lithium toxicity? Vomiting, diarrhea and lethargy Pruritus, rash and photosensitivity Electrolyte imbalance, tinnitus and cardiac dysrhythmias Ataxia, agnosia and coarse hand tremors

a; Serum lithium levels should be between 0.8 and 1.2 mEq/L (remember, the exact numbers may vary slightly depending on the lab). Diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity. Toxicity increases with increasing serum lithium levels, but clients may exhibit toxic findings at lithium levels below 2.0 mEq/L. Dehydration, other medications and other conditions can interfere with lithium levels. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS lithiumtoxicity

The nurse is caring for a client who received tenecteplase to open an occluded coronary artery. Which finding should be of highest concern for the nurse? Hematemesis Bleeding gums Urinary retention Epistaxis

a; Tenecteplase, a thrombolytic agent, breaks down a thrombus by stimulating the plasmin system. The plasmin system is a natural anticlotting system, which breaks down fibrin and dissolves any clots. Since this medication is not specific to a certain type of clot, the client should be expected to have an increased bleeding risk after administration. The most common adverse effect of thrombolytic medications is bleeding and hemorrhage. The nurse should monitor the client for signs and symptoms of abnormal bleeding. Hematemesis means vomiting blood. This is usually related to a bleeding gastric ulcer and should be of highest concern. Epistaxis (nose bleed) and bleeding gums are usually minor bleeding and can be easily monitored by the nurse. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS thrombolyticclotmyocardial infarctionbleeding

The nurse is caring for a client who was admitted with complications related to diabetes mellitus. The client asks the nurse about the purpose for a glycosylated hemoglobin (HbA1c) test. How should the nurse respond? "The test reflects an average blood glucose level for the prior 2 to 3 months." "The test provides a more precise blood glucose value than self-monitoring." "The test measures the amount of circulating insulin in the blood." "The test is performed to detect any renal complications related to diabetes mellitus."

a; The HbA1c test is used to determine the average blood sugar level for the past 2 to 3 months. For most diabetic clients, the goal is to keep the HbA1c at or below 7%. A HbA1c does not measure kidney function or renal damage. A HbA1c also does not measure circulating insulin and the value attained is not the same type of glucose level that a client would check at home. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM endocrine KEYWORDS diabeticHgbA1cglucose

A nurse is educating a client about the use of warfarin at home. The nurse should reinforce the need for the client to monitor which of the following? Consistent intake of foods high in vitamin K Limit of strenuous physical exercise Avoidance of public transportation and large groups of people Extended exposure to outdoor sunlight

a; Warfarin, an oral anticoagulant, works by causing a decrease in the vitamin K-dependent clotting factors produced by the liver. Due to this mechanism of action, vitamin K is used as the antidote for warfarin overdose. A diet high in vitamin K could counteract the therapeutic effect of warfarin. Foods high in vitamin K include dark green leafy vegetables, tomatoes, bananas, cheese and fish. Best practice no longer recommends limiting the intake of Vitamin K-containing foods, instead it is recommended to keep the intake of foods high in Vitamin K 'consistent'. The other actions do not pertain to warfarin. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS vitamin KwarfarinCoumadin

An inpatient psychiatric client diagnosed with schizophrenia is observed talking to unseen people and urinating on the floor. Which action by the nurse is appropriate to address the client urinating on the floor? Toilet the client more frequently with supervision Restrict the client's fluids throughout the day Withhold privileges each time the voiding occurs Require the client to mop the floor after each incident

a; With a client that has altered thought processes, the appropriate nursing approach to change behaviors is to take an active role in attending to the physical needs of the client. The other options are incorrect approaches. Incorrect LESSON Psychosocial Integrity Behavioral Interventions or Behavioral Management COURSE RN Review KEYWORDS behaviorvoid

The nurse is caring for a client diagnosed with bipolar disorder. The client is expected to transfer to a residential facility. A social worker from the facility calls to obtain information about the client. Which action is appropriate concerning this request? "I will need to obtain the client's written consent before releasing information." "I can never give information out over the telephone." "You must contact the health care provider's office to receive referral information." "I can only acknowledge the client is currently being treated at this facility."

a; In order to release information, the nurse should obtain the client's written consent. The client has the right to privacy and protection of confidential information. The other actions are inappropriate or incorrect approaches to this request. Incorrect LESSON Management of Care or Coordinated Care Continuity of Care COURSE RN Review KEYWORDS bipolarsocial workerconsentreferral

The nurse is caring for an 83-year-old client who is experiencing a sudden onset of confusion. Which medication most likely contributed to this change? Antihistamine Anticoagulant Cardiac glycoside Liquid antacid

a; Older adults are more susceptible to the side effects of anticholinergic medications, such as antihistamines. Antihistamines often cause confusion in the older adult, especially at high doses. Cardiac glycosides, anticoagulants and antacids are not associated with confusion or mental status changes in the older adult. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review KEYWORDS confusionsuddenanticholinergic

The nurse is caring for a client who reports the onset of symptoms associated with tardive dyskinesia. Which finding would the nurse expect to observe? Rapid, repetitive tongue movements Fine motor tremors of the hands while eating Behavior changes related to judgment Involuntary yelling of random words

a; Tardive dyskinesia (TD) is a syndrome of involuntary movements that usually affects the face, mouth, tongue, trunk and limbs. TD may occur years after treatment with a neuroleptic agent and may be irreversible. Predisposing factors include older age, phenothiazine treatment, history of smoking and history of diabetes mellitus. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS tardive dyskinesiatongue

The nurse is educating a pregnant woman who was advised to increase the intake of protein and vitamin C to meet the needs of the growing fetus. Which food choice best satisfies these dietary recommendations? Baked chicken and fresh strawberries Cheese pizza with sausage topping Hamburger and a salad Spaghetti and an orange

a; The food choice that best satisfies an increased protein and Vitamin C intake is baked chicken (protein) and fresh strawberries (vitamin C). The other choices might contain some protein and vitamin C as well but are also high in carbohydrates or fats, making them a less nutritious choice. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care Health Promotion, Disease Prevention COURSE RN Review KEYWORDS vitamin Cdietpregnancyprotein CONFIDENCE

A nurse is caring for a client who is being evaluated for a possible myocardial infarction. The nurse notes what appears to be ventricular tachycardia on the cardiac monitor. Which action is a priority for the nurse? Assess airway, breathing and circulation Notify the rapid response team and the health care provider Begin cardiopulmonary resuscitation Prepare for immediate defibrillation

a; The nurse must treat the client, not the cardiac monitor. Always assess the client to determine the next step. This focused assessment includes checking the client's airway, breathing, and circulation (ABCs) and for signs of low cardiac output. Signs of low cardiac output include chest pain, dyspnea, hypotension and an altered level of consciousness. These clinical manifestations would indicate a need for cardioversion and other emergency interventions. The other options would be appropriate after the nurse has assessed the client. Incorrect LESSON Physiological Adaptation Hemodynamics - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS tachycardiaventricularmyocardialinfarction

The nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource? The state nurse practice act in which the assignment is made The policies and procedures of the assigned agency in that state With a nurse colleague who has worked in that state two years ago The American Nurses Association's Social Policy Statement

a; The state Nursing Practice Act is the governing document of the scope of practice in any given state. The assigned agency policy would not govern what the Registered Nurse can do in a state and while a nursing colleague may be knowledgeable, the nurse should review the primary legal document to ensure understanding. The American Nurses Association's Social Policy Statement provides information on the profession of nursing through the Social Contract theory. Incorrect LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN Review KEYWORDS Practice Acttasks

The oncology nurse is caring for a female client who is being treated for metastatic breast cancer. The client is scheduled to receive their first dose of trastuzumab. Which assessment finding is most important to notify the health care provider of? Irregular apical pulse Blood glucose 130 mg/dL Absolute neutrophil count 2.5 (2,500 mm3) Intermittent nausea and vomiting

a; Trastuzumab is a monoclonal antibody used as anticancer therapy for women with HER2-positive breast cancer. The main concern in administering trastuzumab is cardiotoxicity, manifesting as ventricular dysfunction and congestive heart failure. Therefore, the irregular apical pulse is the most important assessment findings. An ejection fraction is obtained as a baseline before treatment and may be monitored every few months while the client is receiving this medication. The other findings are to be expected, normal or near normal and not as important as the irregular apical pulse. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS cancertrastuzumabpulse

The nurse is preparing a presentation focusing on the prevention of Lyme disease. Which statement by a participant would require further clarification by the nurse? "Lyme disease is caused by a virus similar to the flu." "I will call the doctor if I see a rash that looks like a bull's eye." "I should wear light-colored clothing and long pants when gardening." "Lyme disease can spread to my brain if I don't seek treatment."

a; While the symptoms of Lyme disease are similar to influenza, Lyme disease is not caused by a virus. Lyme disease is caused by the spirochete, Borrelia burgdorferi, which is transmitted to humans by deer ticks. Because the ticks are so small, it is easier to see them on light-colored clothing. Long pants and long-sleeved shirts help protect individuals from insect bites. After being outdoors, individuals should assess their body for any ticks or rashes. Parents should be instructed to check children for ticks and rashes. There may be a "bull's eye" rash at the site of the tick bite. Without antibiotics, the disease can spread to the brain, heart and joints of the body. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM nervous KEYWORDS Lyme diseasedisease preventio

The nurse is teaching a client about their colostomy pouch. During the teaching session, when should the nurse teach the client to empty the pouch? When it is one-third to one-half full Prior to meals At the same time each day After each fecal elimination (1 attempt remaining)

a;A colostomy is a surgically created opening in which fecal material exits the body. A colostomy may be located at the ascending, transverse, descending, or sigmoid colon. Depending on the underlying diagnosis, the colostomy could be temporary or permanent. It is essential that the client learn to care for the colostomy including monitoring, cleansing, emptying and replacing the pouch (commonly called an "appliance"). The client should be taught to empty the colostomy bag when it becomes half full. The weight of the fecal material could cause separation from the pouch and the flange. Emptying before meals could cause a decrease in appetite and after each fecal elimination is unrealistic. Emptying at the same time of day does not account for the pouch being empty at that time. Incorrect LESSON Basic Care and Comfort Elimination COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS colostomypouchteach

The nurse is inserting a urinary catheter in an adult female client. The nurse advances the catheter 2 to 3 inches (5 to 7 cm), but no urine return is seen. Which intervention is appropriate for the nurse to do next? Advance the catheter a few more inches. Notify the health care provider (HCP). Inflate the catheter balloon. Withdraw the catheter and try again.

a;For an adult female, a urinary catheter should be inserted about 2 to 3 inches (5 to 7 cm) in the urinary meatus until the urine begins to flow. If the urine does not flow, the catheter can be carefully inserted a bit further. If no urine flows after the further advancement, the catheter is probably in the vaginal canal. Once the inappropriately placed catheter is removed, a new sterile catheter should be used. The nurse should not inflate the balloon until proper placement is confirmed by flowing urine. If the balloon is inflated too soon, the urethra could be damaged. The nurse should never use the same catheter because the risk of contamination with withdrawal is too great. The health care provider should be notified after troubleshooting and a second unsuccessful attempt. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN & PN Review BODY SYSTEM urinary KEYWORDS urinary catheter insertion

A client with late-stage lung cancer was started on chemotherapy two days ago and might be experiencing tumor lysis syndrome. Which findings support this diagnosis? Select all that apply. A serum uric acid level of 22 mg/dL A serum phosphorus level of 1.8 mg/dL A serum creatinine level of 2.4 mg/dL Weakness and muscle cramps A serum potassium level of 3.0 mg/dL

acd Tumor Lysis Syndrome (TLS) is a metabolic complication in response to chemotherapy and is a medical emergency. Massive cell destruction releases intracellular components such as potassium and phosphate that are metabolized into uric acid. High levels of uric acid crystalize in the distal tubules of the kidneys and lead to acute kidney injury (AKI), as evidenced by the elevated creatinine level. TLS usually occurs within 24-48 hours after the initiation of chemotherapy and may persist for about 5-7 days. Hallmark signs of TLS include: hyperuricemia, hyperphosphatemia, hyperkalemia and hypocalcemia. In addition, the client might experience weakness, muscle cramps, nausea and vomiting (N/V) and diarrhea. Incorrect LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN & PN Review BODY SYSTEM urinary KEYWORDS chemotherapycancersyndromeuric acidAKI

The nurse is collecting data from an adolescent client. Which of the following issues should the nurse address? Select all that apply. "How are things going at home?" "Have you gotten in any trouble lately?" "How many sexual partners have you had in the past six months?" "Have you decided what you are going to do after high school?" "Are you currently having conflicts with someone close to you?" "Where are you currently living?"

acef Several professional organizations have published guidelines aimed at improving and maintaining health care for adolescents and young adults. The American Academy of Pediatrics, American Academy of Family Physicians, American Medical Association and U.S. Preventive Services Task Force have similar guidelines for health promotion of adolescents. These guidelines emphasize the need to provide health services to adolescents that meet their physical and emotional needs including physical growth and development, social and academic indicators, emotional well-being and violence, substance use and injury prevention. Closed-ended questions about the client's plans after high school and if they have been in trouble are non-therapeutic and not appropriate in this situation. LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN & PN Review KEYWORDS assessmentadolescenthealth promotiondata collection

