(H) Review Test # 3

What is normal for the nurse to see in a one year old child? 1. Gets to a standing position without help. 2. Able to say several single words. 3. Pulls toys while walking. 4. Builds a tower of 4 blocks.

1. Correct: A 1 year old should be able to get to a standing position without help. May stand alone. 2. Incorrect: Children at 18 months are able to say several single words. 3. Incorrect: Children at 18 months are able to pull toys while walking. 4. Incorrect: Children at 2 years of age can build a tower of 4 or more blocks.

Which nursing statement about a client reflects correct documentation in the hospital medical record? 1. Skin warm and dry to touch. 2. Small wound noted on right arm. 3. Client slept well. 4. Client appears upset at spouse.

1. Correct: Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. 2. Incorrect: The nurse should record findings or observations precisely and accurately. Documentation of an arm wound should include its exact size and location. 3. Incorrect: Stating that the client slept well doesn't provide precise information to be useful. 4. Incorrect: Documenting observed behaviors or conversations is appropriate; however, drawing conclusions about feelings is not.

The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office, there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? 1. I will speak to the charge nurse about your needs so a case manager can be notified to help you with your concerns. 2. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. 3. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? 4. I can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission.

1. Correct: The charge nurse will notify the case manager. The case manager should be involved in coordinating the client's care from the date of admission in order to help the client navigate unexpected situations like a last-minute hospital admission. The ability to make telephone calls to notify family and friends will help to decrease the client's sudden sense of isolation from normal daily life, loss of control, and anxiety. 2. Incorrect: Although sleeping medication may be warranted for this client, the nurse neglects to offer a viable solution to the client's problem. The nursing interventions should focus on assisting the client to explore their feelings. 3. Incorrect: Although this is a helpful response, this answer does not include notifying the case manager. The nurse should forward this request to the case manager who can identify client needs. 4. Incorrect: Calling the primary healthcare provider is inappropriate, as the client requires hospitalization now. The primary healthcare provider will determine if the client should be hospitalized.

The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? 1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." 2. "I have been gaining a lot of weight lately." 3. "My stools are darker. Sometimes they are even black." 4. "When I start hurting, it helps if I drink milk or have a small snack."

1. Correct: The gallbladder assists in digestion of fat. When foods high in fat are ingested, bile is released from the gallbladder to assist in digestion. If gallstones are formed in the gallbladder or are blocking the outlet to the gallbladder, the client may experience epigastric discomfort after a meal high in fat. 2. Incorrect: Weight gain is not associated with gallstones. 3. Incorrect: Black stools indicate blood in the stool and should be further investigated. Black stools are not associated with gallstones. 4. Incorrect: When drinking milk or having a small snack relieves the abdominal pain, a duodenal ulcer may be a possible diagnosis.

Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.

1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate. 2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional evaluation and is receiving supplementation for nutritional needs. After reviewing the nutritional evaluation, the TPN will be formulated accordingly. 3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids for more than 3 days. At that point, the child would be at nutritional risk. After 3 days, the nutritional status of the child should be evaluated due to the food restrictions of a clear liquid diet. 4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is tolerated, then the strength will be advanced; therefore, this client is not at risk.

Which client assignment should the LPN accept from the charge nurse? 1. Child needing pre-operative medication prior to reduction of a fracture. 2. Adult client reporting abdominal pain after being beaten up in a fight. 3. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. 4. Child admitted with cystic fibrosis 2 hours ago.

1. Correct: This is the most stable client that could be given to the LPN. Even though the client has a fracture, the focus is on giving pain medication prior to a surgical procedure. 2. Incorrect: This client could have internal bleeding and other complications not diagnosed. This is not the best client to give to the LPN. 3. Incorrect: This is a more complex client and is least likely to be assigned to a LPN because of the increased need for pain medications, like narcotics, and use of a technological device. Sickle cell pain episodes will vary in it's intensity and frequency. 4. Incorrect: This is a complex client and should not be given to the LPN. This client is a new admit at risk for respiratory distress and potential infections due to the chronic long term effects of cystic fibrosis.

Which nurse is providing cost effective care to a client? (SATA) 1. Providing palliative care to a terminally ill client. 2. Following the discharge plan throughout hospitalization. 3. Reinforce education on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves.

1., 2., & 3. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Reinforcing education to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost-effective. 4. Incorrect. This is a preventive intervention that is cost-saving, however, the PN cannot initiate teaching, but can reinforce it. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and failure to use them could lead to infection, which would then increase the cost of care to a client.

A client is admitted with a diagnosis of myasthenia gravis. What nursing interventions will assist in managing the client's swallowing and chewing impairment? (SATA) 1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids. 4. Position upright with head tilted slightly backwards. 5. Dissolve the client's medications in water.

1., 2., & 3. Correct: Myasthenia gravis is a disorder wherein the postsynaptic neuromuscular junction receptor sites are decreased. This decrease in receptor sites causes decreased muscular depolarization. The clinical manifestations of this disease are progressive muscle weakness and fatigue. Eventually clients may experience difficulty breathing due to weakness and fatigue of the respiratory muscles. Muscle fatigue impairs chewing and swallowing. These actions decrease the risk of aspiration, decrease the work of muscles, and allow for improved swallowing. 4. Incorrect: The head should be positioned slightly forward (chin tuck, head turn). 5. Incorrect: The client's medications should not be dissolved in water due to the client's difficulty swallowing. Liquids should be thickened.

A client is going home on a potassium sparing diuretic, spironolactone. What should the nurse tell the client about this medication? (SATA) 1. You may be at risk for high potassium levels. 2. Check with primary healthcare provider before taking over the counter potassium. 3. Consume potassium rich foods in moderation. 4. You may be at risk for hypokalemia . 5. You should increase your intake of potassium rich foods.

1., 2., & 3. Correct: With potassium sparing diuretics, hyperkalemia may occur if the kidney function is compromised, or takes potassium supplements. The client should check with the primary healthcare provider before taking over the counter potassium supplements due to risk of hyperkalemia. Too much potassium rich foods could raise serum potassium levels. 4. Incorrect: Loop diuretics are likely to cause hypokalemia. 5. Incorrect: Potassium sparing diuretics decrease the amount of potassium excreted with the urine; therefore, there is a risk for hyperkalemia.

The drug nadolol is prescribed to a client with stable angina. Which findings would the nurse expect to observe? (SATA) 1. Decreased anxiety 2. Relief of chest pain 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia

1., 2., & 4. Correct: Nadolol is a beta-blocking agent. Beta-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate, contractility, and blood pressure. These effects decrease the workload on the heart. With decreased oxygen demand (workload on the heart), chest pain is relieved. Beta-blockers decrease cardiac contractility, thereby decreasing cardiac output. Beta blockers also relieve anxiety. 3. Incorrect: Bounding pulses would indicate fluid volume excess, thus making the problem worse. 5. Incorrect: Nadolol is a beta-blocking agent, which blocks the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate; however, decreasing the heart rate to the point of bradycardia would be an adverse effect.

The primary healthcare provider prescribed fentanyl 75 mg IM. The pharmacy dispensed fentanyl 50 mg per mL. How many mL will the nurse administer? Round to one decimal point.

50 mg: 1 mL = 75 mg: x mL 50 x = 75 x = 1.5

The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number.

5mg x 18 kg = 90 mg/day

Which task would be appropriate for the LPN/VN to accept from the charge nurse? (SATA) 1. Collect data on a new client admit. 2. Administer ondansetron IVP to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.

1., 3., 4., & 5. Correct: All of these tasks are appropriate and within the scope of practice for the LPN/VN. The LPN/VN can collect data on a new admit, and the RN would verify and co-sign to complete the assessment. Bolus feeding by way of a gastrostomy tube and reinserting a nasogastric tube would be appropriate assignments for the LPN/VN also. A LPN/VN can monitor the PCA pain medication but cannot initiate or administer the medication. 2. Incorrect: Administering ondansetron IVP is out of the scope of practice for the LPN/VN. The PN cannot administer IV push medications.

The nurse is caring for a client who is drowsy and has an elevated PCO2 level. What are some common medications that can cause this elevated level? (SATA) 1. Narcotics 2. Diuretics 3. Steroids 4. Antiemetics 5. Hypnotics

1., 4. & 5. Correct: Narcotics sedate and decrease the respiratory rate, which increases CO2 retention. Always monitor respiratory rate. Some antiemetics (such as promethazine) are very sedating and will decrease the respiratory rate while increasing CO2 retention. Hypnotics can cause sedation to the point of hypoventilation, which leads to CO2 retention. Always monitor respiratory rate. 2. Incorrect: Diuretics do not affect breathing patterns. 3. Incorrect: Steroids do not affect breathing patterns.

When caring for young adult clients, which developmental tasks would the nurse expect to see? (SATA) 1. Reflecting on life accomplishments. 2. Developing meaningful and intimate relationships. 3. Giving and sharing with an individual without asking what will be given or shared in return. 4. Developing sense of fulfillment by volunteering in the community. 5. Reaching out to give and to guide the next generation.

2. & 3. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect: During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity versus Despair, where there is a reflection of one's life. 4. Incorrect: During middle age, a sense of fulfillment can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to support others. 5. Incorrect: This is a task of middle adulthood. The developmental task is Generativity versus Stagnation. The adult finds ways to support the next generation.

The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? (SATA) 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Applying shaving cream prior to shaving with a razor. 4. Applying hair removal cream. 5. Trimming the hair with scissors.

2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option, the use of clippers or a hair removal cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 5. Incorrect: Trimming the hair causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery.

A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation? 1. Calcium supplement 2. Ferrous sulfate 3. Folic acid 4. Cetirizine

2. Correct: Ferrous sulfate commonly causes constipation and GI upset. These side effects can be diminished with proper diet instruction and taking medication with food. 1. Incorrect: Calcium is essential for bone health, maintaining heart rhythm, and muscle function. It is crucial in growing new bone and maintaining bone strength. Calcium does not generally cause constipation. 3. Incorrect: Constipation and GI upset are not generally associated with folic acid administration. 4. Incorrect: Constipation is an adverse effect associated with cetirizine administration, since it is an antihistamine. Antihistamines dry you up, so the GI tract contents gets thicker, leading to constipation.

Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? 1. Take a stool softener. 2. Increase intake of fruit in the diet. 3. Monitor elimination habits for the next week. 4. Rest after each meal.

2. Correct: Fruit is high in fiber. Increased fiber intake may help to establish regular elimination habits by promoting the movement of material through the digestive system and increasing stool bulk. 1. Incorrect: Not the best initial suggestion. It's better to promote health maintenance routines than to just go with a medication, which could be a temporary fix. 3. Incorrect: The nurse should make a suggestion that will assist the client with normal elimination. This option does not suggest a way to fix the problem. 4. Incorrect: Increased activity is likely to result in more normal elimination. Resting after meals would not increase elimination frequency.