A client has undergone electroconvulsive therapy (ECT). What is an appropriate postprocedure nursing intervention? Expect long-term memory loss for a few hours Remain with client until oriented to time, place and person Permit the client to sleep for four to six hours Offer frequent sips of clear liquids

b ECT is a medical procedure performed under general anesthesia for the treatment of bipolar disorder or major depressive disorder that has not responded to other treatments. During ECT, a small electrical current is passed through the brain, which induces a seizure. It is thought that this procedure alters the chemistry of the brain, which improves symptoms. As with seizures and other procedures performed under general anesthesia, the nursing priorities include assessment and safety. The client will awaken 20 to 30 minutes after the procedure and appear groggy and confused. The nurse should remain with the client until they are oriented to time, place and person. The client should not be immediately given sips of clear liquids due to the risk of aspiration. The nurse should not allow the client to sleep for four to six hours due to the need for assessment. Lastly, long term memory loss should not occur with this procedure Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM nervous KEYWORDS ECTelectroconvulsivetherapypostprocedure

The nurse is assessing the newborn of a mother who tested positive for heroin. Which assessment finding should the nurse anticipate for this infant? Central nervous system depression Irritability Lethargy with excessive sleepiness Large for gestational age (1 attempt remaining)

b Neonatal abstinence syndrome (NAS) is characterized by irritability, continual crying, decreased sleep, fever, diarrhea and seizures. Initial treatment is supportive with the newborn being swaddled to decrease sensory stimulation and offered small frequent feedings. These newborns are usually born small for gestational age and require hypercaloric formula. Incorrect LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS newbornhomeheroinwithdrawalassess

The nurse reviews an order to administer Rho(D) immune globulin to a Rh-negative woman after the birth of her Rh-positive newborn. Which assessment is a priority before the nurse gives the injection? Newborn's blood type Coombs test results Previous RhoGAM history Gravida and parity

b Rho(D) immune globulin is given only if antibody formation has not occurred. A negative Coombs test confirms antibodies have not been formed in the mother. If the Coombs test is positive, the medication is of no value. Rho(D) immune globulin is recommended for Rh-negative mothers between 28 and 32 weeks of gestation and within 72 hours after birth. Rh-negative mothers should receive Rho(D) immune globulin at any time when there is a risk of blood mixing including a miscarriage, abortion, ectopic pregnancy, or an amniocentesis. This medication provides temporary (approximately 12 weeks) passive immunity and will need to be repeated during subsequent pregnancies. It is important to note that Rho(D) immune globulin is considered a blood product. Clients should provide consent and be educated about the effects of this medication. The administration of blood products is not accepted by some cultures and religions. The nurse should accept the client's decision regarding this medication. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS RhnegativenewbornCoombs

The nurse is caring for a client on peritoneal dialysis. While performing a dialysate exchange which finding(s) would alert the nurse that the client has developed an acute complication? Client sleeps throughout fluid exchange Respiration rate of 30 with crackles throughout the lung fields Catheter dressing saturated with clear fluid Pulse 86 and blood pressure 112/74 (1 attempt remaining)

b The development of an increased respiratory rate with crackles bilaterally indicates fluid overload, which is an acute complication of peritoneal dialysis. The vital signs are normal. Sleeping throughout the fluid exchange is normal and indicates the client is comfortable. Clear fluid on the dressing around the catheter indicates leakage of the dialysate fluid and can be controlled by instilling less fluid with each exchange. Incorrect LESSON Physiological Adaptation Unexpected Response to Therapies COURSE RN Review BODY SYSTEM urinary KEYWORDS peritonealdialysiscomplicationcracklesfluid volume

The nurse admits a client to the mental health unit with suspected bulimia nervosa. Which lab result is most likely to confirm the nurse's diagnosis? A serum sodium of 140 mEq/L A pH value of 7.50 A serum calcium of 11 mg/dL A serum glucose of 76 mg/dL

b ;Bulimia nervosa is a disorder characterized by the client engaging in episodic, uncontrolled, compulsive and rapid ingestion of large quantities of food over a short period of time (binging), followed by inappropriate compensatory behaviors to rid the body of the excess calories. To rid the body of the excessive calories, the individual purges via self-induced vomiting or the misuse of laxatives, diuretics or enemas.Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. Gastric acid in the vomitus also contributes to the erosion of tooth enamel. In rare instances, the individual may experience tears in the gastric or esophageal mucosa. Some individuals develop calluses on the dorsal surface of their hands, typically on the knuckles, as a consequence long-term self-induced vomiting. This feature is called Russell's sign after the British psychiatrist who first described it. It cannot be a reliable diagnostic symptom, however, since many individuals with purging behavior are able to induce vomiting without using their hands.A normal pH is between 7.35 to 7.45. A pH of 7.50 indicates metabolic alkalosis related to the loss of hydrogen ions from the stomach due to excessive vomiting. The other lab values are normal. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN & PN Review KEYWORDS bulimianervosapsychosocialmental health

The nurse is caring for a client who recently received an allogeneic bone marrow transplant for the treatment of leukemia. Which nursing intervention is a priority for this client? Introduce the client to another bone marrow recipient Monitor the client for signs of infection Assist the client with ambulation every 2 hours Provide education on infection prevention in the community

b Leukemia is cancer that results in the uncontrolled production of immature WBCs (" blast" cells) in the bone marrow. Hematopoietic stem cell transplantation (HSCT), also called bone marrow transplantation (BMT), is standard treatment for the patient with leukemia who has a closely matched donor, e.g., a sibling (allogeneic). The client has an impaired immune system due to the diagnosis of leukemia and the treatment related to the bone marrow transplant, placing the client at an increased risk for infections. The priority if for the nurse to monitor for signs of infection including a temperature above 100.5 °F (38 °C), chills and cough. The other options are also appropriate for this client; however, they are not the priority immediately following a bone marrow transplant. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review KEYWORDS cyclosporineNeoralinfection

A client with possible Hepatitis C discusses his health history with the nurse. The nurse should recognize which statement by the client as the most important in supporting this diagnosis? "I have had unprotected sexual contact with at least one person." "I had a blood transfusion in 1990." "I ate the best raw oysters last week." "I got back from Africa a few weeks ago."

b he client who received a blood transfusion prior to screening for Hepatitis C (prior to July 1992) may show findings many years later due to Hepatitis C being asymptomatic in the early stages. Other risk factors for Hepatitis C include those who have been on long-term hemodialysis and have regular contact with blood at work. Contracting Hepatitis C from having unprotected sex with a person who has Hepatitis C is rare. However, unprotected sex with multiple partners does increase the risk. Eating raw oysters or drinking contaminated water would increase the risk of Hepatitis A. Travel to Africa would increase the risk of exposure to malaria from mosquitos carrying the disease as well as HIV if the person were exposed to blood carrying the infection or had unprotected sex with someone who was HIV positive. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS hepatitistransfusionliver

The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child? A slice of wheat bread A cup of yogurt An oatmeal cookie A cup of cereal (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

b; Celiac disease is an autoimmune disease that occurs in genetically predisposed people, where the ingestion of gluten leads to damage in the small intestine. Gluten is a general name for the proteins found in wheat, rye, barley and triticale (a cross between wheat and rye). Gluten helps foods maintain their shape, acting as a glue that holds food together. Gluten can be found in many types of foods, even ones that would not be expected. Children or adults with celiac disease should eat a gluten-free diet. An oatmeal cookie, wheat bread and cereal contain gluten and should be avoided. Dairy products are generally considered gluten-free and are an appropriate snack choice for the child. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS celiac diseaseglutengluten-free

The school nurse is educating teachers that the number of children diagnosed with fifth disease has increased. Which clinical manifestation of fifth disease should the nurse emphasize to the teachers? Macule that rapidly progresses to papule and then vesicles Bright red cheeks, with a "slapped face" appearance Discrete rose pink macules will appear first on the trunk and fade when pressure is applied Koplik spots appear first followed by a rash that appears first on the face and spreads downward

b; Fifth disease is also referred to as parvovirus infection or erythema infectiosum. Some people may call it slapped-cheek disease because of the face rash that develops resembling slap marks. It is also commonly called fifth disease because it was fifth of a group of once-common childhood diseases that all have similar rashes. The other four diseases are measles, rubella, scarlet fever and Dukes' disease. People will not know that a child has parvovirus infection until the rash appears, and by that time the child is no longer contagious. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM integumentary KEYWORDS childschoolskinrashfifth disease

The nurse is caring for a 14-year old child who has been tentatively diagnosed with hyperthyroidism. Which of these findings noted on the initial nursing assessment require intervention by the nurse? A comment by the client: "I just can't sit still." An apical heart rate of 190 bpm A 10% weight loss in the last month, despite an excellent appetite A report of irritability worsening in the past two weeks (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

b; Hyperthyroidism is the result of an overactive thyroid gland and characterized by increased metabolism. The clinical manifestations of hyperthyroidism may include goiter (enlarged thyroid), hyperactivity, heat intolerance, tachycardia, warm skin, exophthalmos and weight loss. The parents may notice the child has difficulty sleeping and poor school performance related to distractibility. A sudden increase in the client's heart rate, blood pressure, or level of irritability may be associated with thyroid storm. Thyroid storm is caused by a sudden release of thyroid hormones and is a medical emergency that could progress to heart failure and shock. The other options are expected related to the tentative diagnosis of hyperthyroidism. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM endocrine KEYWORDS Grave'shyperthyroidismexophthalmoschild

The charge nurse makes assignments for the nursing team, which consists of registered nurses (RNs) and licensed practical nurses (LPNs). Which client should be assigned to the LPN? A 35 year-old who is 12 hours post cardiac catheterization A 58 year-old with a history of hypertension, diagnosed with possible angina A 65 year-old scheduled for discharge after angioplasty and stent placement A 49 year-old diagnosed with a new onset atrial fibrillation with a rapid ventricular response

b; LPNs should not be assigned clients that are unstable or require in-depth assessment and education. The LPN scope of practice does not include new admissions or the administration of blood products. For these options, the most stable client is the 58-year-old diagnosed with possible angina. An RN would need to provide education or frequent assessments on the other clients. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS UAPLPNassign

The nurse is teaching a group of women in a community clinic about osteoporosis. Which explanation should the nurse include? It is best to avoid foods high in purine, such as bacon, liver and shellfish. It is important to increase calcium intake and weight-bearing exercise. Performing regular range-of-motion exercises will help with inflamed joints. Ice, rest and ibuprofen will help with the symptoms of osteoporosis. (1 attempt remaining)

b; Osteoporosis (OP) is a chronic, progressive metabolic bone disease marked by low bone mass and the deterioration of bone tissue, leading to bone fragility and an increased risk of fractures. Care focuses on proper nutrition, calcium supplementation, exercise, drugs and the prevention of falls.Osteoporosis is often mistaken for osteoarthritis (OA). Ice, rest, NSAIDs and range-of-motion exercises are used to treat symptoms of OA and/or Rheumatoid Arthritis (RA).Purine-rich foods need to be avoided with gout. Purine-rich foods increase uric acid production, which worsens the symptoms of gout. Incorrect LESSON Physiological Adaptation Alterations in Body Systems COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS osteoporosisteaching

The nurse is monitoring the level of consciousness for a client who experienced a head injury. During the last assessment, the client scored a 15 on the Glasgow Coma Scale (GCS). Now, the client opens eyes to verbal command (GCS 3), has purposeful movement to painful stimulus (GCS 5) and is using inappropriate words (GCS 3). Which intervention by the nurse should be implemented first? Continue to monitor level of consciousness Call the rapid response team and health care provider Increase the flow of oxygen Raise the head of the bed

b; The GCS measures the client's highest motor response, verbal response, and eye response with scores ranging from 3 to 15. The GCS can be used to monitor progress and predict a client's outcome or prognosis. In the last assessment, this client was scored a 15 on the GCS, which indicates the baseline. Upon reassessment, the client's responses have decreased indicating a worsened neurological state. This requires urgent intervention and the rapid response team and health care provider should be notified. If the nurse continues to monitor the level of consciousness without notifying the HCP and the rapid response team, the client's condition could worsen. It is possible the change is related to increased intracranial pressure (ICP), but this needs to be determined before the other actions are taken. Correct! LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS braininjuryassessmentGlasgow

While caring for a newborn, the nurse notes a high-pitched cry, irritability and lack of interest in feeding. The nurse suspects the newborn is experiencing neonatal abstinence syndrome. Which intervention is most appropriate for this newborn? Remove the swaddling blanket from the newborn. Dim the lights and reduce the noise in the room. Offer the newborn formula every four hours. Do not allow the newborn to use a pacifier.

b; A high-pitched cry, irritability, poor feeding, increased respiratory rate, fever, vomiting and diarrhea are all clinical manifestations of neonatal abstinence syndrome (NAS). NAS is a term used to describe the behaviors exhibited by the infant exposed to drugs in utero.Appropriate treatment of NAS includes reducing environmental stimuli (dimming the lights in the room, reducing noise in the room, speaking in a soft voice), swaddling, oscillating (vibrating) cribs and pacifiers. Incorrect LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS newbornwithdrawalstimuli

The nurse is caring for a client who is experiencing alcohol withdrawal. The client is experiencing tremors and nausea. The client's vital signs are within normal limits, but the client is sweating profusely. Which nursing intervention is a priority for this client? Ask the family to leave the bedside to provide privacy Monitor for agitation or hallucinations Update the client regularly on their progress Assess the client's vital signs every 6 hours

b;During alcohol withdrawal, the client may experience many clinical manifestations. Six to eight hours after alcohol cessation, the client may experience tremors, nausea and agitation. After eight to ten hours, the client may experience increasing perceptual changes such as hallucinations, unconsciousness, seizures, or delirium. This is a medical emergency and the nurse should anticipate administration of lorazepam or chlordiazepoxide. After twelve to twenty-four hours, the client may experience tonic-clonic seizures and diazepam may be administered. Monitoring the client for Delirium tremens (DTs) is a nursing priority. DTs are a medical emergency and if left untreated have a significant risk of death. Vital signs and monitoring for clinical manifestations of DTs should be done more often than every 6 hours. During this time, regularly updating the client on their progress may cause frustration with the client. Additionally, if the client wants the family at the bedside, privacy is not needed. Incorrect LESSON Psychosocial Integrity Chemical and Other Dependencies, Substance Use Disorder COURSE RN & PN Review KEYWORDS alcoholdetoxificationnaltrexonesubstance abuse

A nurse is caring for a trauma victim who experienced significant blood loss. The client has received multiple transfusions. Which test would be the most accurate indicator of oxygenation? Pulse oximetry Arterial blood gases (ABGs) Hemoglobin and hematocrit (H and H) Complete blood count (CBC)

b;During hypovolemic shock, priority interventions focus on perfusion of tissue. ABGs are the most accurate measure of oxygenation at this time. An ABG test measures PaO2, PaCO2, pH, HCO3 and oxygen saturation. During hypovolemic shock, the extremities will be vasoconstricted. Pulse oximetry, a peripheral test, would not be as accurate. A CBC examines all components of blood, including hemoglobin and hematocrit. While these may be helpful, the ABG will provide the most accurate data concerning oxygenation. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS blood gasestransfusionoxygenABG

A nurse is interviewing the parents of a child who was recently diagnosed with asthma. During data collection, which question is a priority for the nurse to ask? "Did you paint your home recently?" "Do any pets live in the home?" "Have you recently purchased new furniture?" "Do you have plants in the home?"

b;Many cases of childhood asthma are associated with environmental triggers, such as animal dander. These triggers stimulate the inflammatory response and constriction of the terminal bronchioles. Animal dander is a very common allergen affecting children and adults. Other triggers include pollens, carpeting, cigarette smoke and household dust. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM respiratory KEYWORDS childasthmaassessenvironment

The nurse is preparing a 5-year-old child for a scheduled tonsillectomy and adenoidectomy. The parents express concern about the child's reaction to being in the hospital. Which nursing intervention would best prepare the child? Introduce the child to the entire staff the day before surgery. Encourage the child to bring a favorite toy to the hospital. Arrange a tour of the operating and recovery rooms. Explain the surgery one week prior to the procedure.

b;Small children need the comfort and reassurance of familiar things while hospitalized, such as the stuffed animal the child hugs for comfort and takes to bed at night. These familiar items are a link with home and the world outside the hospital. All toys brought into the hospital should be assessed for safety. Incorrect LESSON Health Promotion and Maintenancel Aging Process COURSE RN & PN Review KEYWORDS tonsillectomychildsurgeryprepare

The nurse is evaluating comprehension of a client newly diagnosed with testicular cancer. Which statement by the client indicate an understanding of this type of cancer? "If they find lymph node involvement, I am pretty much dead, aren't I?" "After surgery, I can have a prosthesis placed inside my scrotum." "I will probably never be able to have children after receiving chemotherapy." "I should have been better about using a condom during sexual intercourse."

b;Testicular cancer is a rare cancer that most often affects men between 20 and 35 years of age. With early detection and treatment, testicular cancer has a 95% cure rate. It can occur in one testicle or both. Surgery is the main treatment for testicular cancer. For stage 0 or 1 (localized disease), a unilateral orchiectomy is usually performed. A gel-filled silicone prosthesis may be surgically implanted into the scrotum at the time of the orchiectomy or later if the client desires. If there are concerns about sterility, the client has the option of sperm storage. Sexual intercourse, with or without a condom, does not cause testicular cancer. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM reproductive KEYWORDS testicular cancerstage

The nurse is assessing a client admitted for acute exacerbation of chronic obstructive pulmonary disease. Which assessment finding would support this diagnosis? An S3 heart sound Audible expiratory wheezing Inspiratory laryngeal stridor Crackles in the lung bases

b;The nurse must be able to identify and differentiate assessment findings such as adventitious lung sounds. Wheezing is associated with a narrowed, smaller airway. In an acute episode of obstructive airway disease, breathing is likely to be characterized by wheezing on expiration. This sound can often be heard without the use of a stethoscope. The other assessment findings are not typically seen with this diagnosis. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM respiratory KEYWORDS reactive airway diseasewheezing

The nurse is developing a plan of care for a client who underwent total hip arthroplasty 24 hours ago. Which interventions should the nurse include? Select all that apply. Assist the client with a clear liquid diet Provide a seat riser for the toilet or commode Encourage the use of an abduction pillow or splint between the legs Remind the client to not bend the knee of the affected leg while seated Encourage the client to perform leg exercises while in bed Encourage the client to use the incentive spirometer every 2 hours (1 attempt remaining)

bcef To prevent postoperative complications and complications related to immobility, the client should be up in a chair as soon as possible after surgery. While seated, the client should bend the affected leg at the knee. The nurse should reinforce teaching of simple leg exercises while in bed and the use of an abduction pillow or foam wedge to prevent adduction. To prevent atelectasis and pneumonia the client should be encouraged to use an incentive spirometer every 2 hours. Once the client is alert after surgery and not experiencing nausea or vomiting, they can resume a regular diet. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS hiparthroplastysurgery

The nurse is caring for a pregnant client who has orders for a routine alpha-fetoprotein (AFP) blood test. The client asks the nurse what is the purpose of this test. Which is the best response by the nurse? "It tells us how far along your pregnancy is." "Placental well-being is being evaluated." "Possible neurological defects may be identified." "The results help determine if the baby is growing normally."

c Alpha-fetoprotein (AFP) is a glycoprotein produced by the fetus's liver and small amounts are excreted in the urine and gastrointestinal secretions. The AFP level rises until 14 to 15 weeks of gestation and then will begin to decline. Elevated levels of AFP in maternal circulation associated with an increased risk for neural tube defects, such as spina bifida and meningocele. If the test is elevated, further evaluative tests are indicated. The other responses are incorrect. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS pregnantbloodtestAFP

The nurse is caring for a 14-year-old adolescent who attempted suicide. Which stressor is most likely to occur during adolescence and contribute to the risk of suicide? Financial strain and increased financial responsibilities The ending of a long-term romantic relationship Peer pressure and social isolation A challenging academic environment (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

c During adolescence, an important benchmark is to achieve a sense of identity and peer acceptance. Peer pressure is a common occurrence during adolescence. Social isolation can be self-imposed or can occur as the result of the inability to express feelings to peers or family members. A challenging academic environment, financial responsibilities, or the end of a romantic relationship are not stressors commonly associated with an adolescent attempting suicide. Correct! LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS suicideadolescentisolation

The nurse in a long-term care facility is evaluating the plan of care for an older adult client with advanced dementia. The client has had several falls out of bed. Which initial intervention should the nurse implement? Have the client sleep in a recliner at the nurse's station with a tray table across their lap Position all side rails of the bed up and move the bed close to the door Put the bed in the lowest position with a thick pad or mat on the floor next to the bed Place the client in a bed with an enclosure mesh tent attached to the frame (1 attempt remaining)

c Falls out of bed are a common occurrence in the long-term care setting. Although it is nearly impossible to eliminate all falls, the nurse can implement interventions to reduce the risk for injury related to a fall. The goal is to start with the least invasive and restrictive intervention to preserve the client's rights, regardless of their level of cognitive function. 'Low' beds and 'landing' mats to soften the fall should the client roll out of bed are commonly used in long-term care settings and represent an appropriate, initial intervention to implement for this client. The other interventions are much more restrictive and should be used only after less restrictive interventions have been attempted. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review KEYWORDS fall preventiondementialong-term care

The nurse is caring for a 12-year-old client with thalassemia. What lab value is most important to monitor for this client? Serum creatinine level Prothrombin time Hemoglobin level Platelet count

c ;Thalassemia is a hereditary blood disorder in which the body makes an abnormal form or inadequate amount of hemoglobin. Hemoglobin is the protein in red blood cells that carries oxygen. The disorder results in large numbers of red blood cells being destroyed, which leads to anemia. Therefore, it is most important to monitor the hemoglobin level for this client. The other lab values do not pertain to thalassemia. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS thalassemiabloodtransfusionhemoglobin

The nurse is caring for a client that is taking prednisone and aspirin for rheumatoid arthritis. Which action by the nurse is appropriate for this client? Monitor the client's temperature every two hours Assess the client's pain level once a shift Test the client's stool for occult blood Apply a hot pack to a warm, acutely inflamed joint

c; Rheumatoid arthritis is a chronic, progressive immunologic disorder. This type of arthritis is associated with progressive inflammation of joints and pain. The client's pain level should be assessed more often than once a shift. However, the client's temperature does not need to be measured every two hours. The client is at risk for gastrointestinal bleeding with the use of these two medications. The nurse should anticipate checking the stool for occult blood and monitor the client for signs and symptoms of anemia. When joints are acutely inflamed and warm on palpitation, the nurse should apply an ice pack, not heat. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS prednisoneaspirinoccultstool

A nurse is caring for a client following a Computed Tomography (CT) scan of the kidneys with contrast. Which of these findings would require prompt intervention by the nurse? The client states they have felt mild nausea since the procedure The client states that the urethra feels irritated and sore from the catheter Elevated serum creatinine above baseline Soreness reported at the IV site

c; A CT scan provides three-dimensional information about structures within the body. Oral or injected dye (contrast) is generally used during this scan to provide detailed images. After the scan, the nurse should monitor for complications associated with the contrast including anaphylaxis or contrast-induced nephropathy. Contrast-induced nephropathy is defined as a 25% increase of the serum creatinine above baseline within 48 hours of the procedure. While mild nausea and soreness at the IV site are problems requiring intervention, they are not the immediate concern. A catheter is not required for this procedure. LESSON Physiological Adaptation Unexpected Response to Therapies COURSE RN Review BODY SYSTEM urinary KEYWORDS urogramanaphylaxisdyetestallergy

The nurse is performing a routine assessment on a six-month-old infant. The child's mother states that the child weighed 7 pounds 8 ounces at birth. Which would be an appropriate finding for the weight of the child at this visit? Gain six ounces each week Add two pounds each month Double the birth weight Triple the birth weight

c; Appropriate growth and development of a child is an indicator of adequate nutrition, good health and absence of chronic illness. Although growth rates vary, infants normally double their birth weight by six months. At 12 months, the weight should be triple the birth weight. Important anthropometric measurements for the pediatric population include: height or length, weight, body mass index (BMI) and head circumference. The head circumference will generally be measured at every routine health care provider visit until the child is 2-years-old. The measurements will be recorded on a graph and compared to previous measurements and to percentiles of their peers. Children falling between the 5th and 95th percentile are considered to have a normal growth range. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS infantgrowthnormalweight

The nurse is providing discharge education to a client who will be starting daily atenolol for the treatment of hypertension. The nurse should emphasize to notify the health care provider if which of the adverse effects occur? Decreased exercise tolerance Dizziness in the morning Slow, irregular heart rate Decreased libido (1 attempt remaining)

c; Atenolol is a Beta-1 selective adrenergic blocking agent or a "beta blocker." These medications are commonly used to treat hypertension or chronic angina. Due to their selectivity, they are the preferred medications for clients who have the comorbidities of Chronic Obstructive Pulmonary Disease (COPD). Common adverse effects often relate to the therapeutic action of the drug and include impotence, decreased libido, dizziness, decreased exercise tolerance, slowed heart rate, arrhythmias and heart failure. The client should be taught to assess their heart rate and to notify the health care provider of any changes to the heart rate or rhythm. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hypertensionatenololtenorminbradycardiahypotension

A new nurse is delegating tasks to the unlicensed assistive personnel (UAP). If delegated, which task would require intervention by the nurse manager? Empty the urethral collection bag and provide perineal care Feed a 2-year-old with a broken arm Bathe a woman receiving brachytherapy with an internal radon device Assist an elderly client to the restroom

c; Caring for a client receiving brachytherapy with a radon implant and the associated hardware is complex. Additionally, movement of this client and exposure of healthcare workers to the radiation should be limited. The other tasks are simple and within the expectations of a UAP's duties. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS managerinterventionUAPcharge nurse

The nurse is providing care for a client who is diagnosed with schizophrenia and treated with clozapine. The client reports that his leg has developed an involuntary movement and he can feel his heart beating. Which other assessment findings should the nurse gather before calling the health care provider (HCP)? Bowel sounds in all four abdominal quadrants Total urinary output for the last 24 hours Vital signs including oral temperature Glasgow Coma Scale (GCS) to measure level of consciousness

c; Clients taking clozapine and other medications that have a direct effect on the central nervous system (CNS) are at risk for developing Neuroleptic Malignant Syndrome (NMS). NMS is a generalized syndrome that includes hyperthermia, hypertension, tachycardia, slowed reflexes and involuntary movements. This is an emergency and the nurse should notify the health care provider. Bowel sounds, level of consciousness and urinary output are not warranted for this focused assessment. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS schizophreniaquetiapinestiffagitatedsweatingtemperature