After a thoracotomy, which intervention by the nurse would enable the client to cough most effectively? 1. Allow 4 hours of rest between deep breathing and coughing exercises. 2. Splint the incision during deep breathing and coughing exercises. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours.

2. Correct: Holding a pillow firmly over the incision (splinting) when deep breathing and coughing supports the incision and surrounding tissues and reduces pain. This helps so much with the ability to control the pain and produce an effective cough. 1. Incorrect: They have to cough more frequently than every 4 hours. Encourage every 2 hours. Deep breathing and coughing expands the lungs and helps with expectoration of mucous and secretions that accumulate in the airways after surgery. 3. Incorrect: It takes longer than a few minutes to liquefy secretions, and if the stomach is full, vomiting may occur. 4. Incorrect: A thoracotomy is a surgical incision into the chest wall. After the thoracotomy, we don't want to clap and vibrate the incision.

A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this new nurse? 1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to insert the feeding tube. 4. Insert the feeding tube as learned in nursing school.

2. Correct: The best action for the nurse is to look up how the procedure is done in the agency policy and procedure manual. The nurse could then discuss the procedure with a fellow nurse and ask that nurse to observe during the procedure. 1. Incorrect: This is passive and will not give the new nurse the experience needed. The best action would be to look up how to do the procedure. Then the new nurse could discuss with another nurse, and have that nurse observe the insertion of the feeding tube by the new nurse. 3. Incorrect: This is not the best option. The new nurse needs to learn how to insert a feeding tube. This will not help the new nurse learn. Actually doing the procedure after checking the policy and procedures manual will give the new nurse the experience needed. 4. Incorrect: Nursing school knowledge is needed but also check agency policy and procedure manuals. Then the new nurse can discuss the procedure with a fellow nurse and ask that nurse to observe the feeding tube insertion.

A client in the long-term care facility has been prescribed hydrochlorothiazide. What side effect should the nurse expect to observe? 1. Increased potassium levels 2. Orthostatic hypotension 3. Increase in weight 4. Decreased urine output

2. Correct: The client may experience drop in blood pressure upon standing, particularly when the medication is first prescribed. The nurse should tell the client to change positions slowly. 1. Incorrect: Hydrochlorothiazide lowers potassium levels, and a potassium supplement may also be prescribed. 3. Incorrect: Since fluid loss results from diuretic use, the client is likely to see a weight loss. 4. Incorrect: This diuretic may result in increased diuresis.

A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother? 1. Accepts the treatment of the nurse and think that it is appropriate. 2. Takes offense to the abrupt nature of the treatment. 3. Thinks that the nurse is busy and needs to rush. 4. Thinks that the nurse is very efficient.

2. Correct: The family is likely to be offended by the abrupt manner of the nurse. The Hispanic culture is present time oriented and desire attention and interaction. It would not be relevant that the nurse may be busy. To overlook this cultural variation is rude and does not treat the mother with dignity. 1. Incorrect: The nurse is not demonstrating cultural sensitivity. The family is not likely to accept this abrupt approach due to the cultural differences related to time and the desire for more genuine personal interaction. The Hispanic mother may be offended by the direct interviewing approach of the nurse. 3. Incorrect: The mother is likely to be offended with this abrupt response. Efficiency is not a priority as much as attentiveness and care, particularly with an ill child. The cultural frame of reference is present time in which other events should not interfere with the present situation. Expectations for genuine, personal interaction are also a part of the culture. 4. Incorrect: The mother is likely to interpret the nurse's actions as rude. The American culture is future time oriented and desires efficiency; the Hispanic culture is more interested in relationships and what is occurring at the present time.

A prescription is written to give MSO4 8 mg intramuscularly now. What should the nurse do next? 1. Check the order prescription prior to sending it to the pharmacy. 2. Notify the primary healthcare provider for clarification of the prescription. 3. Notify the pharmacy that the prescription is needed immediately. 4. Gather the supplies needed for an injection.

2. Correct: The nurse should notify the primary healthcare provider, because MSO4 is an abbreviation that is on the Joint Commission's "do not use" list. MSO4 can mean morphine sulfate or magnesium sulfate. Notifying the primary healthcare provider to clarify the prescription will prevent a medication error from occurring. 1. Incorrect: The prescription should not be sent to the pharmacy until after it is clarified with the primary healthcare provider. 3. Incorrect: MSO4 is not an approved abbreviation. Before notifying the pharmacy, make sure you know what the prescription is for. 4. Incorrect: You might be making a medication error if you assume you know what you are giving.

The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Is confused and disoriented. 2. Is scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse.

2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client. 1. Incorrect: There is no indication of confusion or disorientation. 3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch. 4. Incorrect: There is no indication of a desire to reminisce from the information in the question.

The nurse is gathering data on a health history with a client who is 10 weeks pregnant. During the interview, the client states, "I'm not so sure I'm really happy about this pregnancy". Which response by the nurse is most appropriate? 1. Many women feel ambivalent about being pregnant. 2. Tell me more about how you are feeling. 3. Why do you feel this way? 4. It seems there is never a good time to get pregnant.

2. Correct: Use of the open ended statement provides the client an opportunity for clarification of her feelings, ideas and perceptions. This also emphasizes the importance of the client's interaction. 1. Incorrect: While it is true that ambivalence about pregnancy is normal, the client should be afforded the opportunity to explore the interwoven feelings of wanting and not wanting to be pregnant. 3. Incorrect: Asking "why" questions can put the client in a defensive position and is not therapeutic.This can be intimidating for the client. 4. Incorrect: This response reflects a personal opinion and may be irrelevant for this client. This is imposing the nurse's ideas on the client.

Which findings will direct the nurse towards determination that a client is experiencing normal grief? (SATA) 1. Anhedonia is prevalent. 2. The client states, "I am having fewer bad days". 3. Smiles at the nurse while talking about life. 4. Dysphoria is noted. 5. The client states, "I have been crying less".

2., 3. & 5. Correct: A client going through a normal grieving process will experience a mixture of good and bad days. The client is able to experience moments of pleasure and cries less. 1. Incorrect: Anhedonia is the inability to experience pleasure, which is seen in clinical depression. 4. Incorrect: Dysphoria is a mood of general dissatisfaction, restlessness, depression, and anxiety. This is often seen in clinical depression.

What method should the nurse tell the client about the detection of prostate cancer? 1. Abdominal x-rays to detect the presence of lesions and masses. 2. A serum calcium test to detect elevated levels, which may indicate bone metastasis. 3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate. 4. A magnetic resonance image (MRI) study to detect tumors and other abnormal growths.

3. Correct: Prostate cancer is the second most common type of cancer and the second leading cause of cancer death in men. Early detection improves outcome. DRE and PSA should be offered annually beginning at age 50 to men who have a life expectancy of at least 10 years and at age 45 in high-risk groups. The DRE estimates the size, symmetry, and consistency of the prostate gland while the PSA measures for elevated levels consistent with prostatic pathology, although not necessarily cancer. Declining PSA levels are useful in determining efficacy of treatment for prostate cancer. 1. Incorrect: Radiologic studies are not screening tools for this disease. Abdominal xrays can show the size, shape and position of abdominal organs. 2. Incorrect: Hypercalcemia may indicate cancerous bone involvement, but it's not a screening tool. Hypercalcemia is a condition in which the calcium level in the blood is above normal. 4. Incorrect: MRI is a diagnostic tool, not a screening tool. MRI is a test using magnetic fields to produce images of body structures.

The nurse is caring for an immobile client. Which complication is the nurse's priority? 1. Orthostatic hypotension 2. Urinary tract infection 3. Pressure ulcer 4. Deep vein thrombosis

4. Correct: A venous thrombus has the potential to dislodge and travel to the lungs and heart: impairing circulation and oxygenation. A venous thrombus can be life threatening. 1. Incorrect: Orthostatic hypotension is low BP that occurs when going from lying or sitting position to standing position. It is not as life threatening as deep vein thrombosis. 2. Incorrect: Urinary tract infections can be painful and serious. They are treated with antibiotics. Urinary tract infections are not as life threatening as deep vein thrombosis. 3. Incorrect: Prolonged pressure causes injury to the skin and underlying tissue. Most pressure ulcers heal with appropriate treatment. Pressure ulcer is not as life threatening as deep vein thrombosis.

After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse collect data on first? 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.

4. Correct: Being restless is an early sign of hypoxia, so oxygen may be necessary. Remember oxygenation takes priority over the other issues with these clients. The client may also be exhibiting manifestations of fluid volume deficit (FVD) 1. Incorrect: This is a stable client, so no indication of immediate distress is indicated. A small amount of drainage on the dressing of a client who had a appendectomy 3 hours ago would not be assessed first. 2. Incorrect: This is a stable client because confusion is part of Alzheimer's disease. Safety issues for a confused client should be evaluated. The client with dehydration is exhibiting possible manifestations of decreased oxygen level and/or fluid volume deficit (FVD) and should be assessed first. 3. Incorrect: This is a stable client with no indication of immediate distress. Crust forming on the Steinmann pins should be removed from the pin insertion site. However, this client would not be given priority over the client with dehydration.

Which client diagnosis would require the nurse to initiate droplet precaution? 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Whooping cough

4. Correct: Droplet isolation precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). Healthcare workers should wear a surgical mask while in the room. Mask must be discarded in trash after leaving the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. 1. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room {examples: MRSA, VRE, diarrheal illnesses, open wounds, Respiratory syncytial virus (RSV)}. Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. 2. Incorrect: Airborne isolation precautions are used for diseases or very small germs that are spread through the air from one person to another (examples: Tuberculosis (TB), measles, varicella). Healthcare workers should ensure client is placed in an appropriate negative air pressure room (a room where the air is gently sucked outside the building) with the door shut. Wear a fit-tested NIOSH-approved N-95 or higher level respirator while in the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. Ensure the client wears a surgical mask when leaving the room. Instruct visitors to wear a mask while in the room. 3. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room.

After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action? 1. Leave the client lying with the unaffected ear facing up. 2. Place a cotton ball firmly into the affected ear for 15 minutes. 3. Pull the pinna of the ear down and back. 4. Gently massage the tragus of the ear.

4. Correct: This is a correct nursing measure that will facilitate the flow of medication in the auditory canal. 1. Incorrect: The client can remain on the side for 5 to 10 minutes with the affected ear up to help distribute the medication and prevent the medication from escaping the ear canal. 2. Incorrect: The cotton ball is placed loosely at the opening of the auditory canal for 15 minutes to prevent the medication from escaping the canal when the client changes positions. 3. Incorrect: The pinna is pulled up and back on an adult client when instilling the ear drops to straighten the ear canal.

A client with persistent vomiting reports weakness and leg cramps. Which acid base imbalance would the nurse anticipate? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Correct: Symptoms of metabolic alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis. 1. Incorrect: Not respiratory related. It is a metabolic acid-base imbalance. 2. Incorrect: Not respiratory related. It is a metabolic acid-base imbalance. 3. Incorrect: Not acidosis. There is loss of gastric acid and potassium with persistent vomiting, leading to metabolic alkalosis.

What activities should the nurse reinforce to a group of adolescents who have been diagnosed with rheumatoid arthritis? (SATA) 1. Jogging 2. Volleyball 3. Tennis 4. Bicycle riding 5. Swimming

4., & 5. Correct: Rheumatoid arthritis is an autoimmune disease that affects the joints and other body symptoms. Low impact activities on joints are best such as swimming and bike riding. 1. Incorrect: Jogging is a high impact activity for joints. This is not appropriate for a client with rheumatoid arthritis. 2. Incorrect: Playing volleyball is a high impact activity for joints and would not be appropriate for a client with rheumatoid arthritis. The pressure on the joints may result in additional damage to the joints. 3. Incorrect: Playing tennis is a high impact activity for joints, and tennis should not be a recommended sport for a client with rheumatoid arthritis.

A client is to receive an antibiotic in 50 mL of D5 W over 30 minutes using an infusion pump. The nurse will set the infusion pump to deliver how many mL per hour? Round off to the nearest whole number.

50 mL: 30 min. = x mL: 60 min. Multiply means together and extremes together. 30 x = 3,000 30x = 3,000 30 30 x= 100

The LPN is verifying that a new LPN understands the principle of least restrictive intervention on a psychiatric unit. In what order should the new LPN correctly place interventions from least to most restrictive? Place in correct order from least restrictive to most restrictive. Walk the client out to the courtyard. Verbally tell the client to stop the unacceptable behavior and escort client to another part of the day room. Take the client to the quiet room for a time out. Place client in the isolation room with staff observation. Restrain client's arms with wrist restraints. Use four point soft cloth restraints.

First, verbally tell the client to stop the unacceptable behavior and escort client to another part of the day room. This is the least restrictive. Second, walk the client out to the courtyard. This removes the client from the situation while still allowing some freedom. Third, take the client to the quiet room for a time out. This removes the client from the situation but also sets restrictions on where and with whom they can interact. Fourth, place client in the isolation room with staff observation. This is more restrictive than the quiet room, but doesn't require restraints. Fifth, restrain client's arms with wrist restraints. This is a two point restraint which is much more restrictive than the isolation room. Lastly, use four point soft cloth restraints. This is the most restrictive.

A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client? 1. Medium rare steak, potato salad, peas and coffee 2. Ham sandwich, chips, fruit salad and juice 3. Broiled white fish, baked potato, mixed salad and tea 4. Baked chicken, vegetable medley, rice and milk

3. Correct: Fish is allowed if it has fins and scales. Shellfish is not kosher. Pasta, potatoes, salads and tea are allowed. 1. Incorrect: Although steak is allowed, all traces of blood must be gone. 2. Incorrect: No pork products are allowed, so no bacon, ham, or sausage. 4. Incorrect: Milk is not allowed at the same time as meat. There should be at least three hours separating the two.

A client suffering from major depression spends all day in bed. Which nursing action should the nurse take? 1. Frequently initiate contact with client. 2. Frequently round at regular intervals. 3. Patiently wait for the client to come out of the room. 4. Ask client, "Why are you still in bed"?

1. Correct: Be accepting and spend time with the client even though pessimism and negativism may seem objectionable. Focus on strengths and accomplishments and minimize failures. 2. Incorrect: The nurse should round at frequent irregular intervals so that the client does not know when to expect the nurse and can plan suicide attempt. 3. Incorrect: The nurse should seek out the client. The depressed client is not likely to come looking for someone. 4. Incorrect: Do not confront the client about why the client is not doing something. This will not promote trust and client may not know why.

A client diagnosed with schizophrenia comes up to the nurse and says, Tick, tock, duck clock. Clock, clock, tick, tock. How would the nurse document this impaired communication? 1. Clang association 2. Echopraxia 3. Perseveration 4. Magical thinking

1. Correct: Clanging, or clang associations, involves choosing words based on their sounds rather than their meanings and usually involves alliteration or rhyming. 2. Incorrect: Echopraxia involves the client purposelessly imitating movements made by others. 3. Incorrect: Perseveration involves the client persistently repeating the same word or idea in response to different questions. 4. Incorrect: Magical thinking involves the client believing that his or her thoughts or behaviors have control over specific situations or people. Ex: It's raining; the sky is sad.

Which home safety measures are appropriate for the nurse to remind an older client about prior to discharge post total hip replacement? (SATA) 1. Install a grab bar in the tub. 2. Turnsnight light on at bedtime. 3. Use assistive devices only when leaving home. 4. Go barefoot while in the home. 5. Ensure chairs in the home are low.

1. & 2. Correct: Placing a grab bar in a slippery tub can assist the older adult in getting into and out of the tub. Turning on night lights at night ensures that the older adult can navigate safely, thus reducing the risk of falls. 3. Incorrect: If the adult has an assistive device, it should be used inside and outside of the home. 4. Incorrect: The client should wear proper fitting shoes that have nonskid protection all the time. 5. Incorrect: Chairs should not be too low. The hip should be higher than the knees when sitting.

What vitamin is important in reducing the risk of peripheral neuropathy in a client with alcohol abuse? 1. Vitamin D 2. Fat soluble vitamins 3. B vitamins 4. Potassium

3. Correct: Yes! It is the B vitamins. Long term heavy alcohol use puts one at risk for neuropathy. 1. Incorrect: Not vitamin D 2. Incorrect: While the liver is affected, the fat soluble vitamins are affected. The peripheral neuritis is related to the B vitamins. 4. Incorrect: Potassium is an electrolyte.

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

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

A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. Remove the client from the room. Activate the fire alarm. Close the door to the client's room. Obtain the fire extinguisher. Extinguish the fire.

Remember RACE: Rescue the client; activate the alarm; contain the fire in the client's room; extinguish the fire. This standard process ensures safety for the client first and then the remaining people in the facility next. First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client's room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire.

Which symptom would the client who overdosed on barbiturates most likely exhibit? 1. Bradypnea 2. Hyperthermia 3. Hyperreflexia 4. Tachycardia

1. Correct: Barbiturates are central nervous system (CNS) depressants. They will slow the respiratory rate. 2. Incorrect: Barbiturates would not cause hyperthermia. 3. Incorrect: Barbiturates are CNS depressants. They would diminish reflexes. 4. Incorrect: Barbiturates are CNS depressants. They would slow the heart rate.

For a client with a major burn, which evaluation criteria best indicates that fluid resuscitation is effective during the first 24 hour of care? 1. Urine output of 30-50 mL per hour 2. Increase in weight from preburn weight 3. Heart rate of 130 beats per minute 4. Central venous pressure of 22 mm

1. Correct: Urine output is the best indicator of adequate fluid replacement during the first 24 hours. 2. Incorrect: The weight is not a good indicator now because of the large volume of fluids being infused. These extra fluids would increase the weight. Edema is a problem because of third spacing. 3. Incorrect: The heart rate should come down with adequate fluid replacement. 4. Incorrect: The CVP reading is too high. This indicates that too many fluids have been given.

A client in the manic phase of bipolar disorder is constantly interrupting a group session. What should the nurse do? 1. Engage the client to walk with the nurse to make another pot of coffee 2. Ask the client to reflect on behavior to determine if it is appropriate 3. Ask the group to tell the client how they feel when interrupted 4. Instruct the client to perform jumping jacks and count aloud to get rid of some energy.

1. Correct: Yes! Get them away and doing something purposeful. 2. Incorrect: The client is in the manic phase and feels invincible. This is not the time for the client to reflect on the disruptive behavior. 3. Incorrect: Sometimes this will be helpful during times of therapy, but the client is manic at this time, and probably will not believe them. 4. Incorrect: No. This, is getting the client active, but can the group continue with this attention seeking jumping, counting person? No. Get the client away from the activity.

The nurse should monitor the results of which laboratory test for a client taking atorvastatin? 1. Complete blood count (CBC) 2. Cholesterol level 3. Troponin level 4. Cardiac enzymes

2. Correct:Atorvastatin is a lipid-lowering agent. The expected outcome of treatment with atorvastatin is lowering of the serum cholesterol and triglycerides. 1. Incorrect: The CBC results would not be used to evaluate the effectiveness of treatment with atorvastatin. 3. Incorrect: The troponnin level evaluates the presence of cardiac muscle damage. 4. Incorrect: Cardiac enzymes would monitor for cardiac muscle damage.

A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought about getting a family member to help with the baby?"

3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked. 1. Incorrect: The nurse is diagnosing the client with maternity blues, which consists of tearfulness, despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening problem. Assume the worse. Think about the safety of mom and baby.

Which client should the nurse see first? 1. A child whose colostomy bag is leaking 2. A three day post-op client requesting pain medication 3. A child admitted with failure to thrive, whose mother requested formula 4. A client with a blood pressure drop from 150/80 to 120/60.

4. Correct: Assume the worst. This client's drop in BP is significant. 1. Incorrect: This is a stable client. There is no indication of immediate distress. 2. Incorrect: This is a client 3 days post-operative. According to Maslow, pain is a less urgent need. 3. Incorrect: The client is not in immediate distress. Nutrition is not as high a priority as circulation.

Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? 1. Clinical nutritionist 2. Primary nurse each shift 3. Primary healthcare provider 4. Case manager

4. Correct: An important role of the case manager in the multi-disciplinary team care approach is coordination of client care. The case manager oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services to the client. 1. Incorrect: The clinical nutritionist is a member of the multi-disciplinary team, but does not coordinate and organize the delivery of care outside of the client's nutritional needs. 2. Incorrect: The primary nurse each shift develops and executes the plan of care for the client, but is not the organizer and coordinator of all the services to the client. 3. Incorrect: The primary healthcare provider is a member of the multi-disciplinary team, but is responsible for prescribing healthcare for the client, not organizing the services.

A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic? 1. Are you feeling afraid now? 2. I am here with you. 3. Let's discuss something else. 4. You know that is not true.

1. Correct: The nurse should speak to the underlying feeling of the client's statement which is fear. 2. Incorrect: The nurse is offering self. This does not respond to the underlying message in the client's statement that indicates fear and false information. 3. Incorrect: The nurse is changing the subject. This is a non-therapeutic response by the nurse that will decrease communication between the nurse and the client. 4. Incorrect: The nurse is arguing with the client. This is a non-therapeutic response by the nurse that will decrease communication between the nurse and the client.

A client appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? (SATA) 1. Providing information to the client. 2. Promoting client compliance. 3. Providing emotional support. 4. Ensuring the client's wishes for treatment are followed. 5. Fostering a sense of security.