The nurse is providing discharge education to a client diagnosed with coronary artery disease. The client is prescribed to use a nitroglycerin transdermal patch at home. Which statement by the client indicates a correct understanding of safe medication administration? "This drug can lead to hypertension. So, I will monitor my blood pressure at home." "I can place this patch on broken skin. It will absorb better." "I will remove the old patch and cleanse the area before applying a new patch." "I will keep a record of chest pain occurrences now that I have this patch." (1 attempt remaining)

c; Numerous administration errors have been reported with nitroglycerin paste and patches. The errors include improper storage and basic administration. The client should be taught to remove the previous patch before applying the new patch and to properly label the tube of nitroglycerin paste and keep it out of the reach of children. When selecting an area to place the patch, the skin should be intact and show no signs of irritation. Nitroglycerin paste has been used erroneously as lotion and caused toxic effects. Nitroglycerin causes vasodilation, which increases the blood supply through the coronary arteries. This may cause hypotension in clients. Some other common side effects include lightheadedness, nausea, dizziness, headache and redness or irritation of the skin covered by the patch. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN & PN Review BODY SYSTEM cardiovascular KEYWORDS anginanitroglycerin

The interdisciplinary team is meeting to discuss the discharge plan for a client following total hip replacement surgery. Which assessment finding is most important for the team to address? The adult daughter will be responsible for shopping and driving the client after discharge The partner expresses some discomfort with the dressing change. The home is a two-story and all bedrooms and bathrooms are located upstairs. The client does not like the taste of the oral potassium supplement medication.

c; Nurses are charged with the responsibility to advocate for clients. Because of the intimate work with clients, nurses often discover critical information that will impact discharge planning. It is important to share these insights with the health care team to ensure the client's needs are met after discharge. A client who has undergone major orthopedic surgery can expect some mobility impairment after discharge. The nurse should ask questions regarding the physical characteristics of the home including stairs, location of essential rooms, bathroom set up, pets and carpeting. Therefore, it is most important to identify and address any potential safety issues in the client's home. Correct! LESSON Management of Care or Coordinated Care Collaboration with Interdisciplinary Team COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS dischargeplanassessmentsafety

The nurse is caring for a client who is scheduled for a right orchiectomy due to testicular cancer. The client asks what will be removed during this surgery. Which response is the best by the nurse? A dissection of related lymph nodes by the testes A surgical removal of the entire scrotum A surgical removal of one testicle A partial surgical removal of the perineal area

c; The affected testicle is surgically removed along with its tunica and spermatic cord. The other genitals and the perineal area are not involved. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS orchiectomycancertesticularsurgery

the nurse is reviewing the written orders for a newly admitted client. The nurse has difficulty reading the health care provider's handwriting. Which action should the nurse take first? Ask the pharmacy for assistance in the interpretation Leave the order for the oncoming staff to follow up on Call the provider for clarification of the order Contact the charge nurse for an interpretation

c; The nurse should call the health care provider to clarify this order. Relying on another person's interpretation of the order is risky. It is not appropriate to leave the order for the oncoming shift to follow up. Order entry systems are minimizing these types of problems. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review KEYWORDS readshiftorder

The home health nurse is educating the parent of a child who has a chronic condition that limits mobility. Which statement best describes the effects of immobility in children? Immobility promotes independence and self-reliance in children Immobilized children quickly develop confusion and mental status changes The physical effects of immobility are similar in both children and adults Children are more susceptible than adults to the multisystem effects of immobility

c; The physical effects of immobility are similar for clients of almost any age. Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, constipation, bone demineralization and cardiopulmonary complications. Immobility can negatively impact self-image and having to rely on others to meet their basic needs, especially in adolescents. Planning and providing nursing care in creative ways, and involving children in their care and providing age-appropriate diversion can help reduce the effects of immobility. Older adults with chronic conditions are at greatest risk for developing confusion. Incorrect LESSON Basic Care and Comfort Mobility, Immobility COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS childmobilityimmobility

The client tells the nurse that they are fearful of the planned surgery because of evil thoughts from a close family member. What is the best response by the nurse? Request a language translator Ignore the superstitious feelings Explore the client's feelings Notify the health care provider (1 attempt remaining)

c; Therapeutic communications are based on attentive listening to expressed feelings. If the nurse is not familiar with the cultural beliefs of a client, the nurse's acceptance of feelings should be followed by further questions about the client's feelings to gain insight into the client's culturally-determined belief system. The other responses are not therapeutic or appropriate in this situation. Correct! LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS fearsurgeryevil

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). What is the priority goal for the client during the procedure? Prevent memory loss and confusion Eliminate suicide ideations Maintain an open airway Reduce the client's depressive symptoms

c; With ECT, a seizure is induced by administering a dose of electrical current through electrodes placed either bilaterally or unilaterally on the right side of the frontotemporal area of the client's head. The procedure is typically performed in a special setting with an anesthesiologist and critical care nurses present. Due to the anesthetic agents administered for the procedure, maintaining an open/patent airway is the priority goal during the ECT procedure. The most common side effects of ECT are temporary memory loss and confusion. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM nervous KEYWORDS depressionECTelectroconvulsivesuccinylcholine

The nurse is caring for a client who is frequently admitted for acute exacerbations of asthma. The client admits that she does not use her medications as prescribed because she often does not feel short of breath. Which explanation by the nurse best describes the long-term consequences of uncontrolled airway inflammation? Chronic bronchoconstriction of the large airways will occur The client will experience frequent bouts of pneumonia Lung remodeling and permanent changes in lung function will result The alveoli will degenerate and balloon out

c; Asthma is categorized as a chronic, hyper-responsive disorder affecting the terminal bronchioles. Exacerbation of asthma or an "asthma attack" is an acute event. However, the effects of increased number of exacerbations and not using the medication is lung remodeling. This lung remodeling results in more narrow airways and increased mucous. By explaining the consequences of not using the medication, the nurse is reinforcing the need for daily management. Degeneration of alveoli causing increased expansion is a result of emphysema. Asthma does increase the risk of pneumonia, but this option does not address the permanent long-term issues associated with not taking the medication as prescribed. Chronic bronchoconstriction of the large airways is not associated with asthma. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmaconsequencelung

A 14-month infant is brought to the emergency department with irritability, lethargy for two days, dry skin and increased pulse rate. What additional questions should the nurse ask to assist the health care provider with determining the proper diagnosis? Reverse of sleep-wake cycles Change in eating habits The number of wet diapers in the past two days Use of daycare

c; Based on these clinical findings, the nurse might suspect that the infant is dehydrated. Asking about the number of wet diapers would assess for decreased urine output, a key finding in dehydration. Asking about increased concentration of the urine would also be appropriate. The other questions, while appropriate, would not provide the most helpful diagnostic information. Correct! LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS infantdehydrationassessment

The nurse is assessing a client who takes a prescribed antipsychotic medication. Which findings require immediate discontinuation of this medication? Agitation and constant state of motion Involuntary rhythmic stereotypic movements and tongue protrusion Hyperthermia and severe muscle rigidity Cheek puffing and involuntary movements of extremities and trunk

c; Hyperthermia, severe muscle rigidity and malignant hypertension are findings associated with neuroleptic malignant syndrome (NMS). NMS is a serious complication associated with the use of antipsychotic drugs. Repetitive, involuntary movements of the face or body may be a sign of tardive dyskinesia related to antipsychotic use. This is a serious concern, but not an emergency. Tardive dyskinesia may be irreversible, even after the medication has been discontinued. Agitation and being in a constant state of motion are most likely related to the illness being treated, such as bipolar disorder or schizophrenia. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS discontinueantipsychoticNMShyperthermiarigidity

During the 1-month well-baby checkup, the parents respond to questions about their newborn. Which of the parents' comments is of greatest concern to the nurse? "We notice the baby is fussy and cries a lot." "The baby seems to want to eat every couple of hours." "When the baby spits up, it shoots across the room." "The baby does not sleep for longer than two hours at a time."

c; Spit up that shoots across the room is indicative of projectile vomiting. Projectile vomiting, chronic hunger, poor weight gain, distended upper abdomen are clinical manifestation of pyloric stenosis. Hypertrophic pyloric stenosis (HPS) occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric canal. This produces an outlet obstruction and compensatory dilation, hypertrophy and hyperperistalsis of the stomach.This condition usually develops in the first few weeks of life, causing nonbilious vomiting, which occurs after a feeding. Projectile vomiting may develop and the infant is fussy and hungry after vomiting. Infants with HPS have nonbilious vomiting in the early stages. Vomiting usually begins at 3 weeks of age but can start as early as 1 week and as late as 5 months. Vomiting usually occurs 30-60 minutes after feeding and becomes projectile as the obstruction progresses. Initially the infant is hungry and irritable, but prolonged vomiting may lead to dehydration, weight loss and failure to thrive.The other comments indicate normal behavior for a 1-month-old infant. Incorrect LESSON Reduction of Risk Potential Potential for Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS pyloric stenosisassessmentprojectilevomitnewborn

The nurse is teaching a 10-year-old child prior to heart surgery. Which form of explanation is best for this client? Introduce the child to another child who had heart surgery three days ago Provide a verbal explanation just prior to the surgery Explain the surgery using a model of the heart Provide the child with a booklet to read about the surgery

c;According to Piaget, the school-age child is in the concrete operations stage of cognitive development. The use of something concrete, such as a model, will help the child understand the explanation of the heart surgery. The other options are not appropriate for the developmental age or they are not therapeutic methods of teaching children. Correct! LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS childheartsurgerydevelopmentalneedPiaget

The nurse is obtaining a health history from a 14-year-old client. Which method is appropriate for this client? Have the mother present to verify the information Use the same type of language as with adult clients Allow the client the opportunity to express feelings Focus the discussion on behaviors of the peer group

c;Adolescents need to express their feelings during the health history. This should be encouraged by the nurse. Generally, adolescents will talk freely when provided with privacy and a nonthreatening environment. Discussing the peer group is important, but not the priority. If the nurse uses the same language as with adult clients the adolescent may not understand the questions. Correct! LESSON Health Promotion and Maintenance Techniques of Physical Assessment or Data Collection COURSE RN Review KEYWORDS healthhistoryfeelingadolescent

The nurse is caring for a 14-month-old client who had a surgical repair of a cleft palate several days ago. The parents ask the nurse about meals after discharge. Which lunch is the best example of an appropriate meal for this client? Baked chicken, apple sauce, cookie and juice Hot dog, carrot sticks and juice Soup, ice cream and milk Peanut butter and jelly sandwich, chips and milk

c;After cleft palate surgery, the parents should prepare soft foods. Any foods with sharp edges or particles may traumatize the surgical site. The other options include foods with rough edges such as carrots, chips and cookies. Correct! LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS cleft palatesurgery

The nurse is preparing to administer digoxin to a client admitted for acute decompensated heart failure. Which action is the priority before giving this drug?? Auscultate the lungs for crackles in the bases Monitor oxygen saturation on room air Assess the apical pulse for a full minute Assess the client's weight and compare to the baseline

c;Digoxin, a cardiac glycoside, is used to slow the heart rate and increase the force of contraction. The priority for the nurse is to count the client's apical pulse for one full minute, even if the heart rhythm is regular. Typically, when the pulse is less than 60, digoxin should not be given. The other actions are also appropriate assessments for a client with heart failure. However, they are not the priority when administering digoxin. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS digoxinheart failureatrial fibrillationafibapical pulse

The nurse is caring for clients in an assisted living facility. A client enters the day room wearing a sheer night gown. Which nursing action is the most therapeutic in response to the client's attire? Tactfully explain appropriate clothing for the unit Ask the client's daughter to address the client's attire on her next visit Assist the client to her room and help her select appropriate attire Quietly point out how the other clients are dressed on the unit

c;This action assists the client to maintain self-esteem while modifying her behavior. By pointing out the other clients' attire, the client could feel ashamed and self-conscious. Explaining appropriate attire does not directly address the situation as effectively as assisting the client. The action needed should be direct and timely, but avoid embarrassment for the client. Correct! LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS therapeuticbehaviorself-esteem

The nurse is taking a health history from the parents of a child who is admitted for Reye's syndrome. Which recent illness would the nurse identify as a significant risk of developing Reye's syndrome? Hepatitis Rubeola Influenza Meningitis

c;Varicella (chickenpox) and influenza are viral illnesses that have been identified as risks for the development of Reye's syndrome. It is important for nurses to educate parents to not use aspirin in children (birth to 19 years of age). The use of aspirin in the presence of viral infections can increase the risk of Reye's syndrome for children. Correct! LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM lymphatic KEYWORDS Reye'schildinfluenzaaspirin

The nurse is caring for a client with Type I diabetes. Which finding requires immediate intervention by the nurse? Intense thirst and increased urination Mild discomfort at the injection site Diaphoresis and shakiness Reduced sensation in the periphery

c;When caring for a client with diabetes mellitus, the nurse must be knowledgeable about the clinical manifestations of hyperglycemia and hypoglycemia. Hyperglycemia is characterized by polyphagia, polydipsia and polyuria (the 3 Ps). The client will also experience weight loss as the cells are not receiving adequate amounts of glucose for energy. Signs of hypoglycemia include diaphoresis (sweating) with cool skin. The client may shake and become confused. It is critical that the nurse recognize these signs and assess the client's blood sugar. Hypoglycemia will require immediate attempts to raise blood sugar and prevent diabetic coma. Hyperglycemia, while concerning, is not as critical as hypoglycemia. Decreased sensation in the periphery is a finding consistent with diabetic neuropathy, which develops over time. The client may describe sensations of tingling, pain, or numbness. The client may feel a mild discomfort at the site of insulin injections, this should be monitored. Incorrect LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM endocrine KEYWORDS assessphysicaldiabeteshypoglycemia

The client is diagnosed with depression. Which therapeutic communication skill is most likely to encourage the client to express feelings? Direct confrontation Projective identification Reality orientation Active listening (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

d Use of therapeutic communication skills such as silence and active listening encourages verbalization of feelings. Reality orientation is used with clients who may have cognitive impairment. Direct confrontation is usually not used except in cases where a risk of physical harm to the client or others is anticipated. Projective identification is used to project the bad object into (not onto) another person so it becomes a part of that person. The person then identifies with that other person, and hence has means for control. Correct! LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS depressionlistentherapeuticcommunication

The recovery room nurse is caring for an infant following the surgical correction of a ventricular septal defect. Which nursing assessment is the priority? Blanch nail beds for color and refill Monitor for the equality of peripheral pulses Auscultate for pulmonary congestion Observe for postoperative dysrhythmias (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

d A ventricular septal defect (VSD) is an abnormal opening between the right and left ventricles of the heart. Surgical repair of this defect focuses on closing the abnormal opening between the ventricles. Because this area is shared by the atrioventricular bundle (bundle of His), which is part of the cardiac electrical conduction system, the priority is to monitor for postoperative dysrhythmias. The other assessment are also important, but do not take priority over monitoring for dysrhythmias. Correct! LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS assesschilddefectventricular septal defect

A client is being discharged with a prescription for warfarin. The client asks "May I take aspirin with this medication? It helps my arthritis." Which response by the nurse is appropriate to address the client's concern? "When you take the aspirin, do not take the warfarin that day." "Use about half the recommended dose of aspirin." "Take the warfarin in the morning and the aspirin at night." "Avoid aspirin because it can increase the bleeding effects of warfarin."

d Aspirin is a salicylate, which inhibits platelet aggregation. When used in conjunction with warfarin, the risk of bleeding increases. Therefore, aspirin and warfarin should not be taken together. It is inappropriate to tell the client to not take the prescribed medication, warfarin. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS warfarincoumadinstentaspirinAlka-Seltzer

The nurse is caring for a client who is prescribed erythromycin 500 mg orally every six hours for the treatment of pneumonia. The nurse should monitor the client for which common side effect? Tendon rupture Orange-red discoloration of urine Esophagitis Nausea and vomiting

d Erythromycin is a macrolide anti-infective medication used that interferes with protein synthesis in susceptible bacteria. Nausea, vomiting and gastrointestinal (GI) upset are common with erythromycin. The other side effects are not commonly seen with this drug. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review KEYWORDS erythromycinIVpneumonia

A nurse is teaching a client with asthma about the correct use of the fluticasone inhaler. Which statement, if made by the client, would indicate that the teaching was effective? "The inhaler can be used when I feel short of breath." "I should not use a spacer with my inhaler." "If I forget a dose, I will double the next dose." "I should rinse my mouth after using the inhaler." (1 attempt remaining)

d Fluticasone is an inhaled corticosteroid used to prevent asthma attacks. After using the inhaler, the client should rinse away any residue in the mouth to reduce the risk of an oral fungal infection. Fluticasone is not a bronchodilator and should not be used as needed for shortness of breath. The client should not double the dose of this medication and should use a spacer with this inhaler. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmaAzmacorttriamcinoloneinhalersteroid CONFIDENCE Need Help

A nurse is caring for a child who underwent a tonsillectomy an hour ago. The child's parents report to the nurse that the child feels very warm. Which intervention should the nurse do first? Reassure the parent that this is normal after surgery. Offer the child cold oral fluids. Administer the prescribed acetaminophen. Measure the child's temperature.

d While a low-grade fever (>101°F or 38.3°C) is common after surgery, the nurse should assess the child's temperature prior to any action. The health care provider (HCP) should be contacted if the temperature is higher than 101.5° (38.6°C). After evaluating the child's temperature, the other options may be implemented. However, the child should not drink fluids until they are alert and should not be given straws, acidic juices, or red/brown fluids. Straws and acidic juices may cause surgical site damage and red/brown fluids may be confused with blood in emesis. Correct! LESSON Reduction of Risk Potential Changes, Abnormalities in Vital Signs COURSE RN & PN Review BODY SYSTEM lymphatic KEYWORDS postoperative carefever

The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-to-thrive (NOFTT). What findings would the nurse expect to observe during the initial assessment? Alert, laughing, playing with a rattle and sitting with support Dusky in color with poor skin turgor over abdomen Irritable and "colicky," making no attempts to turn or sit up Pale skin, thin arms and legs and uninterested in surroundings

d Diagnosis of NOFTT is weight consistently below the 3rd to 5th percentile for age and gender, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in the percentile rank of two major growth parameters in a short period of time. The nurse would expect to see a child who avoids eye contact, has pale skin, thin arms and legs, and is easily fatigued. NOFTT is due to psychosocial problems such as neglect, lack of knowledge about proper feeding or of the infant's needs. Many times the child engages in self-stimulatory behaviors (head banging or rocking) and is wary of close contact with people. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review KEYWORDS infantfailure to thriveNOFTT

The nurse is caring for a client diagnosed with heart failure who will begin treatment with digoxin. Which therapeutic effect would the nurse expect to find after administering this medication? Decreased chest pain with decreased blood pressure Diaphoresis with decreased urinary output Increased heart rate with increased respirations Improved respiratory status with increased urinary output

d Digoxin (Lanoxin), a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia or tachycardias above 120, arrhythmia, visual or gastrointestinal disturbances. Clients being treated with digoxin should have the apical pulse evaluated for one full minute prior to the administration of the drug. Correct! LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS digoxinlanoxinurineoutput

The nurse is caring for a nullipara client who, at 12-weeks gestation is beginning prenatal care. The client has just learned she is positive for human immunodeficiency virus (HIV). Which of the following statements by the nurse is important for the client to understand regarding infection prevention for her baby? "Breastfeeding is recommended because the health benefits outweigh the risks of HIV transmission" "Medication for HIV will be started immediately after birth for both you and your baby." "Pregnancy is known to accelerate the course of your illness." "A cesarean section will be scheduled before your membranes rupture."

d ; According to research, administration of antiviral medications during pregnancy, a cesarean birth before membranes rupture and exclusive formula feeding have significantly reduced the incidence of perinatal transmission of HIV from mother to child. The nurse should work to encourage the mother to engage with her prenatal care and educate her about the benefits of medication for HIV during pregnancy and cesarean delivery. Pregnancy is not known to accelerate HIV. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS HIVpregnancybreast-feeding

The nurse is caring for a child diagnosed with seizures. While teaching the family and the child about the medication phenytoin, which concept should the nurse emphasize? Omit the medication if the child is seizure-free A rash is normal with this medication Serve a diet that is high in iron Maintain good oral hygiene and dental care

d; Gingival hyperplasia may occur with this medication. It is important that good oral hygiene is maintained. The medication should never be stopped, even if the child is seizure-free. A sudden discontinuation could result in status epilepticus. A diet high in iron interferes with phenytoin absorption and will reduce the effectiveness. A blister-like rash is not normal with this medication and could indicate medication-related Stevens-Johnson syndrome, which is a serious disorder of the skin and mucous membranes. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS phenytoinDilantingumsseizurechildteach

The nurse is caring for a client who has suffered third-degree burns in a motor vehicle accident. The spouse of the client asks the nurse to clarify what is meant by third-degree burn. Which is the best response by the nurse? "The top layer of the skin is destroyed, exposing the dermis." "The skin layers are inflamed. Blisters will appear and may weep." "Muscle, tissue, and bone have been injured." "All layers of the skin were destroyed in the burn."

d; Burns are categorized based on the level of tissue damage. A first-degree burn is a superficial burn that may be pink or red, warm to the touch and painful. An example of a first-degree burn is a sunburn. A second-degree or partial thickness burn is characterized by a blistered appearance, red or pink and painful. An example of a second-degree burn could be a severe sunburn that has blisters. A third-degree burn or full thickness burn includes damage to all layers of the skin and underlying tissues. The area will appear leathery and the color could range from red to black. The area may lack sensation. A fourth-degree burn is also termed a full-thickness burn, but involves muscle, tissue and bone. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM integumentary KEYWORDS burnpediatricfull thickness

The nurse notes that a client's prescription was changed from captopril to losartan, even though the captopril provided effective blood pressure control. Which is the most likely reason for discontinuing the captopril? Sexual dysfunction Rash and itching Blurred vision Dry cough (1 attempt remaining)

d; Captopril is an ACE inhibitor that converts angiotensin I to the powerful vasoconstrictor angiotensin II in the renin-angiotensin-aldosterone system (RAAS). It is used in the management of hypertension and other cardiovascular diseases. A side effect of this medication is a dry cough, which many clients find intolerable. This is a common reason for a client's prescription to change from an ACEI to a similar medication such as an ARB (losartan). The other side effects are not typically seen with an ACEI drug. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hypertensioncaptoprilcapotencough

The nurse is providing prenatal education to a client who has just found out she is 8 weeks pregnant. The woman asks how the health care provider (HCP) knew that she was pregnant by just looking inside her vagina. Which response is the best explanation for this? Slight rotation of the uterus to the right Plug of very thick mucus Pronounced softening of the cervix Bluish coloration of the cervix and vaginal walls

d; Chadwick's signs is a bluish-purple coloration of the cervix and vaginal walls. It develops at 6 to 8 weeks of gestation and is caused by an increased blood supply to the area. Other early signs of pregnancy include Hegar's signs (a softening of the cervical isthmus) and Goodwell's sign (a softening of the cervix). While these are early signs of pregnancy, the HCP would need to compress and palpate the tissue to assess these findings. The HCP would not see the mucus plug. The mucus plug dislodges and passes out of the body just prior to labor. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN & PN Review BODY SYSTEM reproductive KEYWORDS pregnantChadwickbluish

At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. The client asks about preconception diet changes. Which nutritional recommendation is the priority for this client? "Eat at least one serving of fish weekly." "Drink a glass of milk with each meal." "Include fiber in your daily diet." "Increase your intake of green leafy vegetables."

d; Folic acid sources should be included in the diet daily for 3 months before and 3 months after conception. Folic acid is critical in the preconceptual and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida. The recommended amount of folic acid is 0.4 mg daily. The increased levels could be provided by natural sources of food high in folate, fortified foods, or supplements. Folate is widely available in foods, particularly in leafy green vegetables, legumes, ready-to-eat cereals, and some fruits and juices; thus, recommending to increase intake of green leafy vegetables is the priority for this client. While the other recommendations are also appropriate, they are not a priority for the preconceptual and early gestational periods. Correct! LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS assesshealthpregnancydiet

The nurse is speaking with the parents of a 5-year-old boy who is diagnosed with hemophilia A. The parents recently underwent genetic counseling that showed that the mother is a carrier and the father is unaffected. The parents are asking the nurse what the chances are of having another child with this genetic disorder. How should the nurse respond? "All daughters will be carriers of this disease." "There is a 50% probability that another male child would have this disease." "All of your male children will have this disease." "There is a 25% probability that daughters will be a carrier of this disease."

d; Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. When the carrier mother and the unaffected father are pregnant, there are four possible outcomes: a 25% (one in four) chance of having a son without hemophilia a 25% (one in four) chance of having a son with hemophilia a 25% (one in four) chance of having a daughter who is a carrier a 25% (one in four) chance of having a daughter who is not a carrier Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN & PN Review BODY SYSTEM cardiovascular KEYWORDS hemophiliaprobabilitycarrier

The nurse receives a client who was transported to the emergency department for severe hypertension. Which finding requires immediate action by the nurse? Cough with frothy, pink sputum Crackles in the lung bases Jugular vein distension Weakness in the left arm

d; In a client who has uncontrolled hypertension, weakness in the extremities is a sign of cerebral involvement. Cerebral infarctions account for approximately 80% of the strokes in clients with hypertension. The remaining choices indicate fluid overload, which may be associated with heart failure related to the uncontrolled hypertension. While concerning, these are not medical emergencies. Jugular vein distension (JVD) is due to the elevated central venous pressure (CVP). Crackles in the bases of the lungs and a cough with frothy, pink sputum indicate pulmonary congestion. Crackles in all lung fields accompanied by dyspnea and orthopnea would indicate acute pulmonary edema, which would also be considered a medical emergency. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hypertensionweaknessstrokeCVA

The nurse is caring for a client who is receiving isoniazid for tuberculosis (TB). Which assessment finding would indicate the client is having a possible adverse response to this medication? Tingling in extremities Headache and nausea Tinnitus and decreased hearing Yellowing of the sclera

d; Isoniazid is a first-line anti-tuberculosis drug that is used as part of the combination therapy for treatment of tuberculosis. These first-line medications may be used up to 2 years in clients who are being treated for tuberculosis. The use of long-term combination treatment increases the effectiveness and decreases the occurrence of resistant strands. Clients receiving this medication are at risk for drug-induced hepatitis. The appearance of jaundice may indicate an elevation of the client's serum bilirubin levels and liver enzymes (AST and ALT). A small number of clients taking isoniazid develop severe hepatitis that may progress to liver failure and death unless the medication is stopped immediately. Other common side effects include nausea and tingling in extremities. This medication is not ototoxic and does not affect hearing. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM respiratory KEYWORDS tuberculosisTBisoniazidINHadverse