1., 3. & 5. Correct: Client advocacy has been described in many different ways and involves many things such as assistance in gaining needed healthcare, assuring quality of care, protection of client's rights, and simply serving as a mediator between the client and the healthcare system as a whole. Client advocacy involves regular communication in which the nurse explains what is being done or likely to happen, reasons for tests or procedures, and simplifying medical terminology into words that can be easily understood. Emotional support is also an aspect of client advocacy that the nurse should employ. The nurse acts as a client advocate by providing information to the client to alleviate fear of the unfamiliar equipment and by fostering a sense of security. 2. Incorrect: This question addressing client advocacy is not related to client compliance. Client compliance may improve if the nurse served as an appropriate client advocate. However, promotion of compliance is not a basic part of advocacy. 4. Incorrect: This question addressing client advocacy is not related to client's healthcare treatment wishes. This would be related to the client's advance directive.

What side effects would the nurse expect to find in a client who has received too much levothyroxine? (SATA) 1. Angina 2. Bradycardia 3. Hypotension 4. Heat intolerance 5. Tremors

1., 4., & 5. Correct: These are side effects of too much levothyroxine. Levothyroxine is the replacement hormone for clients with hypothyroidism, so if too much is given, they would exhibit symptoms just like someone with hyperthyroidism. These clients also tend to have coronary artery disease (CAD), which is why angina is a significant side effect. 2. Incorrect: Tachycardia, rather than bradycardia, will be seen with too much levothyroxine. 3. Incorrect: Hypertension, rather than hypotension, will be seen with too much levothyroxine.

A client reports difficulty sleeping since starting a new job. The nurse's data collection identifies that the client is also working after hours from home. Which guidelines are appropriate to promote sleep in this client? (SATA) 1. Vary bed times to determine time best to promote sleep. 2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.

2., 3., 4. & 5. Correct: The client should associate bed with sleep, not work. Eating late in the evening may interfere with sleep, especially if a heavy meal. Caffeine late in the evening may increase alertness and interfere with sleep. Many people respond positively to white noise. Music, on the other hand, may make it more difficult to sleep. 1. Incorrect: The same time for bed each day will establish a routine and make sleep easier. Varying sleep times will disturb the client's sleep cycle and circadian rhythm. This would not be helpful to facilitate sleep.

Which nursing actions would indicate proper sterile technique? (SATA) 1. Using clean gloves, the nurse removes sterile forceps from package and places on sterile field. 2. The nurse does not allow any sterile item to get within one inch of the drape border. 3. The nurse's arms stay above the waist. 4. When adding sterile saline to a sterile bowl, the nurse places the inside of the bottle cap up. 5. The nurse discards a package that becomes wet.

2., 3., 4. & 5. Correct: This is a correct procedure. Because the edge of a sterile towel, drape, or tray touches an unsterile surface, such as a table, the edges of the drape are considered contaminated (1 inch). A sterile object or field out of the range of vision or an object held below the waist is contaminated. The inside of the bottle cap is considered sterile. Placing the cap up will keep the cap sterile. When a sterile surface comes into contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. 1. Incorrect: Sterile can touch sterile only. If the nurse touched sterile forceps with clean gloves, the forceps would become contaminated. Further teaching would be needed.

A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate? 1. Your head is turned to the side as if you are listening to voices. 2. I don't hear anyone but you speaking. 3. Tell me what the voices are saying to you. 4. Let's talk about your anxiety right now.

3. Correct: The nurse needs to know what the voices are saying to the client. This is the first thing the nurse would ask if the newly admitted client tells the nurse about hearing voices. The nurse does not know the client or the diagnosis that might be affiliated with this statement. 1. Incorrect: The client has already told the nurse about hearing voices. This is non-therapeutic and negates the value of what the client is saying. 2. Incorrect: Upon admission, the nurse would not start out with this comment. This would come later. First the nurse needs to know what the voices are telling the client. 4. Incorrect: Again, this would come later after the nurse finds out what the voices are telling the client.

Which client assignments are most appropriate for the LPN to accept when working on the pediatric unit? (SATA) 1. 10 year old paraplegic in for bowel training. 2. 2 year old with asthma newly admitted with dehydration. 3. 3 month old admitted with possible septicemia. 4. 7 year old in Buck's traction for a femur fracture. 5. 10 year old transferred from ICU yesterday with a head injury.

1. & 4. Correct: These clients have conditions that the LPN/VN can care for with little assistance from the RN. Bowel training is a health promotion, self care activity that is within the scope of practice for the LPN/VN. Buck's traction is a type of skin traction that is also within the scope of practice for the LPN/VN. 2. Incorrect: This client will probably have IV fluids prescribed that the RN will need to administer. Assessment of lung status would be important since the client is a new admit with asthma. This is a potentially unstable client and would not be appropriate for the LPN/VN. 3. Incorrect: This client, admitted with septicemia, is potentially unstable and will probably require IV antibiotics and very close monitoring due to being very young with a major infection. 5. Incorrect: This client will need close observation and the higher skill level of an RN since there is a head injury and the client spent time in the ICU only one day before.

The nurse is monitoring a client who is being treated with a non-steroidal antiinflammatory medication (NSAID) for an acute flareup of gout. Which finding should the nurse expect to observe? 1. Decrease in pain after beginning medications. 2. Report of severe abdominal pain following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash.

1. Correct. The client usually experiences improvement within 24 hours after beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels. 4. Incorrect. This is not an adverse effect of NSAIDs. In fact, most NSAIDs are also antipyretics and would prevent fever.

A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse? 1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes you to be depressed."

1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression. By giving this type of information to the client, it helps with their understanding of the depression and empowers them with knowledge. 2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder or manic-type behaviors. Decreased levels of thyroid hormones are affiliated with depression, but not increased levels, so this would be wrong. 3. Incorrect: The nurse can discuss this with the client. This would be ignoring the client's desire to have information and post-pone providing much-needed help to the client. 4. Incorrect: This statement may allow for dialogue, but does not answer the client's question.

A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement? 1. Depersonalization 2. Echopraxia 3. Neologism 4. Concrete thinking

1. Correct: Depersonalization, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance). 2. Incorrect: The client who exhibits echopraxia may purposelessly imitate movements made by others. 3. Incorrect: Neologism is the invention of new words by a psychotic client. 4. Incorrect: Concrete thinking, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development.

Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.

1. Correct: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery. 2. Incorrect: Contractions are not close enough for this client to be an emergent situation. Also, since this is a multigravida client and not fully dilated yet, she is not a high risk client. 3. Incorrect: This client is in the active phase of labor, but there is much work to be done before she is fully dilated and engaged for delivery. 4. Incorrect: This client is not in labor and is a non-emergent client, particularly compared to client #1.

What action should the nurse take when a client receiving 40 mL/hr of enteral feedings has a gastric residual volume of 250 mL? 1. Recheck gastric residual volume in 1 hour. 2. Reduce the infusion rate and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 250 mL and continue the feedings at the same rate.

1. Correct: The action is to recheck gastric residual in 1 hour. This may be a sign of intolerance. Reasons for delayed gastric emptying must be determined if 250 mL or more remains on 2 (1 hour apart) checks. 2. Incorrect: Reducing the rate does not fix the problem. There is a reason for delayed gastric emptying. Four hours is too long to recheck residual volume. 3. Incorrect: Changing the feeding schedule does not fix the problem. To change from continuous to intermittent will not address the concern of the 250 mL of gastric residual volume. 4. Incorrect: Do not discard residual volumes. Discarding residual volumes can disrupt a client's fluid and electrolyte balance. Standard practice is to give it back. When you have high residuals, the client should be rechecked in 1 hour to determine if delayed gastric emptying is present.

In what position should the nurse place a client post intracranial surgery? 1. Head of bed elevated 30 degrees 2. Supine 3. Dorsal recumbent 4. Recovery position

1. Correct: The goal after intracranial surgery is to keep the intracranial pressure (ICP) from rising while optimizing the cerebral perfusion pressure (CPP). The ideal position for this client is HOB elevated and the head in neutral position. 2. Incorrect: Placing the client in supine position may increase ICP. Supine position is achieved when the client is lying flat. 3. Incorrect: Dorsal recumbent position will increase ICP as this position will increase peripheral return. The client in dorsal recumbent position is lying flat with the knees flexed and separated. 4. Incorrect: The recovery position is side lying position with one knee flexed. This position can also increase ICP.

What is the best method for the nurse to verify correct nasogastric (NG) tube placement after insertion? 1. X-ray of the upper GI 2. Gastric aspiration and pH testing 3. Auscultation of air instilled into the stomach 4. Visualization of the tube markings

1. Correct: The gold standard for nasogastric feeding tube placement is radiographic confirmation with X-ray. This is the most reliable method! 2. Incorrect: Both respiratory and gastrointestinal aspirates may be similar in color and may be misinterpreted. 3. Incorrect: This method cannot differentiate tube placement in the stomach or lung. The practitioner may still hear a rush of air. 4. Incorrect: Visualization of tube markings does not provide a reliable verification that the tube is in the stomach. This has never been a reliable way of verifying placement.

Which task would be appropriate for the LPN to accept from the charge nurse? 1. Changing a colostomy bag. 2. Hanging a new bag of total parenteral nutrition (TPN). 3. Teaching insulin self administration to a diabetic client. 4. Administering IV pain medication to a two day post op client.

1. Correct: The only procedure listed that is within the LPN/VN's practice range is changing the colostomy bag. This is a task that can be delegated to the LPN/VN. 2. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. This is outside the scope of practice for the LPN/VN. Therefore, the RN must perform this task and cannot delegate this to the LPN/VN. 3. Incorrect: Teaching is outside the scope of practice for the LPN/VN. Teaching can be reinforced by the LPN/VN, but they cannot perform the initial teaching. Teaching insulin self-administration cannot be delegated to the LPN. 4. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/VN. This should not be delegated to the LPN/VN.

A client has a prescription for digoxin 0.125 mg PO every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take? 1. Administer the digoxin. 2. Hold the digoxin. 3. Notify the primary healthcare provider. 4. Repeat the digoxin level.

1. Correct: This is a normal digoxin level. The nurse would administer the prescribed digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL. 2. Incorrect: This is a normal digoxin level. The nurse would administer the prescribed digoxin. 3. Incorrect: There is no need to notify the primary healthcare provider of a normal digoxin level. 4. Incorrect: There is no need to repeat a normal laboratory value.

Which components of the communication cycle should the nurse include as necessary for effective verbal communication? (SATA) 1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 4. The sender and receiver share the same life experiences. 5. There can be incongruence between the verbal and nonverbal message.

1., 2. & 3. Correct: The communication cycle includes the sender, a clear and concise message, the receiver, plus verbal or nonverbal feedback to acknowledge understanding of the message. The sender is the person who delivers the message, and the receiver is the person who receives the message. 4. Incorrect: The sender and receiver may not share the same life experiences; however, therapeutic communication can still be achieved. The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one another's meaning and respond accordingly. However, this is not required for effective verbal communication. 5. Incorrect: There should be congruence between verbal and nonverbal communication. Incongruency can lead to misunderstanding and miscommunication.