The nurse is caring for a client in their home. Which approach is the most effective method to prevent infections when providing care to clients in the home? Wearing non-powdered latex-free gloves to examine the client Using a barrier between the client's furniture and the nurse's bag Wearing a mask with a shield during any eye/mouth/nose examination Handwashing before and after examination of clients

d; Regardless of location, proper hand hygiene remains the most effective method for preventing infection. Nurses should practice these techniques and teach proper hand hygiene to the client and family. The nurse should wash hands before and after examining the client and before taking equipment out of the nurse's bag. The nurse's bag should be a nonabsorbent material and a barrier should be placed between the bag and the client's furniture. Personal protective equipment (PPE) should be donned in the same manner used in inpatient facilities when a client has an infectious disease or when the nurse is expecting to be in contact with body fluids. However, wearing gloves during a routine assessment of all clients will inhibit the assessment abilities of the nurse. Correct! LESSON Safety and Infection Control Standard Precautions, Transmission-Based Precautions, Surgical Asepsis COURSE RN Review BODY SYSTEM immune KEYWORDS infectionpreventwashing

The nurse is caring for a client who is the victim of domestic violence. The client states, "If I just could follow directions, this would not have happened." This statement indicates the client is experiencing which feeling? Fear Helplessness Rejection Self-blame

d; Self-blame Correct! Intimate partner violence is defined as physical, sexual, stalking and psychological aggression by a current or former partner. The nurse is often the first health care worker in contact with these victims. Victims of domestic violence may be immobilized by a variety of affective responses with one being self-blame. The nurse's responsibility is to make a safety plan with the victim and follow any facility policies or procedures concerning victims. However, the victim has a right to self-determination without judgement. Correct! LESSON Psychosocial Integrity Abuse, Neglect COURSE RN Review KEYWORDS domesticviolencevictim

The nurse is preparing to assess a 3-year-old using the Denver II Developmental Test. The child's mother asks the nurse to explain the purpose of the test. Which statement by the nurse is correct? "It helps to determine the development of motor function." "It measures a child's intelligence level and compares it to a standard." "It evaluates psychological responses to certain stimuli." "It assesses a child's development in several categories."

d; The Denver II Developmental Test is a screening test to assess children from birth through six years of age in personal/social, fine motor adaptive, language and gross motor development. This screening test determines the highest level of functioning in these areas at the time of the examination. The screening is quick and inexpensive, but any low scores will need to be evaluated by more precise exams. The screening does not include psychological responses to stimuli or intelligence levels. It does not solely test for the development of motor function. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS Denver II Testdevelopmental screeningchild

The nurse is caring for a client who was diagnosed with a deep vein thrombosis (DVT). The client reports sudden shortness of breath and the oxygen saturation decreases to 87% on room air. Which intervention is a priority action by the nurse? Begin continuous cardiac monitoring Call the health care provider (HCP) Administer the PRN albuterol nebulizer Administer oxygen to maintain a saturation of 92%

d; An acute onset of dyspnea and hypoxia is a classic finding of pulmonary embolism (PE). A client with a DVT has a risk for part of the clot breaking off and traveling to the lungs. The administration of oxygen to correct hypoxia is the highest priority. After administering oxygen, the HCP would need to be notified and the nurse should anticipate orders for diagnostic tests (Pulmonary Angiogram, d-dimer, CT scan). Albuterol nebulization is a standard treatment for respiratory distress related to asthma, COPD and anaphylaxis. However, it is not used for dyspnea due to a PE. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS DVTshortness of breathoxygen

While assessing a client's blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. However, the nurse is able to palpate the systolic pressure reading. Which action should the nurse take first? Use an electronic BP cuff in another location to verify the systolic pressure Take the BP in the same location after waiting two minutes Review the medical record to find the client's baseline BP Check to ensure the diaphragm of the stethoscope is being used

d; If a BP can be palpated for the systolic reading but nothing is heard on auscultation, the first action is to check to see if the stethoscope is turned to the bell side (a peripheral BP is taken using the diaphragm side of the stethoscope.) Then the nurse would wait two minutes between readings of a BP in the same arm to allow the vessels to recover from being squeezed. The electronic cuff would also require a two minute wait. The nurse should also be aware that the electronic cuff may not read pressures below 80 mm Hg. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS BPblood pressurestethoscopesystolic

The charge nurse is informed about a conflict between two unlicensed assistive personnel (UAP) on the unit. Which approach is most appropriate to achieve effective conflict resolution? Explain the consequences of not resolving their differences. Encourage the UAPs to '"vent" their anger. Require the UAPs to meet 1-on-1 until they reach a compromise. Deal directly with the conflict affecting the workplace.

d; When managing conflict in the workplace, it is most important to deal with the issue directly. The conflict occurs, it should not be minimized or ignored. When there is a conflict, people tend to feel angry and although "venting" may feel good, is is usually counterproductive. Forcing the UAPs to reach a compromise is not appropriate. If necessary, potential consequences of not resolving the conflict between the UAPs should be discussed. Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS UAPconflictresolveissue

The nurse is caring for a client who was admitted two days ago to the psychiatric unit for major depression. The client continues to be withdrawn and not interact with staff or other clients. Which action by the nurse would be most appropriate to encourage the client to increase interactions with others? "Our team here thinks it's good for you to spend time with others." "It is important for you to participate in group activities." "Come with me so you can paint a picture to help you feel better." "Come play a board game with me and another staff member."

d;By inviting the client directly to participate in a game with just a couple of other people provides clear, direct and positive behavioral expectations of the client that can gradually engage the client in small group interactions. By focusing on one activity, the client may have lessened anxiety when compared to an unstructured discussion. By stating what the "team thinks," the client may feel embarrassed or targeted. While it is important for the client to interact more with others, group activities may be too stressful at this time. Painting, while it may be therapeutic to lessen anxiety, does not promote interaction. Incorrect LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS depressionwithdraw

The nurse is obtaining the health history for a 71-year-old client who is being admitted for mitral valve replacement surgery related to mitral valve stenosis. During the health history, the nurse should ask if the client experienced which health issue as a child? Encephalitis Hay fever Measles Rheumatic fever

d;Clients that present with mitral valve stenosis often have a history of rheumatic fever or bacterial endocarditis as a child. These illnesses cause valvular damage due to the infection, which leads to thickening and calcification of the valve. These changes will affect the cardiac system by causing the left atrium to dilate, the left atrial pressure to increase, the pulmonary pressure to increase and the right ventricle will hypertrophy. The client will experience shortness of breath on exertion, paroxysmal nocturnal dyspnea, palpitations and dry cough. Eventually, the client will experience right sided heart failure. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS mitral valve replacementgeriatricsurgerystenosisrheumatic fever

The nurse is providing information about diet and nutrition for a client newly diagnosed with Meniere's disease. Which statement by the client demonstrates an understanding of the education? "I should restrict the amount of fluids I drink every day." "Eating a diet high in protein and iron will protect me from infection." "I will avoid spinach, broccoli and any other foods high in vitamin K." "I should eat more fresh fruits, fresh vegetables and unprocessed foods."

d;Meniere's disease is a disorder of the inner ear that causes severe dizziness. Clients with Meniere's disease should limit foods high in sodium. It is important to drink plenty of water to stay hydrated and protect against dizziness and headaches. Caffeine, chocolate and alcohol may make symptoms worse. Clients taking warfarin should avoid foods high in vitamin K and clients diagnosed with cystic fibrosis should eat a diet high in protein and iron. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM nervous KEYWORDS nutritionhydrationmeniere'seducation

The nurse is interviewing a young client who expresses hopelessness. Which of the following questions is a priority for the nurse to ask? "Have you spoken to anyone about this feeling?" "How long have you felt like this?" "Does anything help relieve these symptoms?" "Have you thought about suicide?"

d;One in ten young adults experiences a period of major depression and suicide is a leading cause of death in the United States. It is a priority for the nurse to assess if the client is planning to harm themselves. This should be done with a direct question that if positive ("yes"), should be followed with additional questions to determine if the client has a plan to carry out suicide. The other questions are also helpful, but are not the priority at this time. Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS nursing diagnosisdiagnoseshopelessnessviolence

The nurse is obtaining the health history for a client with the help of an interpreter. To promote clear communication with the client, which of these actions is appropriate for the nurse to use? Look at the interpreter when communicating the needed questions Provide the interpreter with a list of questions to address and stay with the client Ask the client to speak slowly and clearly with pauses after every statement Arrange the setting so the interpreter and client can be easily seen by the nurse

d;The nurse should look directly at the client when speaking to the client with an interpreter. The nurse should observe the client for nonverbal cues while the client answers the questions. This is best achieved by arranging the setting so the nurse, interpreter and client can easily see each other. It is important to note that the nurse is interviewing the client. It would be inappropriate for the nurse to write a list of questions for the interpreter. Additionally, the client should speak in their normal tone and speed for the interpreter. Incorrect LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS interpretercommunication

The nurse on the mental health unit is assigned to a client diagnosed with post-traumatic stress disorder (PTSD). What priority interventions shall the nurse include in the client's plan of care? Select all that apply. Medicate the client with a sedative while they experience flashbacks. Assign the same staff to the client as often as possible. Stay with the client during periods of flashbacks and nightmares. Discuss the coping strategies the client is using in response to the trauma. Place the client in a secluded area away from others. Encourage the client to talk about the trauma at their own pace.

Assign the same staff to the client as often as possible. Correct! Stay with the client during periods of flashbacks and nightmares. Correct Response Discuss the coping strategies the client is using in response to the trauma. Encourage the client to talk about the trauma at their own pace.; Trauma-related disorders such as PTSD can be described as the client's reaction to an extremely distressing experience, such as natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, or being the victim of torture, terrorism, rape or other crimes that cause severe emotional shock and have long-lasting psychological effects.Interventions that are considered trauma-informed highlight the importance of respect for the client, collaboration and connection, providing information about the connections between trauma and other health concerns, instilling hope and empowering the trauma survivor to guide and direct their recovery plan.A PTSD client may be suspicious of others in their environment. It is a priority to facilitate building a trusting relationship. The presence of a trusted individual may reassure the client and calm their fears for their personal safety. Debriefing or talking about the traumatic event is the first step in the client's progression toward resolution. The long-term resolution of the client's post-traumatic response is largely dependent on the effectiveness of the client's coping strategies.Interventions such as seclusion may be retraumatizing to a client with a history of trauma and are only indicated if the client exhibits behavior that presents imminent risk of harm to themselves or others.Administering a sedative without a clear, clinical indication is considered a chemical restraint. This should never be used for the convenience of the staff or as a punishment. The nurse should first try other measures to decrease agitation such as talking down (verbal intervention). Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN & PN Review KEYWORDS PTSDsedativetraumarestraint

The nurse and client discuss the progress that has been made toward the client's goal of quitting smoking. This is a typical step in which phase of the therapeutic relationship? Termination Working Pre-interaction Orientation (1 attempt remaining)

a; During the termination phase, the nurse and client will discuss progress towards the goal and feelings about the termination of the therapeutic relationship. In the orientation phase, the nurse and client will become acquainted and discuss roles and goals. In the working phase, the nurse and client strategically work towards the set goals and discuss any concerns that may arise. Incorrect LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS therapeuticrelationshipprogressstress

Which nursing practice best reduces the chance of communication errors that could lead to negative client outcomes? Use standardized forms for client handoffs Document nursing care at the end of the shift Speak using a professional tone on the telephone Maintain respectful working relationships with all staff

a;Nurses should use standardized forms to improve communication between caregivers. A standardized form will decrease the risk of omitting pertinent information concerning the client's care. The options of maintaining a respectful working relationship and using a professional tone while speaking on the telephone are good practice, but not as vital as standardized forms. Documenting nursing care at the end of the shift is incorrect. Documentation should be done immediately following the provision of care. This will decrease the likelihood of omitting important information. Incorrect LESSON Management of Care or Coordinated Care Performance Improvement (Quality Improvement) COURSE RN & PN Review KEYWORDS communicationhandoffstandardized

The nurse is caring for a client receiving mechanical ventilation when the device signals a high-pressure alarm. The nurse should include what assessments in addressing this alarm? Select all that apply. Assess for obstructing secretions Assess client for signs of bronchospasm Assess client for partial or total extubation Assess tubing to ensure it is not kinked Assess the client's behavior (coughing, biting, gagging, etc.)

abde High pressure alarms are usually caused by something preventing or blocking air from being delivered by the ventilator to the lungs. Common causes for this include kinked tubing, secretions and/or bronchospasms, or the client fighting the tube. Low pressure alarms are usually caused by air escaping the closed unit. A total or partial extubation would cause a low-pressure alarm. LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN & PN Review KEYWORDS mechanical ventilationhigh-pressure alarm