A LPN/VN plans to reinforce education that was provided to a group of new parents about how to prevent burn injuries in children. What points should be included? (SATA) 1. Eliminate use of placemats. 2. Establish "no" zones for space heaters. 3. Cover unused electrical outlets. 4. Warm baby bottle in microwave for 30 seconds. 5. Set the hot water heater thermostat to 140°F (60°C).

1., 2., & 3. Correct: Placemats and tablecloths can be pulled down by children. If something hot is sitting on it, the child can be scalded. The parents should be taught to block access to stove, fireplace, space heaters, and water heaters. They need to be inaccessible to small children. Covering unused electrical outlets will prevent a child from sticking things, such as a fork, in it which could result in an electrical burn. 4. Incorrect: The parents should not use microwave at all for warming the bottle. Food and liquids can heat unevenly and burn the child. 5. Incorrect: Hot water heater thermostats should be set to below 120°F (48.9°C). Bath water should be around 100°F (38°C) to prevent burn injuries with children. The water should be tested before allowing the child to step into the bath also.

The palliative care nurse is reinforcing instructions with the family of a client who is experiencing nausea and vomiting on methods of controlling these symptoms. What methods should the nurse include? (SATA) 1. Offer electrolyte replacement drinks or broths. 2. Avoid cooking close to the client. 3. Provide light, bland food. 4. Drink liquids less often. 5. Drink tea infused with ginseng.

1., 2., & 3. Correct: These are all methods that can help control nausea/vomiting symptoms. Sports drinks and broths can help with hydration. Juices and soft drinks should be avoided. Smells from foods cooking can lead to nausea and vomiting. Bland foods in small portions may be tolerated vs. fried or heavy foods. 4. Incorrect: The client should drink small amounts of liquid more often. If tolerated, fluids will help prevent dehydration. Avoid milk products and sugary drinks as they will increase nausea and loss of fluids. 5. Incorrect: Ginseng is a herb that improves mental and physical abilities. This question is asking for nausea and vomiting prevention/control.

The nurse is reinforcing teaching to a client, who has reduced peripheral circulation, on how to care for the feet. What points should the nurse include? (SATA) 1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses.

1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time 30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to moisten the skin. Lotion will also soften calluses. Do not put lotion between the toes; moisture there can cause fungus growth. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary healthcare provider first.

The nurse is helping a client to bed when the client begins having a generalized seizure. Which action should the nurse take? 1. Place a tongue blade in the client's mouth. 2. Assist the client to the floor in a side-lying position. 3. Restrain the client. 4. Notify the primary healthcare provider.

2. Correct: By assisting the client to the floor, the nurse prevents harm to the client. The side-lying position prevents aspiration should the client vomit. It helps to keep the airway clear and this is the first priority. 1. Incorrect: When a client is experiencing a seizure, nothing should be placed in the client's mouth. Efforts to hold the tongue down can injure teeth. 3. Incorrect: The client should not be restrained. However, linens or a pillow should be placed around the client to prevent injury. 4. Incorrect: The primary healthcare provider may be notified after the client is safe. The airway is priority as the initial action. Do something to help the client.

Which interventions are appropriate for the nurse to initiate for a client post liver biopsy? (SATA) 1. Apply direct pressure to site immediately after needle is removed. 2. Monitor puncture site every 15 minutes for 1 hour. 3. Position client on left side. 4. Keep client NPO for 24 hours. 5. Advise client that pain may occur as the anesthetic wears off.

1., 2., & 5. Correct: Anyone who has a liver problem is at risk for bleeding. The clotting factor produced in the liver is prothrombin. Anytime a needle is inserted into the body and removed, bleeding can occur. Whenever there is risk for bleeding, the preventive measure is to apply pressure. The puncture site should be monitored frequently. The client may experience some discomfort at the biopsy site once the anesthetic wears off. 3. Incorrect: Lying on the left side does not put pressure on the puncture site. The liver is on the right side, as is the puncture site. 4. Incorrect: The client should be prescribed NPO for 2 hours. The client's usual diet as tolerated will be resumed after the 2 hours.

Three hours after delivery of a client's newborn, the nurse monitors for bladder distention. What signs would the nurse note if the client's bladder is distended? (SATA) 1. Fundus 3 cm above umbilicus 2. Excessive lochia 3. Voids 200 mL every 2 hours 4. Fundus in abdominal midline 5. Tenderness above symphysis pubis

1., 2., & 5. Correct: Monitor client for signs of distended bladder, such as fundal height above the umbilicus or baseline level, and/or fundus displaced from midline over to the side. Bladder that bulges above the symphysis pubis, excessive lochia, tenderness over the bladder area, frequent voiding of less than 150 mL (indicative of urinary retention with overflow) are also signs of a distended bladder. 3. Incorrect: Voiding every 2-3 hours should be encouraged to prevent possible displacement of the uterus and the development of atony. The clients ability to do this would prevent bladder distention. 4. Incorrect: Fundus in abdominal midline is what we want and is not a sign of bladder distention. We do not want it displaced over to the side from midline.

What information should the nurse give a pregnant client who comes to the clinic reporting hemorrhoids and constipation? (SATA) 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. More fluid and fiber is needed in the diet. 4. Use a mild laxative to alleviate constipation. 5. Increase daily fluid intake.

1., 2., 3. & 5. Correct: As pregnancy progresses, the enlarging uterus increases abdominal and rectal pressure. GI motility slows due to hormonal influences. Pregnant clients may benefit significantly from dietary changes including adequate hydration and increased fiber intake. 4. Incorrect: Medications, including laxatives, should not be taken by pregnant women unless prescribed by the primary healthcare provider. If needed, the primary healthcare provider may prescribe a stool softener but a laxative is not typically recommended because of possible fluid and electrolyte shifts.

In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? (SATA) 1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 4. Save effort by lifting rather than rolling, turning, or pivoting. 5. Utilize muscles of the back rather than muscles of the shoulders. 6. Obtain assistance from other nurses as needed.

1., 2., 3., & 6. Correct: When in a standing position, the center of gravity is at the center of the pelvis. The wider the base of support and the lower the center of gravity the nurse maintains, the greater the stability for the movement. Using both the arms and the legs provides a sense of balance for the activity. It is always smart to seek more assistance when needed to avoid injury to self. 4. Incorrect: Rolling, turning, and pivoting are less likely to cause injury than attempting to lift. Lifting puts more strain on the back than these other methods. 5. Incorrect: The larger muscles of the thighs, buttocks, and shoulders should be utilized for activity because the smaller muscles such as those in the back and arms are more susceptible to injury.

The nurse is caring for a client with a perineal burn. The skin is not intact. How will the nurse know if a perineal infection is occurring? (SATA) 1. Color changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased pain

1., 2., 3., 4. & 6. Correct: Infection may cause color changes, drainage, odor, fever and increased pain. 5. Incorrect: Bleeding is a sign of hemorrhage, trauma, or other blood disorders, but is not caused by infection.

The nurse is planning care for a client who has a fractured hip. Which nursing interventions are appropriate for this client? (SATA) 1. Turn every two hours 2. Place a pillow between legs when turning 3. Sit in a chair three times per day 4. Encourage fluid intake 5. Encourage ankle and foot exercises

1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT). 3. Incorrect: The client has a fractured hip that has not been surgically fixed. Sitting up in a chair could do more injury and cause more pain.

The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to reinforce as the client enters this phase? (SATA) 1. On going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. 3. Decrease programmatic exercise plan. 4. Relapse prevention plan. 5. Continued peer support.

1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The weigh-ins increase accountability for prolonged behavioral change. Anytime that a new behavior is instituted, there is a chance that the person will return to old habits. Having a plan in place may help the person to stay on track. Ongoing peer support can be very helpful as the client continues in the maintenance phase. 3. Incorrect: A programmatic exercise plan is still needed. If this is taken away or reduced too much, the client may return to old habits. Increasing physical activity is essential to maintain weight loss.

Which tasks would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? (SATA) 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for the client returning from surgery is a basic procedure. 2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of pain medication. That is what you are asking the UAP to do here. The client has received a narcotic and you have asked the UAP to evaluate the effectiveness of the medication. 5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice for the UAP. This is a procedure which requires a licensed personnel. Catheter placement must be confirmed, client identity checked, tube site flushed with water or sterile water and flow rate determined.

Which documentation entries by the LPN would be appropriate to place in a client's electronic record? (SATA) 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.

1., 3, & 5. Correct: These are written correctly with complete, concise and objective information for each statement pertaining to the client. 2. Incorrect: "Appears" is a subjective word. Remember to use objective words. Pain should be assessed in an objective manner, such as by using a pain scale that is appropriate for the client's age and communication abilities. If the client were unable to respond to a pain scale assessment, the nurse would need to describe objectively the behavior of concern; for instance, the nurse could document "client moaning, guarding abdominal area with both hands, and knees pulled towards chest". 4. Incorrect: Do not use trailing zeros after a decimal point to prevent incorrect dosage. Likewise, always lead a decimal point with a zero (0.5).

What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? (SATA) 1. White blood cell count of 3,800 (3.8 x 109/L) 2. White blood cell count of 15,000 (15.0 x 109/L) 3. Platelet count of 90,000/µL (90 x 109/L) 4. Platelet count of 450,000/µL (450 x 109/L) 5. Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) 6. Red blood cell count of 7.3 million/mcL (7.3 x 1012/L)

1., 3., 5. Correct: Pancytopenia is a condition in which there is a concurrent leukopenia (a reduction in white blood cells), thrombocytopenia (a reduction in platelets), and anemia (reduction in red blood cells). The normal white blood cell count is 5,000-10,000 (5.0 to 10.0 x 109/L), so a level of 3,800 (3.8 x 109/L) represents leukopenia. The normal platelet count is 150,000-400,000/µL (150 - 450 x 109/L), so a level of 90,000/µL represents thrombocytopenia. The normal red blood cell count for a Female is 4.2 - 5.4 million/mcL ( 4.2 - 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 - 6.1 million/mcL (4.7 - 6.1 X 1012/L). Therefore, a red blood cell count of 3.0 million/mcL (3.0 x 1012/L) is indicative of anemia, regardless of the sex of the client. 2. Incorrect. The normal white blood cell count is 5,000-10,000 (5.0 to 10.0 x 109/L). A WBC count of 15,000 (15.0 x 109/L) is considered leukocytosis (elevated WBC level). 4. Incorrect: The normal platelet count is 150,000-400,000/µL (150 - 450 x 109/L). Therefore, a platelet count of 450,000/µL (450 x 109/L) would be an elevated platelet level (thrombocytosis). 6. Incorrect: The normal red blood cell count for a Female is 4.2 - 5.4 million/mcL (4.2 - 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 - 6.1 million/mcL (4.7 - 6.1 X 1012/L). Therefore, a level of 7.3 million/mcL (7.3 x 1012/L) is elevated (polycythemia).

Which findings does the nurse expect to find when monitoring a client admitted with left sided congestive heart failure? (SATA) 1. Ascites 2. Bibasilar crackles 3. Orthopnea 4. Hepatomegaly 5. Anorexia

2. & 3. Correct: Bibasilar crackles that do not clear with coughing occur with left sided heart failure. Fluid backs up into the lungs. Orthopnea occurs in left sided heart failure when the client lies flat, because fluid backs up into the lungs. 1. Incorrect: Ascites is seen with right sided heart failure because fluid backs up into the systemic venous circulation, causing stasis in the abdominal organs. 4. Incorrect: Hepatomegaly is seen with right sided heart failure because of the venous engorgement and stasis in the liver. 5. Incorrect: Anorexia is seen in right sided heart failure due to venous engorgement and venous stasis within the abdominal organs.

The nurse is reinforcing teaching to the family of a diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? 1. It is not necessary to treat mild hypoglycemia indicated by irritability. 2. Treat a mild episode with 10-15 grams of carbohydrate. 3. The client should consume 12 ounces of regular cola. 4. The client should consume 2 cups of orange juice without added sugar.

2. Correct. 10-15 grams of carbohydrate should raise the blood sugar 40 - 50 mg/dL. Then the family can check the blood sugar and repeat the carbohydrate if necessary. 1. Incorrect. The blood sugar level may drop rapidly and result in changes in level of consciousness. The family should be taught to always worry about hypoglycemia. 3. Incorrect. Twelve ounces of cola would raise the blood sugar too high. Twelve ounces of cola contains about 39 grams of carbohydrates. 4. Incorrect. Two cups of orange juice would equal approximately 52 grams of carbohydrates. This would raise the blood sugar too high.

Which task would be appropriate for the nurse to assign the unlicensed assistive personnel (UAP)? 1. Assess any pressure ulcers noted on clients. 2. Report if any client indicates pain. 3. Monitor amount of chest tube drainage. 4. Demonstrate coughing and deep breathing exercises to post-op clients.

2. Correct. It is within the scope of practice for the UAP to ask the client if they are experiencing pain. The nurse will then assess the pain. The nurse can delegate, assess, develop a plan of care and evaluate. 1. Incorrect. This is an RN task. The UAP does not have the appropriate education to assess a pressure ulcer. This is not within their scope of practice. 3. Incorrect. The UAP cannot assess or evaluate. This is an RN task. Monitoring the amount of chest tube drainage is an appropriate action for the nurse. The UAP cannot monitor the amount of chest tube drainage. 4. Incorrect. The UAP cannot teach. This is an RN task. The nurse cannot delegate teaching or demonstrating to the UAP.

Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegetable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chick peas and asparagus, apple, tea

2. Correct: Gout is manifested by pain and inflammation that occurs when too much uric acid crystallizes and deposits in the joints. This is a good choice as it is low in purine and fat. Purines are broken down into uric acid. A diet rich in purines can raise uric acid levels. Meat and seafood increase the risk of gout. Dairy products may lower risk for gout. 1. Incorrect: The client should not eat tuna, which is high in purine. 3. Incorrect: Gravy is a high purine food and should be avoided. Also avoid artificial sweeteners. 4. Incorrect: Although spinach and asparagus can be consumed in moderation, they still contain purines, so it is not as good of a choice as the vegetable soup, toast and skim milk.

Which menu selection by the client diagnosed with cholelithiasis indicates understanding of a proper diet? 1. Fried chicken, rice and gravy, broccoli and cheese, custard pie 2. Grilled pork chops in peach sauce, baked sweet potato, sherbet 3. Oven roasted bbq ribs, baked beans, tomato slices, ice cream 4. Pasta topped with boiled shrimp and butter sauce, salad, bread pudding

2. Correct: In cholelithiasis, the bile becomes super saturated with cholesterol. This leads to precipitation of cholesterol which presents as gall stones. A client with cholelithiasis should avoid foods high in fat. Foods high in fat include any fried foods, cheeses, milk, custard, cream, ice cream, pies, cakes, red meats, and baked beans. 1. Incorrect: This diet of fried food is high in cholesterol. Foods high in fat should be avoided. 3. Incorrect: This meal seems to be prepared in a healthy manner with being oven roasted; however, the ribs are high in fat (cholesterol). Ice cream is also high in fat content. 4. Incorrect: Butter sauce and bread pudding are high in fat. Boiled shrimp is a seemingly healthy choice; however, butter sauce and bread pudding are high in fat content.

The nurse has identified that a client receiving oxygen has nasal irritation. Which client action would require the nurse to intervene? 1. Application of gauze padding beneath the tubing. 2. Use of petroleum jelly on the nares and cheeks. 3. Mouth and nose care every 4 hours as needed. 4. Placement of the oxygen mask straps well above the ears.

2. Correct: Petroleum jelly is a combustible substance. It should not be used with oxygen therapy. 1. Incorrect: The nurse would not need to intervene if the client applied gauze padding beneath the tubing to protect the skin. This is acceptable. 3. Incorrect: The nurse would not need to intervene if the client provided mouth and nose care every four hours as needed to protect the skin and mucus membranes. This is acceptable. 4. Incorrect: The nurse would not need to intervene if the client placed the oxygen mask straps well above the client's ears to protect the skin. This is acceptable.

The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan? 1. Primary healthcare provider 2. Case manager 3. Physical therapist 4. Occupational therapist

2. Correct: The client's case manager should be contacted regarding the order for pending discharge from the healthcare facility. The case manager coordinates care and provides the client with information and resources for an individualized discharge plan. 1. Incorrect: The primary healthcare provider does not assume the case management role in the acute care facility setting, and generally does not coordinate the discharge planning process. 3. Incorrect: The physical therapist is a member of the multidisciplinary team and might help evaluate, but does not coordinate discharge planning. They are not responsible for case management and coordination of overall client care for discharge from the facility. 4. Incorrect: The occupational therapist is a member of the multidisciplinary team and might help evaluate, but does not coordinate discharge planning. They are not responsible for case management and coordination of overall client care for discharge from the facility.

A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen? 1. Yes, I believe that God will heal you. 2. Many people of faith believe that one way God works to heal is through medication. 3. We are talking about taking your medications right now. 4. What if God does not heal you and you should have taken the medication?

2. Correct: This allows the client to keep the belief that God will heal but will do it through the medication. This promotes compliance with the prescribed medication regimen. 1. Incorrect: The nurse does not know if God will heal the client and does not promote compliance with the prescribed medication regimen. The nurse is responding in the nontherapeutic technique of agreeing. 3. Incorrect: This approach may make the client angry, which will close the communication between the client and the nurse. It also does not promote compliance with the prescribed medication regimen. The nurse is responding in the nontherapeutic technique of rejecting. 4. Incorrect: This approach is argumentative and puts the client on the defense, which will close the communication between the client and the nurse.

A client has an acute onset of fever, chills and RUQ pain. The vital signs are: Temp 99.8°F (37.7°C), HR 132, RR 34, B/P 142/82. Arterial blood gas (ABG) results are: pH 7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Correct: This client has a severe infection. Hyperventilation due to such issues as anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: With hyperventilation, the client will not have respiratory acidosis because the CO2 is being blown off, not retained. The pH is high (7.53), indicating alkalosis. 3. Incorrect: This acid-base imbalance is not metabolic related. The bicarb is within normal range and the pH is high, indicating alkalosis. 4. Incorrect: This acid-base imbalance is not metabolic related. The increased respiratory rate is the problem and the bicarb is within normal range. The CO2 is low, indicating that it is respiratory related.

After applying oxygen using bi-nasal prongs to a client who is hypoxic, the nurse should implement which action? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply vaseline petroleum to nares and gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

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

A client suffers from a right radial fracture. The client now reports severe pain in the right arm accompanied with edema in the fingers. The nurse suspects what finding? 1. Carpal tunnel syndrome 2. Compartment syndrome 3. Subsequent ulnar fracture 4. Ulnar nerve palsy

2. Correct: This situation best describes compartment syndrome. Compartment syndrome is when edema within a closed space may result in vascular compromise and decreased blood flow with eventual neurologic compromise. There are five Ps of compartment syndrome: pallor, pulselessness, pain, paresthesias, and paralysis. 1. Incorrect: This does not describe carpal tunnel syndrome. The key to this question is that this client has recently sustained a right radial fracture. 3. Incorrect: This does not describe ulnar fracture. The key to this question is that this client has recently sustained a right radial fracture. 4. Incorrect: This does not describe nerve palsy. The key to this question is that this client has recently sustained a right radial fracture.

The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client? 1. Place the finger at heart level. 2. Warm the finger prior to the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level.

2. Correct: Warming the finger will increase circulation to the site, thereby increasing blood flow. 1. Incorrect: The finger should be dependent to enhance blood flow to the site, so it needs to be below the level of the heart to be effective. 3. Incorrect: The injector should be placed firmly against the skin; otherwise the client may get an insufficient stick and require another stick. 4. Incorrect: The finger should be in a dependent position to increase blood flow to the site so as to prevent the need for another stick.

A client is scheduled for an electroencephalogram (EEG). Which intervention should the nurse implement? 1. Keep NPO and hold medication. 2. Hold sedatives, but allow client to have breakfast and other medicines. 3. Administer meds, but hold anticonvulsants. 4. Give additional fluids and some caffeine prior to the test.

2. Correct: Yes, prior to an EEG we want the client to eat so the glucose level does not drop. In addition, they should take medications except sedatives prior to the EEG. 1. Incorrect: No, give them food, and give them their meds except sedatives. 3. Incorrect: No, give all meds including anticonvulsants unless specifically ordered. 4. Incorrect: No, the client does not need extra fluid. They will just have to stop and urinate, and caffeine will increase the electricity in the brain and interfere with the test.

The nurse is providing care for a client admitted with a diagnosis of myasthenia gravis. Which nursing interventions should the nurse include in order to decrease the risk of aspiration? (SATA) 1. Provide thin liquids such as water with meals. 2. Offer small bites of food. 3. Allow client to rest between each bite of food. 4. Offer small meals in the morning and larger meals in the evening. 5. Provide meals 30 minutes before administration of cholinesterase inhibitor medication.

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

The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. What actions should the nurse take to ensure client safety? (SATA) 1. Document the medication with times and doses to be given, then administer the medication as prescribed. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. 5. Call the pharmacy to see if the medication needs to be changed.