A nurse arrives at a child daycare center that was the site of an explosion. Which child should be tagged "green" or needing minimal treatment? A toddler with severe and deep abrasions over 98% of the body An infant with bulging of the anterior fontanel while crying A school-age child with singed eyebrows and hair A preschooler with a lower leg fracture on one side and an upper leg fracture on the other

b In a disaster or mass casualty situation, the color-coded triage system is used to identify victims based on severity of injuries. The "black" category is for victims who are already deceased or have such extensive injuries that they would not be expected to survive. The "red" category is for client needing immediate treatment for survival such as those with chest injuries or open fractures. The "yellow" category means the client does have a chance of survival with medical intervention. The "green" category means that the victim needs minimal treatment and will be expected to survive the injuries. A bulging fontanel with crying is to be expected in an infant; therefore, this client should receive a green tag. LESSON Safety and Infection Control Emergency Response Plan COURSE RN Review KEYWORDS disasterchildtreat

The nurse is providing discharge education to a client with moderate persistent asthma. The nurse should instruct the client to administer which medication first? Mast cell stabilizer Bronchodilator Glucocorticoid Anticholinergic

b;Bronchodilators, such as albuterol, are beta-agonist drugs that relieve bronchospasm by relaxing the smooth muscle of the airway. These medications should be inhaled first to open the airways, which will allow the other medications to move more deeply into the lungs and increase their effectiveness. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmaMDIinhaler

The nurse is caring for a client who was admitted to the psychiatric unit with a diagnosis of bipolar disorder. The client constantly tries to help the housekeeping staff and demands constant attention. Which activity is most appropriate for this client? Reading Table tennis Cards Checkers

b;The client is exhibiting the need for an outlet of physical energy. Table tennis allows for physical activity with limited attention requirements. The other options could over-tax the client's level of self-control because the client needs to be physically active. Incorrect LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS bipolaractivity

The nurse is teaching a parent about the prevention of diaper dermatitis. Which of the statements by the parent indicates understanding? "I will use rubber pants to assist with toilet training." "If a rash occurs, I will put oil on the skin before putting the diaper on." "I will change the diaper every 2-3 hours during the day." "Diaper dermatitis is associated with chronic itching." (1 attempt remaining)

c Diaper dermatitis is an inflammatory reaction of the skin that is covered by a diaper. This inflammatory response is related to exposure to urine and feces. Prevention is the best management of diaper dermatitis and includes frequent diaper changes and changing feces soiled diapers as soon as possible. Atopic dermatitis is associated with chronic itching. Rubber pants should not be used as they increase the risk of diaper dermatitis. If a rash does occur, the parents should be instructed to allow the child to go diaper-less for a period of time during the day. Creams are available but oils will increase the moisture on the skin. Correct! LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM integumentary KEYWORDS dermatitisinfantteachdiaperfood

The spouse of a client appears distressed about the client's impending death. Which intervention is a priority for the nurse? Explain the stages of death and dying to the family Recommend an easy-to-read book on grief Assess the family's patterns for dealing with death Leave the client and spouse alone for privacy

c; When a new problem is identified, it is important for the nurse to first collect accurate information. This is crucial to ensure that the client and the family's needs are adequately identified in order to plan and implement nursing care. Once the situation has been assessed and a plan has been established, the nurse can focus on teaching or referral to other resources. Incorrect LESSON Psychosocial Integrity Grief, Loss COURSE RN Review KEYWORDS heartfailuredeathassessgrief

The nurse is providing pre-operative care for a 2-month-old diagnosed with a congenital heart defect. Which intervention is best for meeting the child's nutrition and health needs? Supplement bottle feedings with water Mix medications with formula or breastmilk in a bottle Support the mother who breastfeeds Provide bottle feedings every 2 hours

c; Infants with congenital heart defects have increased nutrition needs and tend to tire quickly during feeding. Breastmilk offers the optimal nutrition and requires less effort from the infant when compared to bottle feeding. Infants with congenital heart disease usually do better when fed more often and on demand. This is usually 8 to 12 times a day. The nurse should support the mother's efforts to breastfeed. The infant should not be given water since there are no calories or vitamins in water. Medication should never be mixed with milk or formula. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS infantheartdefectcongenital

The nurse in a pediatrician's office is performing an assessment on an 8-month-old infant. Which finding should be reported to the health care provider? Toes fan out when the lateral sole of the foot is stroked Rolls from abdomen to back Falls forward when in a seated position Lifts head from the prone position

c;The infant should be able to sit unassisted after approximately 6-months-old. The infant falling forward indicates that this developmental milestone has not been met and should be reported to the health care provider. The infant rolling and lifting their head are expected findings. The Babinski reflex is elicited by stroking the lateral sole of the foot from heel to toe. From birth to approximately 12-months-old, the expected response is a fanning out of the toes. Correct! LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS assessinfantsitfall

The nurse is discussing health promotion activities with a group of new parents. One parent expresses concern about Reye's syndrome and asks about prevention methods. How should the nurse respond? "Seek medical attention for serious injuries." "Report exposure to this illness as soon as possible." "Avoid use of aspirin for viral infections in children." "Immunize your child against this disease."

"Avoid use of aspirin for viral infections in children." Correct! The nurse should educate the parents about reading drug labels for over-the-counter (OTC) medication and following the directions closely. To answer the parent's question, the nurse should explain that salicylates (such as aspirin) are contraindicated for children with viral infections such as chickenpox or influenza due to an increased risk of Reye's syndrome. Since viral infections can be common in children, salicylates should be generally avoided in children under the age of 19. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM nervous KEYWORDS clinicReye'sprevention

The nurse is caring for a 4-year-old child. The parents state they must leave the hospital, but will return at 6pm. After they leave, the child asks when he will be able to see his parents. Which option is the best response by the nurse? "They will be back right after you eat supper." "In about two hours, you will see them." "After you play awhile, they will be here." "When the clock hands are on the numbers 6 and 12."

"They will be back right after you eat supper." Time is not completely understood by preschoolers. Preschoolers interpret time with their own frame of reference of activities that they have experienced. Thus, it is best to explain time in relationship to a known and common event. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS childpreschooltime

The nurse is caring for a client who has end-stage renal disease and is scheduled for hemodialysis later today. The client has an arteriovenous fistula. Which interventions should the nurse implement to help prepare the client for dialysis? Select all that apply. Hold all oral medications Administer Vitamin D, as prescribed Ensure the client eats a high fiber, high protein breakfast Assess the patency of the fistula Weigh the client Administer the phosphate binder, as prescribed

Administer Vitamin D, as prescribed Assess the patency of the fistula Correct Response Weigh the client Correct Response Administer the phosphate binder, as prescribed The nurse should administer medications as prescribed, such as vitamin D and sevelamer (a phosphate binder). These medications may be prescribed to help control both serum calcium and phosphate levels. Some medications that are dialyzable or could lower blood pressure are held until after the procedure. The client should eat a meal that is easily digestible at least 2 hours before the procedure begins. A meal high in fiber and protein is not easily digested. The nurse should assess the client's weight as a baseline prior to the procedure and measure vital signs. The access site should be assessed including palpating a thrill, auscultating a bruit and palpating pulses and circulation distal to the site. Incorrect LESSON Physiological Adaptation Hemodynamics - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS kidney diseasehemodialysisphosphate bindervitamin

A client is transported to the emergency department following a boating accident and submersion in cold water. The client is conscious, shivering and confused. What interventions should the nurse implement? Select all that apply. Massage extremities Administer warmed IV fluids as ordered Monitor level of consciousness Remove wet clothing Provide warmed blankets Give the client warm tea Monitor vital signs

Administer warmed IV fluids as ordered Correct Response Monitor level of consciousness Correct Response Remove wet clothing Correct Response Provide warmed blankets Monitor vital signs The client is at risk for hypothermia. The nurse should remove wet clothing carefully. External rewarming, such as warmed blankets or heat packs, which are placed under the arms and on the neck, chest and groin. The client may also be ordered to receive warmed IV fluids and humidified oxygen to help stabilize the core temperature. Monitoring should include vital signs, level of consciousness, cardiac rhythm and core body temperature. The client should not receive any oral fluids until their condition is stabilized and extremities should not be massaged. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review KEYWORDS accidenthypothermia

The nurse is caring for an 81-year-old client with colorectal cancer. Previously, the client's pain was managed with acetaminophen with codeine. However, the client is now experiencing frequent, severe pain and intravenous morphine has been prescribed. What should the nurse recognize about this order? Appropriate despite the risk of diarrhea and abdominal upset Inappropriate due to the potential of respiratory depression Inappropriate and demonstrates lack of knowledge related to pain control Appropriate pain management and should be available around the clock

Appropriate pain management and should be available around the clock Older adults with cancer pain are frequently undermedicated. Pain management with IV morphine, while risky, is appropriate with proper assessment and monitoring of the client. The client should be started on the lowest, effective dose and the pain should be re-evaluated after administration. The nurse should assess the client for respiratory depression, constipation and altered mental status. Incorrect LESSON Pharmacological (and Parenteral Therapies) Pharmacological Pain Management COURSE RN Review BODY SYSTEM nervous KEYWORDS morphinecancerpainintravenous

During a routine clinic visit, the nurse is providing education to a client with a history of Type 1 diabetes mellitus. The client's glycosylated hemoglobin (HbA1C) was 11%. Based on this result, which teaching concept should the nurse emphasize? Continue with the current effective regimen Rotate injection sites with every injection Assess blood sugar and treat with insulin before meals and at bedtime Proper storage of oral medication used to decrease glucose level

Assess blood sugar and treat with insulin before meals and at bedtime ype 1 diabetes mellitus is caused by an autoimmune destruction of the beta cells within the pancreas. These cells are responsible for making insulin. Because of this the client will be dependent on insulin and no oral antihyperglycemic agents will be effective. A glycosylated hemoglobin of 11% is elevated and indicates inadequate glucose control over a period of 2 to 3 months. Rotation of sites should be done regularly to prevent skin breakdown and to ensure proper delivery of the drug, but it is not a priority at this time. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM endocrine KEYWORDS diabetesglycated hemoglobinteach

The nurse manager of an emergency department is planning for the arrival of a high number of clients due to a mass casualty event nearby. Which style of leadership would be most appropriate under these circumstances? Engage in collaborative practice Assume an autocratic, decision-making role Apply an integrative leadership approach Adopt a transformational, nondirective approach

Assume an autocratic, decision-making role A manager should change their leadership style to fit the circumstances. During an emergency or crisis situation, decisions will have to be made fast and the manager will not have time to solicit input from staff; therefore, an autocratic or authoritarian leadership style is most appropriate in this situation. The other leadership styles would be appropriate in different situations, but not an emergency or crisis situation. Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS charge nurseleadershipautocratic

The nurse is interviewing the mother of a 9-month-old infant. The mother states the infant is eating some table foods and she wishes to switch him to whole milk instead of the iron-fortified formula. Which information is the priority for the nurse to discuss with the mother? Continue introducing new food Offer fruit juice in a sippy cup occasionally Change the baby to whole milk Continue with the present infant formula

Continue with the present infant formula;It is recommended that infants continue drinking formula until the age of 12 months. Dairy milk has less iron and is harder for the infant's system to digest. The mother can continue to slowly introduce table foods, but should continue formula feedings. The mother can offer 2 to 4 ounces of fruit juice a day, but this may interfere with the infant drinking the more nutritious formula. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN & PN Review KEYWORDS infantmilk

The nurse is caring for a child who is receiving treatment for lead poisoning. The nurse understands that the most serious effect of lead exposure is related to which of the following? Lead colic and constipation Damage to the central nervous system Impaired kidney function Anemia and fatigue

Damage to the central nervous system Lead toxicity can affect every organ system but it is especially dangerous for the brain. Lead can even alter the structure of the blood vessels in the brain and can lead to bleeding and brain swelling. In children, lead exposure is associated with lower IQ scores, learning disabilities, hyperactive behavior and impaired hearing; higher levels of exposure can cause seizures and death. Neurological effects may persist into adulthood, despite treatment. Anemia (and fatigue), damage to the kidneys and abdominal pain (also called lead colic) are potentially reversible with treatment. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS childleadpoisoningbrain

The nurse is providing education to a client that will be discharged with a prescription for sublingual nitroglycerin as needed for acute angina. The nurse should include which of the following in the teaching? If pain is not relieved after the sixth dose, call 911 If acute angina occurs, stop activity and take the medication as directed Drink a glass of water immediately after placing the tablet under the tongue Keep the medications locked in a cabinet at their home

If acute angina occurs, stop activity and take the medication as directed The client should be taught the correct self-administration of nitroglycerin during acute angina. On the onset of angina, the client should stop activity and place the nitroglycerin under their tongue. Three sublingual nitroglycerin tablets should be taken in 5-minute increments. If the pain is not relieved the client may be experiencing a myocardial infarction and needs to call 911. Drinking a glass of water with the nitroglycerin could decrease sublingual absorption. The nitroglycerin should not be kept at home, but carried with the client. The client should be told to call 911 if the pain is not relieved after 3 doses, not 6. Incorrect LESSON Psychosocial Integrity Stress Management COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS anginapainanxiety

The nurse is caring for a client who is prescribed warfarin. Which lab test would the nurse monitor to determine a therapeutic response to the drug? D-dimer Bleeding time Partial thromboplastin time (PTT) International Normalized Ratio (INR)