2., 3. & 4. Correct: Administration of a medication that the client is allergic to could result in harm to the client. The primary healthcare provider should be notified immediately of a medication prescription that conflicts with the client's list of medication allergies. The medication should be discontinued on the medication administration record, and the client's allergy band checked against the list of allergies documented in the medication record for accuracy. All of these actions place the nurse in the role of client advocate and ensure the client's safety. 1. Incorrect: No, this medication could cause harm to the client. The client is allergic to this medication. This will not ensure client safety. 5. Incorrect: No, the primary healthcare provider, not the pharmacy, should be notified for medication changes. The primary healthcare provider is responsible for prescribing the medication.

A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement? (SATA) 1. Directly observe the client at least every 4 hours. 2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client. 5. Discourage client's expression of negative feelings.

2., 3. & 4. Correct: Anxiety rises in stimulating environments. Individuals may be perceived as threatened by a fearful and agitated client. Removing dangerous objects will prevent the confused and agitated client from using them to harm self or others. Anxiety is contagious and can be transmitted from staff to client. 1. Incorrect: The client should be observed closely and frequently to ensure safety for self and others. Every 4 hours is not frequent enough and doesn't ensure the client's safety. 5. Incorrect: Accepting expression of negative feelings is therapeutic and helps the client learn more effective ways of dealing with anger, anxiety, or aggression.

What symptoms does the nurse expect to see in a client with bulimia nervosa? (SATA) 1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise

2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating; recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. 1. Incorrect: Amenorrhea (absence of menstruation) is found in anorexia nervosa. This may be caused by increase exercise and an increase in the corticotropin releasing hormone (CRH). 5. Incorrect: Excessive exercise is found in bulimia nervosa as a means to compensate for the binge eating.

A client sustained a skull fracture in a motor vehicle crash. The nurse knows this client is at risk for increased intracranial pressure and, therefore, would place the client in which position? (SATA) 1. Head turned to the side 2. Head of bed at 30 to 45 degrees 3. Head midline 4. Neck in neutral position 5. Left sims position

2., 3. & 4. Correct: Keeping the head elevated, midline, and in a neutral position promotes venous return from the head, preventing a rise in intracranial pressure. 1. Incorrect: Turning the head to the side may obstruct venous outflow, causing an increase in pressure. 5. Incorrect: The sims position is side lying and therefore, the head would be turned to the side. Turning the head to the side may obstruct venous outflow, causing an increase in pressure.

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? (SATA) 1. Uses a clean basin and washcloth to clean the ulcer. 2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 4. Warms saline bottle in microwave for 1 minute. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside.

2., 3., & 5. Correct: The nurse needs to wear sterile gloves when cleaning the wound. Normal saline solution is the preferred cleansing agent because, as an isotonic solution, it doesn't interfere with the normal healing process. Gently clean the wound in a full or half circle, beginning in the center and working toward the outside. 1. Incorrect: Sterile supplies should be used with this procedure because the client is at risk for infection and gangrene. Gauze and salve should be used instead of a wash cloth. 4. Incorrect: Before you start, make sure the cleansing solution is at room temperature. Do not heat in the microwave. It could scald the client!

The client has suicidal ideations with a vague plan for suicide. The nurse, who is reinforcing teaching to the family about caring for the client at home, should emphasize which points? (SATA) 1. Family members are responsible for preventing future suicidal attempts. 2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes.

2., 3., 4. & 5. Correct: A common myth is that the person who doesn't talk about suicide will not attempt it, but this may be a warning sign that the person has a well thought out plan. Warning signs generally exist but may not be recognized by others until after the suicide or attempted suicide. Once a person has made a suicidal attempt, the chances increase that they will attempt it again at a later time. Sudden behavioral changes can signal suicidal intentions, especially if that is the primary focus of their thoughts and feelings. 1. Incorrect: Families should be encouraged to create a safe environment and recognize warning signs, but they may not be able to stop a suicide. Families, in spite of their best efforts, should not be put into a position of guilt if the client is successful with suicide.

The nurse monitors the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? (SATA) 1. Reinforcing teaching about pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques.

2., 3., 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy, and using distraction techniques are all proven interventions that can raise the client's pain threshold. In other words, raise the level at which a client first perceives a stimulus as pain. All of these provide comfort, are non-invasive, and show the client that the nurse cares. 1. Incorrect: Reinforcing teaching regarding pain control does not help the client's pain and would not be appropriate while the client is experiencing pain.

Which tasks should the nurse assign to the unlicensed assistive personnel (UAP)? (SATA) 1. Demonstrate post-operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.

3., 4. & 5. Correct. It is within the role of an UAP to empty the indwelling catheter bag, assist with position change, and apply anti-embolism stockings. The nurse should confirm that these tasks have been done, but they are safe to assign to the UAP. 1. Incorrect. This is beyond the scope of practice for the UAP because teaching and teaching reinforcement is required. 2. Incorrect. The physical therapist is the best team member to manage the TENS unit since this is a pain control device that affects nerves and muscles.

What should the nurse include when reinforcing teaching to a client in renal failure about peritoneal dialysis? (SATA) 1. Instill 250 mL of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used.

3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. 1. Incorrect: The amount of fluid used in peritoneal dialysis is about 2000 to 2500 mL at a time. This filling of the peritoneal cavity is often completed in 10 minutes. 2. Incorrect: Cool fluids would cause vasoconstriction. The effluent should be warmed to body temperature to promote blood flow to enhance the exchange (the more blood flow, the more toxin removal). 5. Incorrect: If all of the fluid does not come out, the client should turn side to side to promote drainage. The Trendelenburg position would cause the fluids to pool in the upper peritoneal area and not drain adequately.

Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check bladder for distension in client who had an indwelling catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.

3. Correct. The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. 1. Incorrect. This is not within the scope of practice for the UAP. The nurse must collect data. Checking the bladder for distension is data collection. 2. Incorrect. This client is not stable if having episodes of syncope that could be related to orthostatic hypotension. Since the client is not stable, the UAP should not obtain the client's BP. 4. Incorrect. The nurse cannot ask the UAP to complete an assessment or evaluation task. This is beyond the scope of practice for the UAP.

While the postpartum nurse was in report, four clients called the nurse's station for assistance. Which client should the nurse see first? 1. Client with three dime sized clots on her perineal pad. 2. Breastfeeding client who is reporting uterine cramping. 3. Client reporting blood running down legs upon standing. 4. Client who had an epidural and is now reporting a headache.

3. Correct: A nurse should see this client first because we are worried about hemorrhage. If the fundus is boggy, a fundal massage will need to be done. Check vital signs for hemorrhage. 1. Incorrect: Clots smaller than a silver dollar are normal. However, do not ignore any bleeding. Always check the client with any signs of bleeding to determine whether the problem is significant. 2. Incorrect: Breastfeeding causes the release of endogenous oxytocin from the pituitary, which causes the uterus to contract. When the uterus contracts, the client may call this discomfort, cramping. This is a normal process necessary for the uterus to return to normal. 4. Incorrect: A post epidural headache can be an indication of inadvertent puncture of the dural membrane. This client will need to be positioned prone, push fluids, given caffeine and may need a blood patch to seal the dural leak. However, the client with possible hemorrhage would be the client that the nurse would need to see first, because this could be more life-threatening.

The primary healthcare provider (PHP) has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's most appropriate action? 1. Administer the injection. 2. Take vital signs. 3. Question prescription with PHP. 4. Notify the nursing supervisor.

3. Correct: A placebo is any medication or procedure that produces an effect in clients resulting from its implicit or explicit intent and not from its physical or chemical properties. An example would be a sugar pill or injection of saline. Some professionals try to justify the use of placebos to elicit the desirable placebo effect or they are used in a misguided attempt to determine if the client's pain is real. These reasons cannot be justified on either a clinical or ethical basis, except in an approved research study. It is deceptive and represents fraudulent and unethical treatment. 1. Incorrect: Giving a placebo is fraudulent and unethical treatment. 2. Incorrect: Taking the vital signs does not take care of the problem of giving a placebo. 4. Incorrect: First, the nurse should discuss the prescription with the primary healthcare provider.

After injecting enoxaparin subcutaneously into the abdomen, which action should the nurse take? 1. Gently rub the injection site when the needle is withdrawn 2. Have the client maintain a side lying position for at least five minutes 3. Remove the needle and engage the needle safety device 4. Apply heat to the site

3. Correct: After a Subcutaneous injection, the needle is removed and the needle's safety device is engaged. 1. Incorrect: Do not massage the injection site of enoxaparin. Rubbing is the same as massaging the site. 2. Incorrect: The client does not have to maintain a certain position following the administration of enoxaparin. 4. Incorrect: Heat is not applied to the injection site after enoxaparin is injected.

What factor would most likely predispose a client with a compound femoral fracture to develop shock? 1. Pooling of the blood in the lower leg 2. Generalized vasoconstriction in the lower extremities 3. Loss of blood into soft tissues surrounding the fracture 4. Depression of the adrenal gland by toxins released at the injury

3. Correct: After a fracture, the factor that would most likely lead to shock is loss of blood into the soft tissue surrounding the fracture. When fractures occur, major arteries can be severed, causing loss of blood into the surrounding tissue. 1. Incorrect: Pooling of blood in the lower extremities is a possibility, but bleeding into the surrounding tissue is more acute. 2. Incorrect: Vasoconstriction in the lower extremities is an appropriate compensatory response for a "shocky" client. Vasoconstriction of the lower extremities will increase blood pressure. 4. Incorrect: Depression of the adrenal glands caused by release of toxins at the injured site is not correct.

The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin.

3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of information. Calling another department does not ensure that the nurse will get as comprehensive information as the MSDS provides. 2. Incorrect: The drug handbook is for medication, not handling of hazardous material. 4. Incorrect: The nurse can place the biopsy into a container with formalin and is within the scope of practice for the nurse.

The nurse reinforces instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? 1. "I'm glad I can still have my evening glass of wine." 2. "I told my daughter not to buy romaine lettuce for my salads." 3. "I will have to limit my intake of spinach, something that I really love." 4. "I am going to eat more canned tuna fish since it is healthy."

3. Correct: Clients taking warfarin sodium must watch their intake of vitamin K, which is present in leafy green vegetables such as spinach. 1. Incorrect: Alcohol affects the use of warfarin sodium. This combination can cause the client to bleed more easily. 2. Incorrect: Iceberg and romaine lettuce are considered low sources of vitamin K, so the client can eat them. 4. Incorrect: Canned tuna is a source of vitamin K, which can decrease the effectiveness of warfarin.

The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial data collection, the client reports experiencing "numb feet." What is the nurse's first action? 1. Check blood glucose level. 2. Check for proper shoe size. 3. Observe the client's feet for signs of injury. 4. Test sensory perception in the client's feet.

3. Correct: Clients with decreased peripheral sensation are at risk for injury to the extremity. They may sustain an injury and be unaware the injury has occurred. In addition to this, diabetics are at risk for poor wound healing (related to impaired circulation) and infection (related to elevated glucose levels). This is the option that should be performed first and takes priority. 1. Incorrect: Checking a fasting blood glucose level is important, but it is not the FIRST action to be taken. Checking the blood glucose level does not fix the problem. The problem is potential risk for injury. 2. Incorrect: Diabetics need well-fitting shoes because the nerves and vessels that go to the feet can be damaged by poorly controlled blood sugar. Check the client first. 4. Incorrect: Checking the sensation in the feet is not fixing the problem. It will be done later but risk for injury is the priority because the client has numbness of the feet.

A term male infant was just delivered vaginally. Which action by the nurse has priority? 1. Apply identification bands. 2. Apply eye ointment. 3. Dry the baby. 4. Obtain footprints.

3. Correct: Cold stress is the biggest danger to a newborn. A newborn is wet, and evaporation will rapidly cool the baby which can cause hypoglycemia and respiratory distress. 1. Incorrect: Applying the identification bands needs to be accomplished before the baby leaves the delivery room, but this is not the immediate priority. 2. Incorrect: Eye prophylaxis can safely be delayed up to two hours after delivery. 4. Incorrect: Obtaining footprints needs to be accomplished before the baby leaves the delivery room, but this is not the immediate priority.

Parents bring their child to the clinic with left knee pain after suffering a fall on the playground. Which action should the nurse initiate first? 1. Instruct the child to extend the affected knee 2. Perform range of motion exercise on both knees 3. Compare the appearance of the left knee to the right knee 4. Have the child soak the affected knee in warm water

3. Correct: Comparing the appearance of the left knee to the right knee is the least invasive action and allows the nurse to see if there is a change in the appearance of the affected knee to the unaffected knee. 1. Incorrect: No. Extending the affected knee may cause further damage. 2. Incorrect: You don't want the child to move the extremity prior to checking for broken bones. Range of motion exercises may cause further damage to the affected knee. 4. Incorrect: Soaking the affected knee in warm water will not help the nurse determine whether or not an injury occurred.

The spouse of a sedated client asks the nurse about the client's test results. The client does not have a healthcare proxy or durable power of attorney. How should the nurse respond? 1. "I can't give you those results. You need to ask the primary healthcare provider for this information." 2. "Those test results are confidential, but since you are the spouse, I can give them to you." 3. "The health information of all clients is confidential and protected by law, so I cannot release the data without the client's consent." 4. "I'll ask the client if I can give you the results, since only a light sedative was used."

3. Correct: Each client's health information is confidential and protected by law. The nurse should inform the client's spouse of this fact, and explain the rationale for health information confidentiality. Family members are often offended or angry upon learning that health information cannot be released to them without the client's consent, but healthcare employees are bound by law to confidentiality. 1. Incorrect: The spouse is not automatically able to receive personal health information about the client.The client has to list the spouse as a person who can receive personal health information. The healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential unless the client has provided consent for the information to be released. 2. Incorrect: Healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential unless the client has provided consent for the information to be released. 4. Incorrect: A client who has received sedative medications cannot give legal consent, as these medications alter a client's level of consciousness and impair the ability to make informed decisions.

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

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

A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? 1. Administer the medication as prescribed. 2. Obtain pre-filled syringes from the pharmacy. 3. Discuss client rights with the primary healthcare provider. 4. Tell the client what has been prescribed.

3. Correct: Not only does deceitful use of placebos in place of appropriate pain treatment violate the client's right to the highest quality of care possible, it clearly poses a moral, ethical, and professional danger to healthcare providers. Perhaps the most important reason for not using placebos in the assessment and treatment of pain is that deception is involved. Deceit is harmful to both clients and healthcare professionals. 1. This is causing an ethical dilemma for the nurse. The nurse is now lying to the client by giving the placebo which is clearly wrong. The client is not aware that the solution administered is sterile saline. 2. Obtaining pre-filled syringes does not correct the ethical dilemma faced by the nurse and does nothing to fix the problem. 4. Telling the client will cause mistrust. It is best to discuss the issue with the primary healthcare provider. A discussion with the primary healthcare provider concerning the saline order should occur prior to any discussion with the client.

The nurse cares for a client who is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which precaution is important for the nurse to implement? 1. Perform hand hygiene after shift report. 2. Implement droplet precaution for the client. 3. Stock the client's room with dedicated equipment. 4. Eliminate dairy products from the client's diet.

3. Correct: The client's room should be stocked with dedicated equipment just for that client to prevent the nurse from spreading MRSA to other clients through cross-contamination. The nurse should perform hand hygiene before and after client contact. Clients that are infected with MRSA should be placed on contact precautions. 1. Incorrect: The nurse should perform hand hygiene before and after client contact. 2. Incorrect: Contact precautions should be implemented. 4. Incorrect: Eliminating dairy products from the client's diet is not necessary.

An expected outcome for a client with pneumonia is: "The airway will be free of secretions." Which action by the nurse is most important in meeting this goal? 1. Check results of ABG's and report abnormal findings. 2. Monitor color of skin, lips, and nail beds for cyanosis. 3. Question an order for a cough suppressant medication. 4. Monitor oxyhemoglobin saturation by oximetry.

3. Correct: The nurse knows the client needs to expectorate the sputum to remove bacteria or prevent bacterial growth. If the cough is suppressed, the bacteria will remain and grow in the lungs. This option is most important to assure outcome of airway being free of secretions. 1. Incorrect: When the problem is in the lungs we check the ABG's to determine how well the lungs move oxygen into the blood and remove CO2 from the blood. 2. Incorrect: Checking color of skin, lips, and nails beds for cyanosis are important in determining adequate oxygenation. 4. Incorrect: Checking the saturations will assist in determining adequate oxygenation.

A client states, "I feel so useless! I know my family thinks I am". What would be the best response for the nurse to make? 1. "Everyone gets down in the dumps at times. I feel that way myself sometimes". 2. "No one in your family feels that way". 3. "You must be very upset. Tell me what you are feeling right now". 4. "Why do you feel this way"?

3. Correct: This statement acknowledges the client's discomfort and conveys empathy and understanding. 1. Incorrect: This is an example of belittling feelings that have been expressed by the client. The nurse may cause the client to feel insignificant or unimportant. When one is experiencing discomfort, it is no relief to hear that others are or have been in similar situations. 2. Incorrect: Attempting to defend someone does not change the client's feelings and may cause the client to think the nurse is taking sides against the client. 4. Incorrect: Asking the client to provide the reasons for thoughts, feelings, behavior, and events can be intimidating and implies that the client must defend his or her behavior or feelings.

A nurse working in a locked psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I am not going to my session today!" What action by the nurse would be most appropriate? 1. Sit with the client and say a prayer. 2. Send the client to the session after explaining that shouting is not allowed. 3. Escort the client to an easel and canvas in order for the client to paint. 4. Call for assistance and put the client in seclusion.

3. Correct: Yes! Get them active. Redirect their activity. This is a much more therapeutic and effective intervention to help the paranoid client. 1. Incorrect: They are agitated and shouting. It is not reasonable to get them to sit and pray. 2. Incorrect: Setting limits is good, but here the client is disruptive and shouldn't go to group at this time. 4. Incorrect: This would not be the best action. Try to redirect the client first. Then, if unsuccessful, seclusion would be considered as a last resort.

The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's disease has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? 1. Calmly sit with the client and have the client repeat the room number at frequent intervals. 2. Have the client remain in own room so the client can become familiar with it. 3. Place a sign on the client's door with the client's name. 4. Hang a familiar object on the door to enhance room recognition.

4. Correct: A client with Alzheimer's is likely to recognize a familiar object before reading the name on the door. 1. Incorrect: You can make the client repeat the room number over and over, but he or she will not remember it, particularly since it is short-term current memory. This is the part of memory that goes first with the Alzheimer's client. 2. Incorrect: Stay in your room until you get used to it? No, this is non-therapeutic for a client with Alzheimer's and could increase their confusion and moody behavior. 3. Incorrect: This seems like an appropriate answer, but clients with Alzheimer's may not recognize their own name or take the time to read.

The nurse is caring for a client with right-sided paresis due to a stroke. The client is preparing for discharge in a few days. The nurse discovers that the spouse has been feeding the client. What should the nurse do? 1. Tell the spouse to require the client to feed independently. 2. Suggest the spouse hire an aide to feed and bathe the client upon discharge. 3. Advise the spouse to consider an extended care facility for the client. 4. Determine the reason why the spouse is not encouraging self-care by the client.

4. Correct: Because family members are important in promoting client self-care and preventing further illness, it is important to include family members in the teaching plan for the client. In a family support model, the goal is client self-care activities through formal and informal support systems. 1. Incorrect: Simply telling the spouse to require the client to perform self-care activities may result in affirmative verbal response from the spouse without actual follow-through after the nurse leaves. 2. Incorrect: Hiring others to perform care activities that the client can do independently does not contribute to the self-care model. 3. Incorrect: No indications that client needs an extended care facility.

A client asks the nurse, "What causes hypermagnesemia?" The nurse should reinforce to the client that hypermagnesemia can occur secondary to what health problem? 1. Peripheral vascular disease 2. Dehydration 3. Liver failure 4. Renal insufficiency

4. Correct: Magnesium is excreted primarily through the kidneys. When the client experiences renal insufficiency, magnesium is held. The incidence of hypermagnesemia is rare in comparison with hypomagnesemia, and it occurs secondary to renal insufficiency. 1. Incorrect: Peripheral vascular disease does not lead to hypermagnesemia 2. Incorrect: Dehydration leads to the electrolyte imbalance of hypernatremia, it does not cause hypermagnesemia. A client who has become dehydrated due to excessive urination may experience hypomagnesemia. 3. Incorrect: Liver failure does not lead to hypermagnesemia. Magnesium is regulated by GI absorption and renal excretion.

A nurse enters a client's room to find the client on the floor having a grand mal seizure. What action should the nurse take? 1. Wrap the client tightly in a blanket as a restraint. 2. Insert a padded tongue blade in the client's mouth. 3. Assist the client back into the bed. 4. Place a towel or sheet under the client's head.

4. Correct: Placing a towel or sheet under the client's head prevents further injury to the client. 1. Incorrect: Restraining the client may cause further injury to the client. 2. Incorrect: Forcing an object into the client's mouth can result in choking the client or injuring the client's teeth and mouth. 3. Incorrect: Lifting the client may cause injury to the nurse and client.

An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the nurse. Which statement by the UAP indicates that further teaching is needed? 1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should be used on all clients." 4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn."

4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client secretions or excretions, a standard mask may be worn. Routine nursing care does not warrant the use of an N95 mask. This type mask is needed for client's who are placed on Airborne Precautions such as for tuberculosis (TB). 1. Incorrect: This is a correct statement regarding the prevention of infection. Hand washing with soap and water is part of standard precautions. 2. Incorrect: This is a correct statement. Gloves are needed when coming into contact with body fluids. 3. Incorrect: This is a correct statement. Standard precautions is part of the first line of defense against the spread of infection.