International Normalized Ratio (INR) Correct! The warfarin dosage is based on the result of a client's daily INR (or prothrombin time [PT]). Warfarin affects the function of the coagulation cascade and inhibits the formation of blood clots. The goal of warfarin therapy is to maintain a balance between preventing clots and causing excessive bleeding, which is why careful monitoring is needed. A Partial thromboplastin time (PTT) is associated with monitoring heparin. A bleeding time test is performed to monitor basic platelet function. The d-dimer test is a test used to diagnose a blood clot. Correct! LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS warfarinCoumadinlabtherapeutic

Several hours after a total gastrectomy, the client's nasogastric tube (NGT) stops draining. After referring to the postoperative orders, which order will the nurse implement first? Reposition the tube until it begins to drain Notify the surgeon Irrigate the nasogastric tube Increase the amount of suction by 5 mmHg

Irrigate the nasogastric tube After surgery, the nurse should closely monitor the nasogastric tube (NGT) to ensure it is suctioning appropriately. Irrigating the NGT is appropriate because these tubes may become clogged. A clogged NGT could lead to acute gastric dilation after surgery. This intervention should be performed first. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS gastrectomynasogastricirrigate

A nurse is caring for a client diagnosed with an obstructing renal calculus. Which focus of the health care provider's orders would the nurse prioritize? Morphine sulfate for pain control Push oral fluids Apply warm compress over flank area Start intravenous antibiotics (1 attempt remaining)

Morphine sulfate for pain control The priority action for an obstructing renal calculus (kidney stone) is to provide prompt relief for the severe pain. Oral hydration or intravenous fluids will help move the stone though the urinary system, but would be prioritized after pain management. Applying a warm compress over the flank may help pain, but would be prioritized after narcotic analgesics for this diagnosis. A kidney stone is not an infection and does not indicate the need for intravenous antibiotics. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS renalcalculipainnarcotic

The nurse is performing a respiratory assessment on a newborn. Which assessment finding would require intervention by the nurse? Symmetric chest movement Nasal flaring Short periods of apnea (<10 seconds) Rapid, shallow respirations

Nasal flaring Newborn respirations are often rapid, shallow and irregular with short periods of apnea (<15 seconds). The respiratory rate of a newborn is dependent on their activity level but ranges from 30 to 60 breaths per minute and chest movement should be symmetrical. While rapid, the respirations should not be labored. Nasal flaring, cyanosis, sternal retractions and expiratory grunting are signs of respiratory distress and should be further evaluated. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM respiratory KEYWORDS airwayobstructionretractionaccessory muscledistressinfantnasal flaring

The nurse is caring for a client who is diagnosed with autism. The client begins eating his meal with his utensils, but places them on the table and begins to use his hands. Which response by the nurse would be best? Make the comment: "I believe you know better than to eat with your hands." Jokingly state: "Well I guess fingers sometimes work better than spoons." Place the spoon in the client's hand and state, "Use the spoon to eat your food." Remove the food and state: "You can't have any more food until you use the spoon."

Place the spoon in the client's hand and state, "Use the spoon to eat your food." This response identifies an expectation and instruction for the client. Since the client has demonstrated that he can use his utensils, he should be expected to maintain this level of independence. The other options are not therapeutic approaches for this client. Incorrect LESSON Psychosocial Integrity Behavioral Interventions or Behavioral Management COURSE RN Review KEYWORDS autismeatbehavior

The home health nurse is developing a plan of care for a 3-year-old client diagnosed with cerebral palsy (CP). Which goals are the priority for this client? Select all that apply. Arrange for genetic counseling Prevent seizures Promote locomotion Select appropriate school environment Treat muscle spasms (1 attempt remaining)

Prevent seizures Correct Response Promote locomotion d; Cerebral palsy (CP) is defined as a disorder of posture and movement from static brain injury perinatally or postnatally, which limits activity. In addition to motor disorders, the condition often involves disturbances of sensation, perception, communication, cognition, and behavior. Some of the disabilities associated with CP are visual impairment, hearing impairment, behavioral problems, communication and speech difficulties, seizures, and intellectual impairment. The priority goals at this age should include the prevention of seizure activity and correction of any associated physical defects and physical/occupational therapy to promote mobility and movement or the ability to move from one place to another (locomotion). Children with CP often suffer from muscle spasms and seizures and typically require pharmacotherapy for both. The other interventions are not appropriate at this age. CP is not a genetic disease. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS cerebral palsycare planpriority goals

The nurse is assessing a client who has an oral endotracheal tube with mechanical ventilation. Which finding requires immediate action by the nurse? Visible mist in the ventilator circuit Diminished breath sounds bilaterally Client is unable to speak Pulse oximetry reading of 86%

Pulse oximetry reading of 86% Pulse oximetry should not be lower than 90% saturation; therefore a pulse oximetry reading of 86% requires immediate action. Breath sounds are diminished but heard bilaterally so the placement of an endotracheal tube ET is most likely in the proper position. A client with an ET tube in place will not be able to speak when the ET tube balloon Is inflated. Due to the need for humidification with mechanical ventilation, it would be expected to have a fine mist visible. Correct! LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS assessETendotrachealtubeventilatoroximetry

The parent of an 8-month-old infant asks the nurse if the child's language development is appropriate for this age. Which sounds should the nurse anticipate at this age? Select all that apply. Squeals and yells to signal happiness or displeasure Vocalizes in response to voices Babbles in a rhythm similar to spoken language Cooing, gurgling and laughing aloud Meaningful words Single vowel sounds such as ah, eh and uh

Squeals and yells to signal happiness or displeasure Correct Response Vocalizes in response to voices Cooing, gurgling and laughing aloud Correct Response Meaningful words Single vowel sounds such as ah, eh and uh In the first few weeks of life, crying communicates unmet needs for infants. Language Developmental Milestones: 1 to 3 months- coos and other vocalizations, begins differentiated crying 4 to 5 months- simple vowel sounds such as ah, eh and uh. 6 months- squealing and yelling 9 to 12 months- imitates speech 12 months- 2 or 3 recognizable words that are connected to a meaning, babbles meaningless sounds in a pattern similar to speech. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN & PN Review KEYWORDS language developmentinfantdevelopmental stage CONFIDENCE Need Help Fair Strong

The nurse is working in a health care setting that utilizes an electronic medical record (EMR) for documentation. Which actions will reduce the risk for inappropriate access to confidential client information? Select all that apply. The nurse utilizes the automatic sign-off to close the medical record after a period of inactivity. The nurse writes down their current password on a list that's kept in the manager's office. The system administration department monitors all medical records accessed by staff members. The nurse reviews only the medical records of assigned clients during their shift. The nurse changes their personal password for the EMR more frequently than required. (1 attempt remaining)

The system administration department monitors all medical records accessed by staff members. Correct Response The nurse reviews only the medical records of assigned clients during their shift. Correct Response The nurse changes their personal password for the EMR more frequently than required. Correct! Practices that support EMR security include frequently changing passwords (using a combination of letters, numbers and symbols) and not sharing passwords with others. The information technology department typically monitors all access to an EMR and tracks unauthorized log-ins. The nurse should only review medical records for their assigned clients. Best practice is to sign or log off when leaving the computer screen and not rely on an automatic timeout because this can leave the system temporarily open for others to view/access confidential client information. Incorrect LESSON Management of Care or Coordinated Care Information Technology COURSE RN & PN Review KEYWORDS informationEMRprivacyHIPAA

The nurse is counseling a postpartum client who has a history of a substance-abuse problem. Which question is a priority when interviewing the client? When was the last time you used illegal substances? Do you feel that you have bonded with your infant? Have you attended any support groups related to substance abuse? How have you managed the stress of being a new mother?

a While all of the questions are appropriate, it is essential to assess whether or not the mother is still abusing illegal substances. This would pose a risk for the client and the newborn. The other questions are appropriate to ask after assessing for recent substance abuse. Incorrect LESSON Psychosocial Integrity Chemical and Other Dependencies, Substance Use Disorder

The nurse is providing discharge education to a client newly diagnosed with chronic obstructive pulmonary disease. The client is prescribed the diskus inhaler Advair (fluticasone propionate and salmeterol). The client asks, "How will I know when the inhaler is empty?" How should the nurse respond? The number of doses that remain will be on the inhaler Drop the canister in water to observe floating Shake the canister to detect any fluid movement Estimate how many doses are usually in the canister

a;There are several methods to monitoring the contents of an inhaler. New MDIs such as diskus inhalers often have counters on them. The counters record the number of doses left in the canister. If the MDI does not have this feature, the client should write the date a refill is needed. This can be done directly on the canister in a permanent marker. Manufacturers do not recommend floating inhalers. The shaking or estimation method will not be accurate. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmaMDIcanisterempty

The nurse is caring for a client who was prescribed alprazolam. When educating the client about the new medication, which intended effect should the nurse include? Alleviate signs and symptoms of spasticity Reduce anxiety and provide a calming effect Increase coordination and the ability to concentrate Reduce symptoms of depression

b; Alprazolam is a benzodiazepine which is as an anxiolytic. The medication will not increase coordination and the ability to concentrate or alleviate symptoms associated with nerve damage, such as spasticity. Alprazolam will not reduce symptoms of depression. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM nervous KEYWORDS xanaxalprazolamanxietycalm

The nurse is providing discharge education to a client who is prescribed alprazolam for a panic disorder. What concept should the nurse emphasize concerning the drug action? The medication works by suppressing dopamine Short-term relief can be expected If you miss a dose, double the next scheduled dose The medication acts as a stimulant

b; Alprazolam is a short-acting benzodiazepine, which works quickly to control panic symptoms by enhancing the effects of the neurotransmitter Gamma-amino butyric acid (GABA). This produces a calming effect. The drug does not suppress dopamine like dopamine antagonists and some antipsychotic medications. Alprazolam will not be increased as tolerated, the lowest dose that controls the symptoms will be maintained. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM nervous KEYWORDS panic disorderXanaxalprazolamteach

The nurse is providing care for a client diagnosed with sickle cell crisis. Which prescribed medication should the nurse clarify with the health care provider? Codeine Hydromorphone Meperidine Morphine (1 attempt remaining)

c Meperidine, an older opioid analgesic, is not recommended in clients with sickle cell disease. Normeperidine, a metabolite in meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus and generalized seizures when it accumulates in the client's system. Clients with sickle cell disease are at high risk for normeperidine-induced seizures. Incorrect LESSON Pharmacological (and Parenteral Therapies) Pharmacological Pain Management COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS sickle cellcrisispainmeperidinedemerolquestion

The nurse is educating a community group about signs and symptoms of a stroke. Which symptom frequently seen with a stroke should the nurse include? Rapid heart rate Stress incontinence Slurred speech Difficulty breathing

c; A stroke is a medical emergency. The nurse should teach the group that immediate treatment is needed to minimize long-term or permanent damage to the brain. A helpful mnemonic for teaching is "F.A.S.T.: F- Facial Drooping, A- Arm weakness, S- Slurred Speech or Speech Difficulty, and T- Time to call 911. The other symptoms are not usually associated with a stroke. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS cerebral vascular accidentCVAstrokegeriatric

A nurse is preparing to assist a mother with breastfeeding for the first time. Which of the following is a priority? Darken the room and allow for privacy for the initial feeding Give the mother several illustrated pamphlets Assist the mother with helping the newborn to latch appropriately Inform the client that breastfeeding is a skill for both the mother and newborn

c; Immediate breastfeeding after birth is associated with physiological benefits for the newborn and mother. While educating about breastfeeding is important, it is essential to ensure the infant has latched appropriately. Darkening the room may be appropriate for subsequent feedings, but it is important for the nurse to support the mother and newborn during the initial feeding. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS breastfeedteachfirst

The nurse is caring for a client who is being treated at home for chronic renal failure. During weekly home visits, which method is the most accurate indicator of fluid balance? Changes in mucous membrane moistness Difference between intake and output Trends in daily weights Skin turgor over at least two areas of the body

c;The most accurate indicator of changes in fluid balance is the daily weight. Any client who has a diagnosis that effects the ability of the body to manage fluid balance should weigh themselves every morning and report a gain of 3 pounds in one week or 1 to 2 pounds overnight. A 1-kilogram (or 2.2 pounds) of weight gain is equal to approximately 1000 mL of retained fluid. Skin turgor, mucous membranes and the net difference between intake and output are not accurate indicators of fluid balance. Correct! LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN & PN Review BODY SYSTEM urinary KEYWORDS renalfluid balanceweight

The nurse is caring for a newborn with tracheoesophageal fistula (TEF). Which assessment is the highest priority? Monitor intake and output Monitor for fever over 101°F (38.3 °C) Observe the newborn for tachycardia with activity Observe the newborn for cyanosis

d With TEF, there is an abnormal opening between the trachea and esophagus. Fluids can easily be aspirated into the trachea and lungs. The 3 Cs of TEF are choking, coughing and cyanosis. The priority is to prevent aspiration and maintain an open airway. The other options are appropriate when monitoring any newborn. However, they are not specific to TEF. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS newbornTEFaspirationpriority

The home health nurse is evaluating the plan of care for a 15-year-old male client with muscular dystrophy. The client is mostly immobile and unable to care for himself. The client is at risk for depression due to which issue? Insecurity Lack of trust Loss of control Dependence

d; A 15-year-old adolescent would be in the stage of development Identity vs. Role Confusion (Erikson). Since this adolescent is dependent on others, it will be difficult for him find his own identity. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS illgrowthdevelopmentdependency